State of The Evidence Review On Urban Health and Healthy Weights

State of the Evidence Review on Urban Health and Healthy Weights
StateoftheEvidenceReviewonUrban HealthandHealthyWeights

Preparedby: KimRaine,PhD,RD JohnC.Spence,PhD JohnChurch,PhD,MA NormandBoul,PhD LindaSlater,MLiS JoshMarko,MPH KarynGibbons,MPH EricHemphill,MSc
Theviewsexpressedinthisreportdonotnecessarilyrepresenttheviewsofthe CanadianPopulationHealthInitiativeortheCanadianInstituteforHealthInformation. Contentsofthispublicationmaybereproducedinwholeorinpartprovidedthe intendeduseisfornoncommercialpurposesandfullacknowledgementisgiven totheCanadianInstituteforHealthInformation. CanadianInstituteforHealthInformation 495RichmondRoad Suite600 Ottawa,Ontario K2A4H6 Phone:6132417860 Fax:6132418120 www.cihi.ca ISBN9781554652044(PDF) 2008CanadianInstituteforHealthInformation Howtocitethisdocument: K.Raine,J.C.Spence,J.Church,N.Boul,L.Slater,J.Marko,K.GibbonsandE.Hemphill, StateoftheEvidenceReviewonUrbanHealthandHealthyWeights(Ottawa:CIHI,2008). CettepublicationestaussidisponibleenfranaissousletitreExamendeltatdespreuvessurlasant enmilieuurbainetlepoidssant. ISBN9781554652051(PDF)
Table of Contents
AbouttheCanadianPopulationHealthInitiative..................................................... iii AbouttheCanadianInstituteforHealthInformation ............................................... v Acknowledgements ...................................................................................................... vii MainMessagesFromStateoftheEvidenceReviewonUrbanHealth andHealthyWeights ..................................................................................................... ix ExecutiveSummaryFromStateoftheEvidenceReviewonUrbanHealth andHealthyWeights ..................................................................................................... xi Abstract........................................................................................................................... xv 1 ProjectBackground......................................................................................................1 1.1 1.2 1.3 Introduction........................................................................................................1 StatementofPurpose.........................................................................................1 ConceptualFramework.....................................................................................1
2 Methodology ................................................................................................................5 2.1 SystematicLiteratureReview...........................................................................5 2.1.1 2.1.2 2.1.3 2.1.4 2.2 LiteratureSearchStrategy ..................................................................5 LiteratureTitleScan ............................................................................6 LiteratureAbstractScan .....................................................................7 LiteratureFullReview ........................................................................7
StakeholderSurvey(InformedOpinion) ......................................................11
3 Results .........................................................................................................................13 3.1 3.2 LiteratureSearchandReviewProcess ..........................................................13 Data:Obesity/HealthyWeights .....................................................................13 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 3.2.7 3.3 3.3.1 OverallFindingsforObesity/HealthyWeights.............................13 TheInfluenceofthePhysicalSettingandSector onObesity/HealthyWeights............................................................14 TheInfluenceoftheEconomicSettingandSector onObesity/HealthyWeights............................................................15 TheInfluenceofthePoliticalSettingandSector onObesity/HealthyWeights............................................................16 TheInfluenceoftheSocioCulturalSettingandSector onObesity/HealthyWeights............................................................16 BehavioursinRelationtoObesity/HealthyWeightsWithin UrbanEnvironments.........................................................................17 SummaryofObesity/HealthyWeights...........................................18 OverallFindingsforFood,DietandNutrition .............................19
Data:Food,DietandNutrition ......................................................................19
3.3.2 3.3.3 3.3.4 3.3.5 3.4
TheInfluenceofthePhysicalSettingandSectoronFood, DietandNutrition............................................................................. 19 TheInfluenceoftheEconomicSettingandSectoronFood, DietandNutrition............................................................................. 21 TheInfluenceofthePoliticalSettingandSectoronFood, DietandNutrition............................................................................. 22 TheInfluenceoftheSocioCulturalSettingandSectoronFood, DietandNutrition............................................................................. 23 OverallFindingsforPhysicalActivity ........................................... 24 TheInfluenceofthePhysicalSettingandSector onPhysicalActivity........................................................................... 24 TheInfluenceoftheEconomicSettingandSector onPhysicalActivity ........................................................................... 25 TheInfluenceofthePoliticalSettingandSector onPhysicalActivity........................................................................... 25 TheInfluenceoftheSocioCulturalSettingandSector onPhysicalActivity .......................................................................... 25
Data:PhysicalActivity.................................................................................... 24 3.4.1 3.4.2 3.4.3 3.4.4 3.4.5
3.5 3.6 3.7
Data:SedentaryBehaviour............................................................................. 26 LevelsofEvidenceforRelationshipsBetweenUrbanEnvironments andObesogenicBehaviourorBodyWeight................................................ 26 PolicyContext .................................................................................................. 28 3.7.1 3.7.2 IssueFraming .................................................................................... 28 PossiblePolicyResponses................................................................ 29
3.8
ResultsofOnlineStakeholderSurvey .......................................................... 30
4 Conclusions ................................................................................................................ 33 ReferenceList ................................................................................................................. 35 AppendixA:ProjectFlowChart ................................................................................. 49 AppendixB:SampleMEDLINE/HealthStarSearchStrategy.................................. 51 AppendixC:ArticleCodingFormandReferenceGuide ............................................ 55 AppendixD:OnlineStakeholderSurvey................................................................... 67 AppendixE:BibliographyofAssessedLiterature .................................................... 71 AppendixF:BibliographyofPolicyDocuments....................................................... 99 AppendixG:PotentialPolicyInstrumentsCategorizedUsing theANGELOFramework ................................................................... 101 AppendixH:AggregateResultsFromOnlineStakeholderSurvey ..................... 105
About the Canadian Population Health Initiative
About the Canadian Population Health Initiative

TheCanadianPopulationHealthInitiative(CPHI),apartoftheCanadianInstitute forHealthInformation(CIHI),wascreatedin1999.CPHIsmissionistwofold: Tofosterabetterunderstandingoffactorsthataffectthehealthofindividuals andcommunities;and Tocontributetothedevelopmentofpoliciesthatreduceinequitiesandimprove thehealthandwellbeingofCanadians. Asakeyactorinpopulationhealth,CPHI: ProvidesanalysisofCanadianandinternationalpopulationhealthevidencetoinform policiesthatimprovethehealthofCanadians; Commissionsresearchandbuildsresearchpartnershipstoenhanceunderstandingof researchfindingsandtopromoteanalysisofstrategiesthatimprovepopulationhealth; Synthesizesevidenceaboutpolicyexperiences,analyzesevidenceontheeffectiveness ofpolicyinitiativesanddevelopspolicyoptions; Workstoimprovepublicknowledgeandunderstandingofthedeterminantsthat affectindividualandcommunityhealthandwellbeing;and WorkswithinCIHItocontributetoimprovementsinCanadashealthsystemand thehealthofCanadians. FormoreinformationonCPHIanditspublications,pleasevisit:www.cihi.ca/cphi.
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About the Canadian Institute for Health Information
About the Canadian Institute for Health Information

CIHIcollectsandanalyzesinformationonhealthandhealthcareinCanadaandmakesit publiclyavailable.Canadasfederal,provincialandterritorialgovernmentscreatedCIHI asanotforprofit,independentorganizationdedicatedtoforgingacommonapproach toCanadianhealthinformation.CIHIsgoal:toprovidetimely,accurateandcomparable information.CIHIsdataandreportsinformhealthpolicies,supporttheeffectivedelivery ofhealthservicesandraiseawarenessamongCanadiansofthefactorsthatcontribute togoodhealth. FormoreinformationonCIHIanditspublications,pleasevisit:www.cihi.ca.
Acknowledgements
Acknowledgements
ThisreportwaswrittenbyKimRaine,JohnC.Spence,JohnChurch,NormandBoul, LindaSlater,JoshMarko,KarynGibbonsandEricHemphill.Thereportwascommissioned bytheCanadianPopulationHealthInitiative(CPHI)oftheCanadianInstituteforHealth Information(CIHI). Itshouldbenotedthattheconclusionsinthereportdonotnecessarilyreflectthose ofCPHIorCIHI. Thisreportwaspeerreviewed.
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Main Messages From State of the Evidence Review on Urban Health and Healthy Weights
Main Messages From State of the Evidence Review on Urban Health and Healthy Weights
Thisreviewrevealedthatevidenceexistsforassociationsbetweenaspectsoftheurban environmentandbehaviourscontributingtoobesity. EconomicenvironmentsForindividuals,alowersocioeconomicstatus(educationlevel, income,employment)wasoftenassociatedwithincreasedobesityamongbothadults andchildren.Forinstance,lowerpersonalincomeaffectsaffordabilityoffood,which demonstratesthemostconsistentinfluenceonfoodconsumption.Similarly,individuals livinginmiddleincometohighincomeneighbourhoodsaremorelikelytobephysically activethantheircounterpartsinlowerincomeneighbourhoods.Lowerincome neighbourhoodsarealsomorelikelytocontaingreateraccesstosourcesofenergydense foods(forexample,fastfoods)andloweraccesstosupermarketsorotherstoresstocking healthyfoods. Whatthismeansisthatinterventionsaimedatimprovingtheincomeandeducational statusofindividualsandfamilieswithinurbanenvironmentsmayhelpaddressdisparities inobesity.Also,improvingaccesstohealthyfoodsandrecreationopportunitiesinlower incomeneighbourhoodsmayhelptocreateahealthyweightfriendlyenvironment. SchoolenvironmentAlthoughschoolsarenotspecifictourbanareas,studiesfrom interventionsperformedinschools(forexample,availabilityofhealthychoicesinvending machinesorpointofpurchasenutritioninformation)showedevidenceforimproving eatingbehaviours.Allstudieshadatleastsomepositiveeffectsonfoodintake,either increasinghealthyfoodchoicesordecreasingunhealthyalternatives,thoughnoschool interventionssignificantlyaffectedbodyweights.However,itshouldbenotedthatsome studiesthathaveassessedtheimpactofschoolbasedprogramsonbodyweightsmay nothavebeenincludedinthisreviewbecausetheydidnotspecifyanurbansetting. Whatthismeansisthatcomprehensiveschoolfoodpoliciesoreducationalinterventions thatpromotehealthyfoodchoicesarelikelytohavebeneficialeffectsonchildrens eatinghabits. BuiltenvironmentThemostconsistentenvironmentalassociationsobservedforphysical activitywereelementsofthebuiltenvironment.Hallmarksofwalkability(forexample, increasedresidentialdensity,mixedusezoningandstreetconnectivity)andaccess torecreationalfacilitiesareassociatedwithhealthybodyweights.Peoplesperceptions oftheirbuiltenvironmentarealsokey. Whatthismeansisthatwalkabilityofneighbourhoodsandaccesstorecreational facilitiesinandaroundneighbourhoodsmayassistinpromotinghealthyweights. LackofinterventionevidenceVerylittleevidenceexistsfortheeffectivenessof interventionsinachievinghealthyweightsinanurbancontext.Moreevaluationsare neededtotakeintoaccountnaturalexperimentsinurbanenvironments(forexample, doestheproliferationofbicyclelanesincreasecycling?). ix
Executive Summary From State of the Evidence Review on Urban Health and Healthy Weights
Rationale and Purpose
Therelationshipbetweenurbanenvironmentsandobesityhasreceivedlittlesystematic attention.Ourpurposewastoreviewandsynthesizetheevidenceon: a) structuralandcommunitylevelcharacteristicsofurbanenvironmentsthatpromote orinhibittheachievementofhealthyweights;and b) theeffectivenessofinterventionstoassisturbanpopulationsinachieving healthyweights.
What We Found in the Literature

Wefoundprobableevidenceforassociationsbetweeneconomicsettingsandobesity. Forexample,alowerindividualsocioeconomicstatus(SES)wasoftenassociatedwith increasedobesityamongadultsandchildren(page15).Lowerpersonalincomesaffect affordabilityoffood,andaffordabilityhasthemostconsistentinfluenceonfoodconsumption. Inaddition,lowerSESindividualsreportmorebarrierstoandlessparticipationin physicalactivity. AswasthecasewithindividualhouseholdSES,neighbourhoodSESwasassociatedwith bodyweights.Forinstance,individualslivinginmiddletohighincomeneighbourhoods aremorelikelytobephysicallyactivethantheircounterpartsinlowerincome neighbourhoods.Lowerincomeneighbourhoodsarealsomorelikelytocontaingreater accesstosourcesofenergydensefoods(forexample,fastfoods)andloweraccess tosupermarketsorotherstoresstockinghealthyfoods. Theschoolenvironmentwasfoundtobeapotentialsettingforinterventionstopromote healthyeatingamongchildren.Programswithintheschoolenvironment(forexample, promotionofhealthyfoods,priceincentives)aregenerallyassociatedwithanincreased consumptionofhealthierfoods(page20). Theurbanbuiltenvironmentwasassociatedwithbothphysicalactivityandhealthy bodyweights.Studiesconsistentlyshowthatfactorsthatpromoteobesity(forexample, urbansprawl,lowintersectiondensity,lowresidentialdensity,lowlandusemix)tend alsotofavoursedentarybehaviourandlowerphysicalactivitylevels(page18).Because mostoftheevidencereviewedwascrosssectional,thissuggeststhatasupportiveurban physicalsettingmaybeadvantageous,butperhapsinsufficientbyitselftohaveasignificant impactonobesity. Cultureandethnicity(socioculturalenvironment)alsofactoredintoourfindings. AdoptionofamoreWesternlifestylehadpredominantlynegativeeffectsonfood, nutritionanddietaryhabits.Furthermore,themoreacceptingcultureswereofcars, thelesslikelytheyweretobephysicallyactive. xi
Duetoalackofsystematicstudiesinthisarea,verylittleevidencewasfoundtosupport theroleofpolicyinpromotinghealthyweights. Similartothelackoffindingsinthepolicyarea,verylittleevidencewasavailablefor theeffectivenessofinterventionsinachievinghealthyweightsinanurbanenvironment.
What We Found Talking With Experts

Agroupofattendeesofanobesitysymposiumheldin2005weresurveyedabout theelementsoftheurbanenvironmentthatcontributetohealthybodyweights.Most respondentsfeltthatthemoreimmediatebuiltenvironment(forexample,biketrails, walkingpaths)hasagreaterimpactonhealthyweightsthanbroadersocietaltrends. Whenaskedwhetherchangescouldbemadetothebuiltenvironmenttoaddressthe issueofobesity,nearlyallrespondentssaidyes.
What We Found in Policy Documents

Obesityhasbeenframedincreasinglyasaglobalthreattohealthandanepidemic. Thegrowingthreatthatoverweightandobesityposesforchildrenoftheworldhasbeen identifiedasamajorpolicyissue.Implicitintheevidenceisanincreasingrecognition ofthecomplexityoftheissueandtheneedforthecoordinatedinvolvementofarange ofpolicyactorsacrosssectorsandsettingstolinkindependentpoliciesandprocesses. Withregardtothepolicyanalysisconducted,alargenumberofpolicyresponseswere identifiedinrelationtoobesityandtheenvironment,butrelativelyfewhavebeen systematicallytested.
Comparison With Other Reviews

Whileitisdifficulttocompareresultsfromdifferentstudiesbecauseofthevariability inmethodsused,ourreviewisconsistentwithotherpublishedreviewsoftheliterature. Forinstance,inareviewofmostlycrosssectionalstudies,Boothandcolleagues38surmise thatthebuiltenvironment,mostoftenassessedattheleveloftheneighbourhood,has thepotentialtoinfluencebodyweights.Oursystematicreviewisingeneralagreement withBoothetal.;however,itisimportanttonotethatourreviewwaslimitedtourban environmentsandalargeproportionofthefindingsweidentifieddidnotreach statisticalsignificance.
Conclusion
Overall,wefoundsomeevidenceforassociationsbetweenstructuralcharacteristics ofurbanenvironmentsandhealthyweightsorthebehavioursassociatedwithhealthy weights.Perhapsthemoststrikingfindinginourreviewwasthecompletelackof evidencefortheroleofpoliticalsettingsandsectorsinrelationtoobesity/healthyweights intheurbancontext.Inadditiontoagapinknowledgeaboutthecomplexassociations amongfactorscontributingtoobesity,therealsoappearstobeaknowledgegaparound theimpactofpossiblepolicyresponses.
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Method for Literature Review

Extensivesearcheswereconductedthroughnumerousdatabasesanddocumentsacross avarietyoffields,includinghealth,socialsciences,urbanplanningandtransportation; 65,929titleswerescanned,resultinginapproximately2,349documentsbeingretrieved, with355includedinthefinalreview.Usingtwoconceptualframeworks,ANGELO (analysisgridforenvironmentslinkedtoobesity)andSDEHP(socialdeterminantsofhealth andenvironmentalhealthpromotion),alldocumentswerecodedforrelationshipsbetween typesofenvironment(physical,economic,political,sociocultural)andlevelsofenvironment (settings,sectors)andobesogenicbehaviour(diet,physicalactivity,sedentary)orbody weight.Findingsfromtheselevelsandoutcomebehavioursweresummarizedandcross tabulatedwithkeyarticlequalityindicatorstodeterminethestrengthoftheevidence gatheredforeachsection.Toassistwithputtingthefindingsintocontext,ananalysis ofpolicyrelevantdocumentswasconducted,alongwithasurveyofresearchersand decisionmakerswhoattendedathinktankonobesityinOctober2005.
xiii
Abstract
Abstract
Rationale:Todate,evidenceonstructuresofurbanenvironmentsandimplications forobesityrateshavenotbeensubjecttosystematicreview.Theevidencebaseforeffective environmentalinterventionsisevenlesswelldelineated. Purpose:Toreviewandsynthesizeevidenceona)structuralandcommunitylevel characteristicsofurbanenvironmentsthatpromoteorinhibittheachievementofhealthy weightsandb)theeffectivenessofinterventionstoassisturbanpopulationsinachieving healthyweights. Method:Extensivesearcheswereconductedthroughnumerousdatabasesanddocuments; 65,929titleswerescanned,resultinginapproximately2,349documentsbeingretrieved, with355includedinthefinalreview.Usingtwoconceptualframeworks,alldocuments werecodedforrelationshipsbetweentypesofenvironment(physical,economic,political, sociocultural)andlevelsofenvironment(settings,sectors)andobesogenicbehaviour (diet,physicalactivity,sedentarybehaviour)orbodyweight.Toassistwithputting thefindingsintocontext,ananalysisofpolicyrelevantdocumentswasconducted,along withasurveyofresearchersanddecisionmakerswhoattendedathinktankonobesity inOctoberof2005. Results:Theanalysisresultedin1,325findings,withthemajoritycomingfromresearch relatedtophysicalactivity(n=712)anddiet(n=349).Thestrongestlevelsofevidence forassociationsbetweenenvironmentsandobesogenicbehaviourorbodyweightwere observedforphysical(diet),sociocultural(diet,sedentarybehaviour,obesity/healthy weights)andeconomic(diet,physicalactivity,obesity/healthyweights)settingsand physical(physicalactivity),economic(diet,physicalactivity,sedentarybehaviour) andsociocultural(diet,physicalactivity,obesity/healthyweights)sectors.Verylittle evidenceexistedfortheeffectivenessofinterventionsinachievinghealthyweights (seetables2and3onpage27). Oftheresearchersanddecisionmakerswesurveyed,mostrespondedthaturbandesign issuesandaccessibilityofphysicalactivityandnutritionopportunities(mainlyinthe physicalsettingandphysicalsector)werethemostimportantfactorsinfluencinghealthy bodyweightsinanurbanenvironment.Respondentsalsofeltthatthesefactorscould beaddressedbypolicyresponses,butnospecificrecommendationswereprovided. Withregardtothepolicyanalysis,alargenumberofpolicyresponseswereidentified inrelationtoobesityandtheenvironment,butrelativelyfewhavebeensystematically tested.Thus,inadditiontoagapinknowledgeaboutthecomplexrelationshipsamong factorscontributingtoobesity,thereisalsoaknowledgegapabouttheimpactofpossible policyresponses. Conclusions:Someevidenceexistsforassociationsbetweenaspectsoftheurban environmentandobesogenicbehaviourand/orobesity/healthyweights,implicating interventionsinpolicyandpractice.However,lackofevidenceoneffectiveinterventions andpolicyinitiativessuggestsaneedforresearchtofillknowledgegaps. xv
Project Background
1
1.1
Project Background
Introduction
TherapidriseinobesityinCanadaoverthepasttwodecades1,2hasledtoasense ofurgencyamongpractitionersandpolicymakersaroundtheneedformoreeffective approachestoobesityprevention.Increasingly,andperhapsintuitively,publichealth researchersanddecisionmakershaveattributedtheemergingobesityepidemictorapid changesinsocialandphysicalenvironments3andhavecalledforabroadermultilevel approachtoprevention.Suchanapproachaddressespolicyandenvironmentalfacilitators ofobesogenic(obesitypromoting)behaviours(forexample,poordietandsedentary behaviour).Severalprominentresearchersmakecompellingargumentsthattheenvironment determinestheprevalenceofobesityinapopulationandthatbroadenvironmental interventionsshouldbemoreeffectivethanindividualbasedinterventionsinreducing thepopulationburdenofobesity.37Yetlittleresearchisavailableonenvironmental influencesonobesity4andthatwhichisknownisinferredfromepidemiologicaland culturalobservations.Todate,evidenceonthechangingstructuresofurbanenvironments andimplicationsforobesityrateshasnotbeensubjecttoasystematicreview.Theevidence basefortheprocessandoutcomesofimplementingeffectiveenvironmentalinterventions isevenlesswelldelineated.Itisthesegapsinknowledgethatwillbeaddressedbythis StateoftheEvidenceReview.
1.2
Statement of Purpose
Purpose:ThepurposeoftheStateoftheEvidenceReviewistoreviewandsynthesize evidencefromresearchandgreyliteratureon: structuralandcommunitylevelcharacteristicsofurbanenvironmentsthatpromote orinhibittheachievementofhealthyweights;and theeffectivenessofinterventionstoassistpopulationsinachievinghealthyweights. ThepurposefollowsdirectlyfromtheCanadianPopulationHealthInitiatives(CPHI) statedresearchquestion: Towhatextentdostructuralorcommunitylevelcharacteristicsofurbanenvironments encourageorinhibittheachievementofhealthyweights?
1.3
Conceptual Framework
TheStateoftheEvidenceReviewwasguidedbyintegratingtwoconceptualframeworks. Thefirst,suggestedbyCPHI,istheSchulzandNorthridgemodelofsocialdeterminants ofhealthandenvironmentalhealthpromotion(SDEHP).8TheSDEHPmodeldescribes fundamental(macro),intermediate(meso/community)andproximate(micro/interpersonal) levelsofinfluenceonthehealthofpopulations.Thesecond,developedspecifically forobesity,isknownasANGELO(analysisgridforenvironmentslinkedtoobesity) bySwinburnetal.7andishelpfulforunderstandingrelationshipsbetweenenvironments andobesityrelevantbehaviours(suchasfoodintakeandphysicalactivity). 1
BasedupontheEpidemiologicalTriad,thebasicpremiseoftheANGELOframework isthattheenvironmentinfluencesbodyweightthroughenergyintakeandenergy expenditure,whichSwinburnandcolleagues7callvectorsormediators.TheANGELO frameworkisa2x4griddescribingenvironmentsbysize(micro/settingsormacro/sectors) andtype(physical,economic,political,sociocultural).Withinthegrid,elementsaffecting foodintake(FI)andphysicalactivity(PA)arecharacterizedasobesogenicorleptogenic (promotingleanness).WhiletheSDEHPmodelhasnotbeenvalidatedwithrespect toobesity,itdoesprovideausefulframeworkfororganizingpotentialenvironmental determinantsofhealthstatus,includingobesity.TheSDEHPmodelisalsonotlimited todietaryandPAbehaviours.Itwasessentialthatthereviewextendbeyondananalysis ofenvironmentaldeterminantsofbehaviours,astheenvironmentmaybecontributing toobesitythroughalternate,yettobedelineatedmechanisms.TheANGELOframework iscomplementary,inthatthelevelsofinfluence(macroandmicro)arecomparabletothe SDEHPsintermediateandproximatelevelsthatCPHIhasidentifiedasmostrelevantto thereviewbecauseoftheirmodifiability.TheANGELOframeworkaddsvalidity,inthat ithasbeenpilotedatthepopulationlevel7foruseinprioritizinginterventionsbyrating forvalidity(evidenceofimpact),relevance(tolocalcontext)andpotentialchangeability.
Table1 Environmental Physical Size/Type Settings (communitylevel) Accessibility to food service outlets (for example, restaurants) Accessibility to food retail opportunities (for example, supermarkets) Economic Affordability of food service outlets Political Socio-Cultural
Conceptual Framework for Review
School food Acceptability or physical activity of active policies transportation (cycling, walking) Work-site food Family role or physical activity models for food policies and activity patterns Availability of health-related services Ethnic and cultural demographics of neighbourhoods Crime and safety
Affordability of food retail opportunities
Accessibility to Affordability of recreational facilities recreational facilities Number and quality of walking paths and cycleways Availability of transit and transit stops
Direct marketing Civic participation of food products in schools (for example, vending machines) Neighbourhood socio-economic status (income, education, employment) Market forces (for example, food production, distribution, price) Socio-economic equity
Sectors (structural)
Urban design
Globalization
Technology and automation Transportation systems
Taxation and subsidies (food price structure) Funding for education, health and social service systems
Cultural acceptability of overweight Media/advertising
Project Background
Sinceeachframeworkusesslightlydifferenttermstoidentifylevelsofenvironmental influence,wehavechosentouseclearlanguagewithtermsthataredescriptivetoawide varietyofstakeholders.Thus,ANGELOsmicroandSDEHPsproximatelevels arenowtermedsettingsandrefertoindividualandcommunitylevelenvironments. Settingsareusuallygeographicallydistinct,arerelativelysmall,andarepotentially influencedbyindividuals.7Similarly,ANGELOsmacroandSDEHPsintermediate levelsarenowtermedsectorsandrefertomorestructuralenvironments(Table1). Ingeneral,sectorsarecommontothewiderpopulation,oftenoperatingatregional, national,andinternationallevels,andtendtobegeographicallydiffuse.7
Methodology
Methodology
ThisStateoftheEvidenceReviewencompassedthreecomponents.First,asystematic reviewofpublishedandgreyliteraturewasconducted.Second,policyrelevantdocuments werereviewedtogetasenseofthepolicycontextinwhichurbanenvironmentalinfluences ofobesityoperate.Third,relevantdecisionmakerswereconsultedtogathertheirinput onthereviewandhowitsfindingsmayrelatetocurrentpoliciesandpractice.
2.1
Systematic Literature Review
Thesystematicliteraturereviewtookplaceinseveralstages,progressingfrominitial literaturesearchestoarticleassessments.Thelargevolumeofliteratureretrievedduring thesearchesnecessitatedamultistagescreeningprocess,graphicallyrepresentedbythe projectflowchartinAppendixA.
2.1.1 LiteratureSearchStrategy
Thefirststageofthesystematicreviewwastoidentifyappropriateliteraturedatabases tosearch.UtilizingtheexpertiseofLindaSlater,alibrarianskilledinliteraturesearch techniquesandstrategies,appropriatebodiesofliteraturewereidentified.Asearch ofmanydatabaseswasconductedtoidentifystudiesaddressingtheresearchquestions. Databasesweresearchedfromthedateoftheirinception(forexample,MEDLINE from1966andEMBASEfrom1998)untilAugust31,2005.Specifically,allresearchthat measuredassociationsand/ortestedinterventionsbetweenintermediateandproximate factorsofurbanenvironmentsandbehaviours(foodintake,physicalactivity,sedentary behaviour)and/orbodyweightweresought. Keywordsincludedbodyweight,obesity,physicalactivity,diet,food,urbanandpolicy,along withtermsrelatedtotheurbanenvironment(forexample,transportation,socioeconomic status).RefertoAppendixBforanexampleofadetailedsearchoftheMEDLINE/HealthStar literaturedatabase.Thefollowingdatabasesweresearched: CochraneDatabaseofSystematicReviews CochraneControlledTrialsRegister ACPJournalClub CampbellCollaboration MEDLINE EMBASE CINAHL HealthPromis(NHSPublicHealth/HealthPromotiondatabase) HealthStar CABAbstracts AGRICOLA BiologicalandAgriculturalIndex
FoodScience&TechnologyAbstracts SociologicalAbstracts SportDiscus WebofScience PsycINFO ERIC Enviroline GreyLiteratureDatabases: OCLCProceedingsFirst OCLCPapersFirst DissertationAbstractsInternational ConferencePaperIndex U.S.GPO(U.S.governmentpublications) CanadianResearchIndex(Canadiangovernmentpublications) OCLCWorldCat(unioncatalogueofmajorresearchlibraries) GoogleScholar TRIS(TransportationResearchInformationServices) Inadditiontodatabasesubjectsearches,thefollowingtaskswereundertakentoidentify additionalrelevantstudiesnotretrievedinthedatabasesearches: citationsearchesonWebofScienceforidentifiedexpertsinthearea,todetermine whattheyhavepublishedandrelatedpaperswheretheyhavebeencited;and examinationofreferencelistsandbibliographiesofidentifiedstudiesandreviews forpotentiallyrelevantstudies. Recordsreturnedfromtheliteraturedatabasesearchesweredownloadedintoareference managerprogram(ProCite)andcataloguedbyliteraturedatabase(forexample, MEDLINE,EMBASE).
2.1.2 LiteratureTitleScan
Thesecondstageofthesystematicreviewinvolvedatitlescantoreducethevolume ofarticlesretrievedfromtheliteraturesearches.Articletitleswereassessedagainst thereviewspurposestatement,aswellasthemorespecificreviewcriteriacontained inAppendixC.Becauselimitedinformationcouldbegleanedfromthearticletitles,only thosethatwereobviouslyunrelatedtothereviewpurposewereeliminated.Allothers withkeywordsrelevanttothepurposeofthesystematicreview(forexample,urban environment,obesity)wereretainedandreviewedinfurtherdetail.
Methodology
2.1.3 LiteratureAbstractScan
Thethirdstageofthesystematicreviewinvolvedexaminingtheabstractsofeacharticle todetermineifthearticlefitintothestatedreviewcriteria.Articlespassingthrough thisstagewererequiredtofulfillthreecriteria,listedasStep1onthearticlecodingform (AppendixC).Allarticlesthatdidnotfulfilloneormorecriteriawereimmediately droppedfromconsideration. Thefirstcriterionwaswhetherthearticleincludedoneormoreofthefourmajortopics fallingunderthereview:obesity/healthyweights,food/diet/nutrition,physicalactivity andsedentarybehaviour.Thearticlemusthavehadoneormoreofthesetopicsaseither themainrationaleforthearticleorasamajorfindingwithinthepaper. Thesecondcriterionassessedwhetherthearticleinvolvedanyenvironmentalsectorsor settingspertinenttothereview.Morespecifically,thestudyneededtobeframedwithin oraroundoneormoreoftheeightsectorsorsettingsprofiledinTable1. Finally,thethirdcriterionwaswhetherthearticleinvolvedanurbanenvironmentina developedordevelopingcountry.Forthepurposesofthisreview,anurbanenvironment wasdefinedashaving...aminimumpopulationconcentrationof1,000personsand apopulationdensityofatleast400personspersquarekilometre,basedonthecurrent censuspopulationcount.Anyterritoryoutsideofurbanareasisclassifiedasrural.9 Becausetherearemanydifferentdefinitionsofurbanandruralaroundtheworld, thisdefinitionwasusedasaguideratherthananabsolutestandard.Literaturehadtoreport ondatacollectedinanurbanenvironmentorprovidebreakdownsofdatasothaturban specificfindingswereapparent.Informationonthebroaderstudysettingwasrarelygiven, unlessitwasamajorpartofthearticleitself;therefore,inthemajorityofcases,reviewers deferredjudgmentofthiscriteriontowhatwasstatedbytheauthorsofthearticle. Therelativelyopenendedsearchstrategyundertakeninthisreviewresultedinarticles ofmanydifferentformatsbeingretrieved.Manyofthearticles,suchastechnicalreports orolderjournaltitles,didnothaveabstractstobescanned.Thisrequiredthatthearticle befoundinitsentiretyandsubjectedtothesameassessmentproceduredetailedabove.
2.1.4 LiteratureFullReview
Thefullreviewofthefinalliteratureselectionsinvolvedtwodistinctprocesses.Thefirst processentailedpullingindividualfindingsfromeacharticleunderreview,withthecoded findingsthenbeingcompiledandanalyzed.Thesecondinvolvedassessingtheindividual articlesforquality,includingratingsofseveralcriticalarticlefeaturesandcodingofthe studydesign.Thisallowedtheauthorstomakeaqualifiedassessmentastothestrength ofthefindingsinanytopicarea.Becausestudiesoftencontainedfindingsonmorethan onetopicareaand/orcontainedmultiplefindingswithinatopic,thefindingratherthan thestudywastheunitofanalysisinthisreview.
CodingArticleFindings
Toprovideasummaryofwhatisknownandunknownabouttheassociationbetween theurbanenvironmentandhealthyweights,findingsandothercharacteristicswere codedandsubjectedtoafrequencyanalysis.Articleswerecodedforcharacteristics ofthesamplepopulation,environmentsizeandtype,directionoffinding/outcome, studydesignandstudyquality(seeAppendixC). CharacteristicsofthesamplepopulationAgegroup,ethniccharacteristicsandgender werecodedwitheachfinding. EnvironmentsizeandtypeAccordingtotheANGELOgrid,theurbanenvironment elementsintheliteraturewerecodedforthesize(settings,sectors),type(physical, economic,political,sociocultural)andspecificfeature(forexample,transportation). Directionoffinding/outcomeThedirectionoftheassociationoreffectwascoded asfollows: 0=noassociation 1=inverseassociation 2=directpositiveassociation 3=ushapedassociation Thenumberoffindingsreportingaparticularpatternwerethencounted.Thisissimilar toaprocedureusedbySobalandStunkard10inareviewofsocioeconomicstatus andobesity. DesignThedesignofthestudywasratedaccordingtocategorizationsofevidence presentedbyPhilp:11 A1=Systematicreviewswhichincludeatleastonerandomizedcontrolledtrial A2=Othersystematicandhighqualityreviews B1=Individualrandomizedcontrolledtrials, randomizedexperimentalstudies B2=Nonrandomized,experimentalstudies B3=Welldesigned,nonexperimentalstudies,controlledstatisticallyifappropriate; alsoincludewelldesignedqualitativestudies C1=Descriptiveandotherresearch(forexample,conveniencesamples)notinB C2=Casestudiesandexamplesofgoodpractice Thisapproachwasadoptedbecauseitallowsstudieswithdifferentdesigns,including systematicreviewsandqualitativestudies,tobeincludedinthesameanalysis.Itisalso consistentwithaframeworkthathasbeenproposedfortranslatingobesityrelated evidenceintoaction.12
Methodology
ArticlefeaturequalityBaseduponthenumberofthreatstointernal/externalvalidity, thestudieswereratedforquality.Thisissimilartotheapproachusedinthesystematic reviewspresentedintheGuidetoCommunityPreventiveServices.13Aselectionoffourcriteria (method,sampling,analysisandresults)wasexaminedtoallowanassessmentofquality acrossthisbroadrangeofstudytypesanddesigns.14Thecriteriawereratedonafourpoint scalerangingfromGood(1)toVeryPoor(4).Theratingswerethensummedacross themajorarticlefeaturesandthestudiesrankedaccordingtotheirrelativescore.Astudy wasdeemedtobeofgoodqualityifitachievedascoreof4or5,offairqualityifitreceived ascorebetween6and8,andofpoorqualityifithadascoreof9ormore.Thisprocess allowedtherelativestrengthofthefindingsineachareaoftheanalysistobeassessed.
Reliability
Severalstepswereundertakentoensurethefidelityofthefindingsofthisreview.All membersoftheresearchteam,alongwithseveralresearchassistants/coders,metonseveral occasionstodevelopanddiscussthecodingscheme.Thisallowedforthecoderstobecome intimatelyfamiliarwiththesystem,andtodevelopanawarenessoftheexpectations oftheinvestigators.Second,codersmetwiththeresearchcoordinatoronfourseparate occasionstocontinuetopractisecoding.Duringthesemeetings,issueswerediscussed andthecodingmechanismfinetuned.Oncethegroupshowedconsistency(thatis,more than90%correctcoding),theybeganreviewingstudies.Throughoutthecodingprocess, biweeklymeetingswereheldtosharetheexperiencesofthecodersastheyprogressed throughtheirwork.Codersfrequentlycommunicatedwiththeresearchcoordinator toensurethataconsistentsolutiontoanycodingissuewasprovided.Ascodingresults weresubmitted,theresearchcoordinatormanuallycheckedeachfindingasitwasentered intotheoverallreviewdatabasetoensureitsvalidity.Anyerrorswereeithercorrected immediatelyordiscussedwiththecodertodeterminethecorrectvalue.
DescriptionofAnalysis
Thearticlescollectedinthisreviewfocusedonfourbehaviour/outcomevariables: food/diet/nutrition,physicalactivity,sedentarybehaviourandobesity/healthyweights. Underfood/diet/nutrition,reviewerswereinterestedinvariousaspectssurroundingthe relationshipbetweenfoodandtheenvironment,suchasthemediatingeffectofaspecific settingondietaryoutcomesandnutrition.Physicalactivityincludedarticlesexploring environmentalfeaturesasbarrierstoorfacilitatorsofbeingphysicallyactive,asdid thoseforsedentarybehaviour.Finally,literatureintheobesity/healthyweightssection concentratedontheeffectofenvironmentalcontextsonbodyweightorbehavioursthat arespecificallytiedtoabodyweightoutcome. Basicfrequencycountswerecalculatedforallcodedvariables,includingdemographic characteristics,settings/sectors,specificenvironments,studydesignandquality,and findingdirections,asdescribedabove.Thesefrequenciesweretalliedatfourlevels: overallresults(allfindings);foreachbehaviour/outcomevariable;foreachsettingand sectorwithineachofthesebehaviour/outcomevariables;andforeachspecificenvironment withineachsettingandsector.Theoverallresultsincludeallfindingsandindicatetrends 9
atamoregenerallevel;forexample,whataresomeofthespecificpopulationsthatare assessedbythistypeofresearch?Atthebehaviour/outcomelevel,trendswithineach ofthefouroutcomegroupscanbeexamined,whilenumbersatthesetting/sectorlevel begintoprovideanindicationofwheretheenvironmentbehaviourinteractionsaretaking place.Dataatthespecificenvironmentallevelallowaglimpseintotheontheground observationsandinterventionsthatresearchershavedocumented.Asresultsareviewed acrossthesefourlevels,patternsconcerningthedistributionofpopulations,broadand specificenvironmentsandtypesofstudiescanbedetermined. Crosstabulationswereperformedtoelicitmorespecificinformationaboutthe associationsbetweenkeyvariablesatvariouslevelsofanalysis(seeFigure1).Specifically ofinteresthereweretheassociationsbetweentheenvironmentsfoundintheliterature andthebehaviours/outcomesoutlinedabove,aswellastheassociationsbetweenthese environmentsandbodyweight.Offurtherinterestweretheassociationsbetween behaviours/outcomesandbodyweightwithintheseurbanenvironments.Crosstabulations werecalculatedwithinandbetweenseverallayersofdata,toilluminateanyassociations therein;forexample,thequalityofthestudiesexaminingthephysicalsettingwithinthe food/diet/nutritionoutcomeorthedirectionoffindingsrelativetothespecificenvironments foundwithinasectorofthephysicalactivityoutcome.Thedetailthatthesestatistics provideisessentialtounderstandingtheinteractionsbetweenthemanycharacteristics andthemanyenvironmentallevelsatwhichtheyinfluencebehavioursandbodyweights.
Figure1
Theoretical Model
10
Methodology
LevelsofEvidence
Onceallstudieshadbeencodedandcheckedforreliability,thosethatwereratedas eitheranAorBundertheStudyDesignsectionoftheassessmenttool,andratedfair orgoodaccordingtothequalityratings,wereaggregatedaccordingtothedirection ofthefindings/outcomeandwithinthevariouslevelsoftheenvironment(settingsand sectors).Then,adeterminationofourconfidenceintheevidencewasmadeasfollows: convincing,probable,possible,insufficientornoevidence.Thesecategoriesforlevelsof evidencearesimilartothosedevelopedbytheWorldCancerResearchFund/American InstituteforCancerResearch15andrecentlyadaptedbySwinburn,Caterson,Seidelland James16inareviewofnutritionandobesity.Levelsofevidenceweredeterminedattwo differentlevelsoftheenvironment:size(settings,sectors)andtype(physical,sociocultural, political,economic).
2.2
Stakeholder Survey (Informed Opinion)
Swinburn,GillandKumanyika12identifyinformedopinionofpractitioners,stakeholders andpolicymakersabletoinformjudgmentsonimplementationissuesasanimportant typeofevidence.Althoughinformedopinionispartlyrepresentedinpeerreviewed andgreyliterature,werecognizethatlimitingthereviewtopublishedliteraturewillalso limitaccesstotheexperienceandopinionsofdecisionmakers.Inordertoaddressthis weaknessofaliteraturereview,weconductedanonlinesurveywithkeystakeholders, decisionmakersandpolicymakersacrossCanada. Informedopinionwassoughtrelativetothefollowingissuesandimpliedquestionsas delineatedbySwinburnandcolleagues:12a)pointsofintervention(whatenvironmental factorsarepotentiallymodifiable?);b)rangeofopportunitiesforaction(whatarecurrent relevantinitiativesthatimplymodifiableandfeasiblestrategies?);andc)selectionofa portfolioofspecificpolicies,programsandactions(whatinitiativeswouldbeachievable andhaveimpact?).Specifically,wesolicitedinformedopiniononspecificinterventions andactionswithrespecttothefollowing: feasibility sustainability otherpotentialpositiveornegativeeffects acceptabilitytostakeholders Keystakeholderfiltercriteriaprovideimportantqualitativecontexttocategorizing promiseforpotentialinterventions.12
11
StakeholderswhoattendedAddressingObesityinCanada:AThinkTankonSelectedPolicy ResearchPrioritiesinToronto,Ontario,inOctober2005werecontactedtosolicittheir participationinanonlinesurvey.Thisthinktankwasattendedbyover90researchers anddecisionmakersandwashostedbytheHeartandStrokeFoundation,theCanadian PopulationHealthInitiative(CPHI),theCanadianInstitutesofHealthResearch(CIHR) andtheChronicDiseasePreventionAllianceofCanada(CDPAC).Anemailletterwas senttoallthosewhoattendedthesymposium.Anintroductiontoourstudywasmade inaletter,andaURLlinkwasprovidedalongwithaninvitationtofilloutanonlinesurvey. Thequestionnairecomprisedfourquestions: 1. 2. 3. 4. Fromyourperspective,listupto3(three)factorsthataremostlikelytohave animpactonhealthyweightsinanurbanenvironment. ArethefactorslistedinQuestion1modifiablebyapolicyresponse?Pleasechoose yes,no,ornotsureforeachfactorthatyoulistedinQuestion1. Listupto3(three)policies/programs/initiativesthatyouknowofthatexistin/for urbanareastoassistpopulationsinachievinghealthybodyweights. Areyouawareofevidenceregardingthecosteffectivenessofthepolicies/programs/ initiativesyoulistedinQuestion3?Pleasechooseyes,no,ornotsureforeach itemyoulistedinQuestion3.
ThefullsurveyasitappearedonlineisinAppendixD.Ethicsapprovalforthesurvey wasobtainedfromtheUniversityofAlbertaHealthResearchEthicsBoard.
12
Results
3
3.1
Results
Literature Search and Review Process
Therawliteraturesearchesrevealed65,929articlesthatfitthesearchcriteria.Following thetitlescan,16,967articlesremained(approximately25%ofthetotal).Theabstract scanstheneliminatedafurther86%ofthesearticles,resultingin2,349thatwerekept. Ofthese,manyrequiredfollowup(thatis,thefullarticlewasretrievedandrereviewed) toverifytheirinclusion,simplybecauseabstractswereoftenlimitedintheinformation theyprovided.Oncethefollowupswerecompleted,608articlesremainedandwere submittedforfullreview.Ofthe608articles,355articleswereultimatelykeptandassessed followingthefullreviewprocess(seeAppendixEforalistofliteratureincludedinthe dataanalysis).
3.2
Data: Obesity/Healthy Weights
3.2.1 OverallFindingsforObesity/HealthyWeights
Oursystematicreviewidentified89articlesmeetingtheinclusioncriteriaandaddressing outcomesrelatedtoobesityorhealthyweights.Thesearticlesincluded228findingsthat werecategorizedintermsofthepreviouslydescribedsettingsandsectors.Thefollowing sectionswilloftenrefertotheprevalenceofobesityasanoutcomeofinterest.However, itisimportanttonotethatmanystudiesuseddifferentcutoffsoractuallymeasuredthe prevalenceofoverweightorpresentedchangesinbodymassindex(BMI)asacontinuous variable.Consequently,theexpressionprevalenceofobesityisusedasacommon expressioninordertosimplifythereadingofthesesections. Mostofthefindingswerecategorizedasbeingpartofthemicroenvironmentallevel, includingtheeconomicsetting(27%),thephysicalsetting(24%),thesociocultural setting(14%)andthepoliticalsetting(3%);otherswerecategorizedatthemacro environmentallevel,includingtheeconomic(23%),sociocultural(7%)andphysical(3%) sectors.Nostudieswerecategorizedinthepoliticalsector. Overall,thefindingswerebasedonasimilarproportionofmalesandfemales(males only=20%,femalesonly=23%,both=38%),andthemajorityofstudies(65%)didnot specifytheethnicityofthepopulation.Therewasnonethelesssomespecificattention towardsminorities,with11%and8%ofthefindingsrelatedtoAfricanAmericansand Latinos/Hispanics,respectively.Approximately50%ofthestudiesaddressedobesity andhealthyweightsinadultsand38%specificallyconsideredchildrenoradolescents.
13
3.2.2 TheInfluenceofthePhysicalSettingandSector onObesity/HealthyWeights

Ahighproportion(47%)ofstudiesonthephysicalsettingfoundnosignificantassociation withobesityorhealthyweights.Thosestudiesthatdescribedasignificantassociation(53%) weresplitevenlybetweenapositive(27%)andnegativeassociation(25%).
BuiltEnvironmentandLandUseMix
Approximatelyhalfofthephysicalsettingfindings(57%)wererelatedtothebuilt environment,suchasintersectiondensity,residentialdensityandlandusemix.Most ofthesefindingscomefromthreestudies.1719Theinconsistenciesintheresultsmentioned previouslycaninpartbeexplainedbyethnicity19orbysex.17Inthisregard,itmay beverydifficulttogeneralizetheresultsofindividualstudies.Forexample,inastudy byFranketal.19basedonacrosssectionalstudyofthecityofAtlanta,agreaterlanduse mixamongresidential,commercial,officeandinstitutionalwasassociatedwithalower prevalenceofobesityamongCaucasians,butdidnotreachstatisticalsignificanceamong AfricanAmericans.Thisstudyalsosuggestedthathigherresidentialdensityand intersectiondensitywereassociatedwithareducedprevalenceofobesity.Itwasproposed thattheseassociationswithobesityaremediatedbygreateramountsofwalkingperday andlesstimespentinacar.Surprisingly,otherstudieshaveshownthataccesstoacar isassociatedwithalowerprevalenceofobesity.20However,asdiscussedinthefollowing sectionontheeconomicsetting,thismayberelatedtosocioeconomicstatus(SES).
WalkabilityandAvailabilityofFacilities
Elevenfindingsfromfivestudies2024weresomewhatequivocalintheirsupportforthe associationbetweenbodyweightandwalkabilityandaccesstofacilities.According toastudyinvolvingfocusgroups,23anotherelementofthephysicalsettingthatcould influencechildrensBMIsinurbansettingswasthepresenceofasafeplacetoplay inlowincomeneighbourhoods.Ontheotherhand,acrosssectionalstudyinCincinnati21 foundnoassociationbetweenchildoverweightandproximitytoplaygrounds,proximity tofastfoodrestaurantsorlevelofneighbourhoodcrime.
SchoolEnvironment
Withintheschoolenvironment,16findingsfromninestudies(forexample,Arbeitetal.,25 Anderson,ShapiroandLundgren,26Robinson27andSahotaetal.28)wereidentified.The majorityofthesefindings(63%)revealednoassociationbetweentheenvironmentandobesity. Forinstance,Arbeitetal.25foundthattheHeartSmartcardiovascularschoolhealthpromotion program,whichincludedchangesincurriculum,schoollunchesandphysicaleducation, resultedinnooverallchangeinBMI.Thestrengthsofthisstudyincludeitsrandomizeddesign (schoolsweretheunitofrandomization).However,childrenwhoshowedimprovements ineatingchoicesandinfitnessexperiencedgreaterimprovementsincardiovascularrisk factorssuchascholesterol.25Whilefewstudieswerefoundinthiscategory,itisimportant tonotethatseveralotherstudieshaveassessedtheimpactofvariousschoolbasedprograms onBMI.Thesestudieswerelikelynotretrievedbyoursearchstrategyforavarietyof reasons,includingthefactthattheydidnotspecifyanurbansetting. 14
Results
Fewfindingswereavailabledescribingtheassociationbetweenobesity/healthyweights andthephysicalsector.SixofthesevenfindingsinthissectorcamefromastudybyLopez.29 Thedatainthisstudywerebasedonsprawlindexvaluescalculated,accordingtothe 2000census,forover300metropolitanareasacrosstheUnitedStates.Aftercontrolling forgender,age,race/ethnicity,incomeandeducation,anincreaseinurbansprawlwas associatedwithanincreasedprevalenceofoverweightandobesity.29
3.2.3 TheInfluenceoftheEconomicSettingandSector onObesity/HealthyWeights

Withintheeconomicsetting,almostall(87%)ofthefindingswereclassifiedassome combinationofSES,income,educationoremploymentstatus.Ingeneral,studiessuggested thatneighbourhoods,municipalitiesorareascharacterizedasdeprived3032orlowSES3336 haveagreaterprevalenceofoverweight/obesity.Somefoundthisassociationstronger infemalescomparedtomalesandinolderadultscomparedtoyoungeradults(cutoffwas 49yearsofage).32Ourreviewisconsistentwiththeinterpretationoftheliteraturebytwo recentreviewarticles.37,38Infact,Boothetal.38suggestthatlowerSESneighbourhoods areaprimaryconcern(p.S116)inrelationtoobesity. TherelationshipbetweenlowerSESandanelevatedBMIhasalsobeenobservedin youngchildrenandadolescents.3942OfparticularinterestintheCanadiancontext,Moffat andcolleaguespresentedtheresultsofastudyconductedinHamilton,Ontario,among children(ages6to10years)attendingelementaryschoolsinthreeneighbourhoodsdiffering bySES.41ThisstudyrevealedthatinthetwolowSESschoolscomparedtothehighSES school,therewereapproximatelytwiceasmanychildrenintheoverweight/obesecategory.41 However,thereissomeevidencethatthismaynotbeauniversalfinding.Forexample, amongasampleofchildrenlivingintheMexicoCityarea,thoselivinginamiddleincome townhadahigherriskofbeingobesewhencomparedtothoselivinginalowincometown.43 AsfortheSESfindings,educationalsodemonstratedconsistentassociationswithobesity withintheeconomicsector.AlowereducationlevelwasassociatedwithhigherBMI, independentofotherSESfactorsamongSwedishadults.44Parentaleducationlevelalso appearstobeapredictorofobesityinyoungadulthood.45 Aninconsistentpatternoffindingsisobservedforeconomicsectorvariablesinassociation withobesityandhealthyweights.Tenof53findings(19%)presentedapositive(beneficial) associationwithobesity,while21(40%)showedanegativeassociation.Theimpact ofSESandsocialpositionisevidentattheeconomicsectorlevel,withapproximately halfofthefindings(52%)suggestingasignificantnegativeassociation.Asopposedtothe settinglevel,SESinthesectorlevelreflectstheSESofacommunityorneighbourhood andnotindividualSES.
15
3.2.4 TheInfluenceofthePoliticalSettingandSector onObesity/HealthyWeights

Fivestudieswithatotalofsevenfindingswereclassifiedinthepoliticalsetting.Five ofthesevenfindings(71%)werecategorizedashavingnosignificantassociationwith obesityandhealthyweights.Thetwootherfindingswerefromaworkplace46andaschool intervention47andsuggestedpositiveassociationswithobesityandhealthyweights. Apreviousreviewarticle48identifiedcommunitybasedinterventionsaimedatcontrolling cardiovasculardiseaseriskfactorssuchasbodyweight,includingtheNorthKareliatrial inFinland,theStanfordthreecommunityandtheStanfordfivecommunitystudies,the MinnesotaHeartHealthProgramandthePawtucketHeartHealthProgram.According tothisreview,sometrialsreportedpositiveresultsforchangeinbloodpressureor cholesterol,butnoneshowedaconvincingeffectonobesity. Nostudiesonthepoliticalsectorwereidentified.
3.2.5 TheInfluenceoftheSocioCulturalSettingandSector onObesity/HealthyWeights

Similartostudiesonthephysicalsetting,studiesonthesocioculturalsettingpresenta broadrangeoffindings.Atotalof33findingswereextractedfrom14studiesinrelation tosocioculturalsettings.Amongthesefindings,approximately30%showednosignificant associationwithobesityorhealthyweights. Theevidencefortheinfluenceofethnicityorculturalassimilationonobesityandhealthy weightswasequivocal.Insomestudies,beingAfricanAmerican49orMexicanAmerican17 wasassociatedwithahigherprevalenceofobesity.Theroleofassimilation(alsodescribed asacculturation)andfamilyattitudetowardsassimilationasapredictorofobesityhas alsobeenexamined.CulturalassimilationwasassociatedwithmoreobesityinMexican Americanmen,whereastheoppositewastrueinMexicanAmericanwomen.17Another studysuggestedthattheassociationbetweenacculturationandBMIisweakandsubject toculturaldifferences.50 Thefindingsfromthesocioculturalsettingthatshowedthemostconsistentassociations withobesityareonesrelatingtoadvertisingandthemedia.Oftheninefindingsin advertisementandmedia,sevenindicatedasignificantpositiveassociationwithobesity whiletwosuggestednoassociation.Theseninefindingshavebeenextractedfrom twostudies.51,52Televisionadvertisementcanfavouranincreasedconsumptionoffood, particularlyinoverweight/obesechildren.52Ontheotherhand,televisionandthemedia alsohavethepotentialtohaveapositiveimpactonbodyweight.Inonestudy,ashort termmassmediaprogramcombinedwithselfhelpmanualsandsupportgroupsled tosignificantshorttermweightloss.51However,itisimportanttonotethatthemedia interventionalonewasnotsuccessful.
16
Results
Onlyonestudyaddressedthenotionofsafety.21Inthisstudyofurban(Cincinnati) lowincomepreschoolers,overweightwasnotassociatedwiththelevelof neighbourhoodcrime.21 Althoughfewerstudieswereavailableforthesocioculturalsector,mostfindings(94%) werestatisticallysignificant.Eightstudieswereidentifiedinthesocioculturalsector, withatotalof17findings.Thesefindingsindicatethatloweducationlevelinadults,53 lowparentaleducationlevelinchildren,54greatertelevisionviewing,55moresedentary leisure23andMexicanAmericanethnicity56wereassociatedwithahigherprevalence ofoverweightorobesity.
3.2.6 BehavioursinRelationtoObesity/HealthyWeightsWithin UrbanEnvironments

Sections3.2.1to3.2.5providedanoverviewoftheinfluenceoftheurbanenvironment onobesityorhealthyweights.However,changesinbodyweightdonotoccurinisolation; theyoccurasaresultofchangesinenergybalance(energyintakeversusenergy expenditure).Althoughothervariablescaninfluencethisequilibrium,physicalactivity andnutritionbehavioursarethemainvariablesofinterest.Thepresentsectionwill describetheenvironmentalinfluencesonobesitywhileconsideringthepotentialmediating (explanatory)roleofphysicalactivity,sedentarybehaviourorfood/diet/nutrition behaviourswithinthesamestudy.Thestudydesignsdonotallowtheestablishment ofacausalrelationshipbetweenbehaviourandobesityoutcomes. Only36studiesincluding185findings(approximately14%ofthetotalnumberoffindings) consideredobesityoutcomesaswellasbehaviouraloutcomes.Comparedtothosestudies andfindingsthatdidnotincludeweightandbehaviours,thefindingsfromcombined studiesweremorelikelytobeexperimental(27%versus12%,2[3,1340]=43.02,p<0.0001) andtoshownoassociation/effectbetweentheenvironmentandbodyweight(47%versus 30%,2[3,231]=7.84,p=0.05). Severalofthesestudieswereconductedinschoolsettings.HeartSmart,KnowYourBody andChildandAdolescentTrialforCardiovascularHealth(CATCH)arethreewellknown schoolinterventionstudies.25,5761Allthreeoftheseinterventionshadaphysicalactivity andnutritioncomponentwithsignificantchangestotheschoolcurriculum,whilesome alsointegratedtheparentsandschoolfoodservicesintotheintervention.Ingeneral, thesestudiesfoundnosignificantimpactonobesity,despitesignificantimprovementsin thechildrensbehavioursandknowledge.Thelargerandmoreconsistentimprovements inbehaviourseemtohaveoccurredfornutritionalbehaviours. OtherstudiesconsideredtheroleofSESinrelationtoobesityandbehaviourrelated outcomes.Forinstance,lowerparentalsocialclasswasassociatedwithlowerphysical activityandgreaterobesityinadolescents;theseassociationsgenerallyremainedthrough theadolescentstransitionstoyoungadulthood.62InotherstudiesthatfoundlowerSES tobeassociatedwithagreaterprevalenceofobesity,membersoflowerSESgroupswere lesslikelytomaintainahealthydietandparticipateinphysicalactivity.36,63 17
Severalstudiesexaminedtheinfluenceofurbandesignonbehaviourandobesity outcomes.19,20,25,64,65ApartfromthefindingsofKellySchwartzetal.,65thesestudies consistentlyshowedthatfactorsthatpromoteobesity(suchasurbansprawl,lowintersection density,lowresidentialdensityandlowlandusemix)tendalsotofavoursedentary behaviourandlowerphysicalactivitylevels.Itisimportanttoreemphasizethatalthough behavioursandobesitymayberelatedtoeachother,thedirectionoftherelationship (obesityleadstomoresedentarybehaviourorsedentarybehaviourleadstoobesity) aswellasthecausalityoftherelationshipcannotbeestablishedfromthesestudies.
3.2.7 SummaryofObesity/HealthyWeights
Insummary,whilemostfindingsarederivedfromcrosssectionalstudies,someofthe associationsbetweentheurbanenvironmentandobesityappeartobemoreconsistentthan others.AlowerSEShasconsistentlybeenshowntobeassociatedwithincreasedobesity inadultsandinchildren.However,notsurprisingly,nostudieshaveassessedtheimpact ofaninterventiontoimproveSESonobesity.ThereforeacausalrelationshipbetweenSES, perse,andobesitycannotbeestablishedordenied.Althoughfewstudiesareavailable tosupportthis(forexample,Ersoyetal.36),itappearsthattheinfluenceofSESonobesity canbemediated,atleastinpart,bybothphysicalactivityandnutritionbehaviours.63 Whilemanystudiesexaminedthephysicalandsocioculturalsettings,thefindings varied,withagreaterthanexpectedproportionofnonsignificantassociations(30%). Someofthemorecommonlyobservedsignificantassociationswithobesitywererelated tothebuiltenvironment(forexample,intersectiondensity,landusemix)andtheuse ofmedia/advertising.Wefoundlittleevidencetosupportschoolbasedinterventionsfor thereductionofobesity,eventhoughtheseinterventionsmayimprovephysicalactivity andnutritionbehaviours.Furthermore,althoughethnicityandthedegreeofacculturation maybeassociatedwithobesityinsomecases,thisassociationhasnotconsistentlybeen observed.Fewstudieswereavailableonthepolicysetting/sector. Althoughlittleexperimentalevidenceexiststosupportthisnotion,interventionsaimed atimprovingSESandeducationlevelsmayhelpaddressdisparitiesinobesity.Furthermore, thereseemstobeaneedforabetterunderstandingofhowtheinfluenceoftheurban environmentresultsinchangesintheprevalenceofobesity.Thismaybeparticularly truefortheschoolsetting,whereseveralinterventionshaveimprovedphysicalactivity andnutritionknowledge/behaviourswithouthavingasignificantimpactonobesity.
18
Results
3.3
Data: Food, Diet and Nutrition
3.3.1 OverallFindingsforFood,DietandNutrition
Overall,349findingsfrom147studiesinvolvedassociationsbetweenurbanenvironments andfood,dietandnutrition. Mostoftheliterature(77%)dealtwithmicroenvironments(settings).Only80findings (23%)addressedmacroenvironments(sectors).Socioculturalenvironmentswere exploredmostfrequently(43%),followedbyeconomicenvironments(32%),physical environments(22%)andpoliticalenvironments(3%). Overall,thefindingswerebasedonasimilarproportionofmalesandfemales(males only=14%,femalesonly=19%,both=40%,notspecified=28%).Thelargestproportion ofstudyfindingsaddresseddietandnutritionbehaviourinadults(47%),including7% inolderadults.Anadditional36%offindingsaddresseddietandnutritionbehaviour inchildrenandyouth,includingyoungchildren(17%)andadolescents(19%). Themajorityoffindings(71%)didnotspecifytheethnicityofthepopulationstudied. Therewasnonethelesssomespecificattentiontowardsminorities,with12%and6% ofthefindingsspecificallyrelatedtoAfricanAmericans/BlacksandLatinos/Hispanics, respectively.Onlyonestudy(twofindings)focusedonanAboriginalpopulation. Mostfindings(65%)didnotspecifytheSESofthepopulationstudied,while13%used income,8%usededucationand6%usedemploymentasindicatorsofSES.
3.3.2 TheInfluenceofthePhysicalSettingandSectoronFood, DietandNutrition

Fortyonestudiesexaminedphysicalsettings(forexample,availabilityof/accessibilityto foodinschools,neighbourhoods,restaurants),foratotalof71findings.Themajority(75%) foundassociations(21%negativeand54%positive)betweenphysicalsettingsandfood intake;theremaining25%foundnoassociation.Morespecifically,ofthe71findings describedinthephysicalsetting,58%dealtwithschoolenvironments,14%related togeographicaccess/neighbourhooddesignand20%involvedrestaurantsorstores; theremaining9%wereclassifiedasotherenvironments,suchashomeenvironments.
Schools
Ofthe41findingsfrom23studiesdealingwithschoolenvironments,most(76%)showed associations(12%negative;63%positive)betweenschoolenvironmentsandfood,diet andnutrition.Onlyonestudywasareview,sixstudieswereobservationalandthe remainder(n=15)dealtwithschoolbasedinterventions.Inoneobservationalstudy,66 consumptionofmoremealsatschoolwasassociatedwithalowertotaldietaryfatintake, apositiveassociation.Twoobservationalqualitativestudiesdealtwithstudentsand parentsperceptionsofschoolfoodenvironments,67,68andbothstudiesrevealedthat schoolenvironmentswithperceivedunhealthyfoodchoiceavailabilitynegatively influencedfoodchoices. 19
Thebulkoftheschoolenvironmentstudiesandfindingsdealtwiththeinfluence ofenvironmentalinterventionsonfoodintake.Allofthesestudiesmanipulatedsomeaspect ofthephysicalenvironmentsuchasavailabilityofhealthychoicesinvendingmachines (forexample,HoerrandLouden69andCrawford70)orpointofpurchasenutritioninformation (forexample,Frenchetal.71andBuscher,MartinandCrocker72),andallhadatleast somepositiveeffectsonfoodintake,eitherincreasinghealthyfoodchoicesordecreasing unhealthyalternatives.Onlyfivestudies(sixfindings)foundnoassociationsbetween theinterventionandchangeindietarybehaviour.Forexample,usingfamilystyleversus cafeteriastylefoodservicehadnoeffectonenergyintake.73Intwostudiesthathadprimarily positiveeffects,28,69negativeassociationswerefoundinonlytwoinstances.Specifically, despiteoverallpositivechangeindiet,Sahotaetal.28founddecreasedfruitconsumption withintheinterventiongroup,andHoerrandLouden69foundanegativeimpactontotal snacksaleswhenhealthyfoodswereofferedinvendingmachines.Studiescomparing theimpactofschoolinterventionsonfood,dietandnutritionfoundnoeffectinlowerSES schoolenvironmentsbutpositiveeffectsinhigherSESschools.57,59Insomecases,changes inschoolenvironmentswerenotassociatedwithbehaviourchanges,butwereassociated withchangesinfoodsalesandhealthierfoodavailability.74
GeographicAccess/NeighbourhoodDesign
Inexamininggeographicaccesstofoodinurbanenvironments,onlysixstudieswerefound. Fivestudiesexamined7578orreviewed37relationshipsbetweenlocalavailabilityoffood andsocioeconomicstatusofresidents,whileonlyonestudyconnectedneighbourhood environmentwithdietaryintake/quality.79InallU.S.studies,greateraccesstohighenergy densityfoods(forexample,fastfood),75,76loweraccesstohealthierfood(forexample, supermarkets)75,77andloweravailabilityofstoresstockinghealthyfoods78wereobserved inlessaffluentormarginalizedneighbourhoods.Althoughrelationshipsamonggeographic accesstofoodoutlets,purchaseoffoodanddietaryintakewerenotestablishedinmost ofthesestudies,theproximityofsupermarketsandotherfoodretailoutletswasshown tobeassociatedwithapositiveinfluence(althoughnosuchassociationwasfoundfor grocerystores)ondietaryquality79inasinglestudyofpregnantwomen.
Restaurants/Stores
Inequitablegeographicaccesstovariousfoodoutletsdoesnotnecessarilymeanthat thefoodavailableatthoseoutletslimitsorpromotescertaintypesofchoicesand predictsdietaryquality.However,consistentwithassumptionsimpliedbyinequitable geographicaccess,twoU.S.studiesinvestigatedtheavailabilityoffoodmeetingnutrition recommendationsindivergentneighbourhoodsandfoundloweravailabilityofhealthy foodsinstores78andrestaurants75ineconomicallydisadvantagedneighbourhoods. NosuchassociationwasfoundinasingleAustralianstudy.80 Twoqualitativestudies68,81examinedpeoplesperceptionsofenvironmentalbarriers tomakinghealthyfoodchoicesandbothfoundthatpeopleperceivedtheavailability offastfoodtonegativelyinfluencefoodchoices,whileChatterjeeetal.81alsofoundthat peoplesperceivedavailabilityofhealthyfoodpositivelyinfluencedfoodchoices. 20
Results
Twostudiesinvestigatedtherelationshipbetweenfoodavailabilityinrestaurantsand foodintake.Forchildren,thenumberofmealsconsumedinrestaurantsnegatively affecteddietquality.66Availabilityoffruit,juiceandvegetablesatrestaurantspositively influencedfoodintake.82Instores,however,noassociationswerefoundbetweenfood availabilityandconsumptionintwostudies.Availabilityoffruit,juiceandvegetables atlocalstoresshowednoassociationwiththeirconsumption.82Availabilityoflowfatfoods atstoresindisadvantagedcommunitieswasnotassociatedwithlowfateatingpatterns.83 Onlyonestudy84intervenedinfoodoutletsbyusingshelflabellinginstorestopromote healthierchoices,andtheinterventionpositivelyinfluencedfoodpurchasebehaviour.
PhysicalSector
Withrespecttotheinfluenceofthephysicalenvironmentonfoodintake,onlyone U.S.study85addressedlargerstructuralphysicalsectors,findingapositiveassociation betweenurbanizationanddietaryquality(micronutrientintake)throughsecondary analysisoftheUnitedStatesDepartmentofAgricultures(USDA)19871988National FoodConsumptionSurvey.
3.3.3 TheInfluenceoftheEconomicSettingandSectoronFood, DietandNutrition

EconomicSectorSocioEconomicStatus
Withrespecttotheinfluenceoftheeconomicenvironmentonfood,dietandnutrition, 26studiesand43findingsexaminedeconomicsectorssuchasSESofpopulations (income,educationandemployment).Themajorityoffindings(72%)reportedassociations (7%negativeand65%positive)betweeneconomicsectorsandfood,dietandnutrition; theremaining28%showednoassociations. Morespecifically,studiesthatderivedcompositemeasuresofSESanddeprivation overwhelmingly(70%offindings)supportedtheideathatlowerSESanddeprivation areassociatedwithpoordietaryquality.63,83,8693Onlyonestudy(twofindings)94found negativeassociationsandonlyfourstudies91,9597foundnoassociations.Wheneducation wasusedasaproxyforSES,similarassociations(75%positive;25%noassociations) werefound.89,92,98102Weakerassociationswerefoundwhenincome(57%positive,43% noassociations)alonewasusedasanindicatorofSES.92,99,102104Onlytwofindingsused unemploymentasanindicatorofSES,andfindingswereequallysplitbetweenpositive associations105andnoassociations.106
EconomicSettings
Agreaterquantityofliterature(68findings)examinedmicroeconomicsettings,such asaffordabilityandneighbourhood/localsocioeconomicstatus,ascomparedto macroeconomicsectors.Themajority(76%)foundassociations(24%negativeand53% positive)betweeneconomicsettingsandfood,dietandnutritionvariables;theremaining 24%foundnoassociations. 21
Oneofthelargestsharesoftheevidence(27%offindings)dealswiththecostoffood.At theneighbourhoodlevel,foodcostshavenotbeenshowntobehigherindisadvantaged neighbourhoods,78althoughlowerincomesinsuchneighbourhoodsmaydeterhealthier choices.Mostfindings(56%)showedassociationsbetweenpriceoffoodandconsumption, withaffordabilityhavingthemostconsistentinfluence(forexample,Horowitzetal.78 andDonkinetal.89).Studiesinwhichtheinterventionwasmanipulationoffoodcostshad inconsistentfindings;somefoundpricedecreasesofhealthyfoodsincreasedconsumption (forexample,Frenchetal.107andHorgenandBrownell108)whileothersfoundnoeffect ofpricinginaworksitecafeteria.109 Whilebotheducationandemploymentstatusatthelocal(neighbourhood)levelconsistently showedassociationswithfood,dietandnutritionvariables(forexample,Oygardand Klepp110andFehily,PhillipsandYarnell111),studiesusingincomeandcompositemeasures ofSESweredividedbetweenthosethatshowedassociations(suchasForsyth,Macintyre andAnderson112)andthosethatdidnot113,114(69%versus31%).
3.3.4 TheInfluenceofthePoliticalSettingandSectoronFood, DietandNutrition

Tenstudiesexaminedtheinfluenceofpoliticalsettingsonfood,dietandnutrition,with atotalof10findings.Associationsbetweenpoliticalsettingsandfood,dietandnutrition wereevidentin60%offindings(50%positive,10%negative);40%offindingsshowed noassociations. Thevastmajorityofstudiesdealtwithschoolasapoliticalsetting,withinterventions inschoolfoodpolicyaccountingfor60%ofthefindings.Interventionsinworksitepolicy (forexample,worksitecounselling,worksitecafeteriainterventions)accountedfor40% ofthefindings. Asinterventionsinschoolswouldtypicallyrequireapolicytoinitiatechangeinthe typesoffoodavailable(aninfluenceontheschoolsphysicalenvironment)ortheprice offoodsoldwithintheschool(aninfluenceontheschoolseconomicenvironment),there issomeoverlapinenvironmentalcontextinthediscussionofschoolenvironmental interventions.Ofthesixfindingsdealingwithschoolenvironments,themajority(67%) foundassociations(allpositive)betweenschoolpolicyandfood,nutritionanddiet variables.Positiveeffectsonconsumptionofhealthierfoods(lowerfatorincreasedfruit andvegetables)wereassociatedwithcomprehensivepolicyoreducational/promotional interventions.115118 Nostudieswerefoundthataddressedtheinfluenceofthepoliticalsectoronfood,diet andnutrition.
22
Results
3.3.5 TheInfluenceoftheSocioCulturalSettingandSectoronFood, DietandNutrition

Themajorityofstudiesandfindingsrelatedtofood,dietandnutritionexploredthe socioculturalenvironment(150/349;43%offindings).
SocioCulturalSettings
Fortyninepapersand119findingsexaminedsocioculturalsettingsandassociations withfood,dietandnutrition.Themajority(71%)foundassociations(20%negative,50% positiveand1%Ushaped)betweensocioculturalsettingsandfood,dietandnutrition variables;theremaining29%foundnoassociations. Themajority(53%)offindingsexaminedhome/familyenvironmentssuchasfamily composition(singleversusdualparent;forexample,Moynihanetal.119),perceivednorms offamilymembers(forexample,OygardandKlepp110)orrolemodellingandavailability offoodinthehome120andtheirinfluenceonfood,dietandnutritionvariables.Notall food,nutritionanddietaryvariableswerecomparablyinfluenced;associationswerefound for71%ofthe63findings(51%positive;21%negative).Threestudies58,121,122applied interventions(schoolbasedparentaleducationorsocialsupport)toimprovefood,diet andnutritionbehaviourswithinthefamilyenvironmentandallwereassociatedwith positivechangesinmostofthedietvariables. Fivestudieswith17findingsexaminedtheroleofethnicityandcultureonfood,diet andnutritionvariablessuchasculturalfoodorbodysizepreferences(forexample,Frank etal.123).Mostfoundassociations(59%;12%negative,41%positiveand6%Ushaped). Onestudy124engagedAfricanAmericanfamiliesinaculturallyappropriateintervention toimprovedietarybehavioursandwassuccessfulinmodifying50%oftargetedbehaviours. Tenstudies51,89,108,125131with21findingsexaminedmediaandadvertisementsatthelocal level(forexample,placinghealthmessagesonrestaurantmenus,localmediabasedweight controlprogramsorchildrenspreferencesforadvertisedfoods).Ofthe21findings,90% showedassociations(52%positiveand38%negative)betweenmediaexposureandfood, dietandnutritionvariables.
SocioCulturalSectors
Withrespecttotheinfluenceofthesocioculturalenvironmentonfood,dietandnutrition, 18papersand31findingsaddressedsocioculturalsectorssuchasethnicity/culture/ acculturationandmedia.Themajority(77%)foundassociations(48%negative,26%positive and3%Ushaped)betweensocioculturalsectorsandfood,dietandnutrition;the remaining23%foundnoassociations.Morespecifically,studiesthatdescribedtheimpact ofethnicityandcultureonfood,dietandnutritionvariablesoverwhelminglysupported theideathatacculturationtoaWesternlifestylehadeffects,predominantlynegative (69%offindings),onimmigrantsfood,nutritionanddietaryhabits.31,96,132134
23
Atthesectorlevel,theroleofmediainpromotingasocioculturalobesogenicenvironment islessclear,with50%offindingsfromonlytwostudiesshowingassociationbetween mediaexposureandfoodconsumption(forexample,Greenetal.133),althoughonerecent, welldesignedqualitativestudy68foundthatparentsandchildrenassociatedjunkfood advertisingwithanenvironmentunsupportiveofhealthbehaviours.
3.4
Data: Physical Activity
3.4.1 OverallFindingsforPhysicalActivity
Thereviewincluded176studieswith712findingsrelatedtophysicalactivityandsome aspectoftheurbanenvironment. Mostofthefindingsinvolvedbothmalesandfemales(33%),whileanother27%were specifictofemalesand13%werespecifictomales.Although5%ofthephysicalactivity findingsinvolvedCaucasian/Whiteparticipantsandanother8%involvedAfrican Americans,themajorityhadnospecificdesignationofethnicityorrace.Intermsofage, adults(38%)werethemostlikelyparticipants,withadolescents(16%),children(12%) andolderadults(8%)accountingforsmallerproportionsofthefindings. Mostofthephysicalactivityfindings(82%)wereclusteredamongthesettings,while thesectorsaccountedforamuchsmallerproportion(18%).Specifically,53%offindings wereinphysicalsettings,19%insocioculturalsettings,2%inpoliticalsettingsand8% ineconomicsettings.Withinthesectors,economicsectorsincludedthelargestproportion offindingsat10%.
3.4.2 TheInfluenceofthePhysicalSettingandSectoronPhysicalActivity
Fiftyninepercent(59%)ofthefindingswithinthephysicalsettingshowedsomeassociation oreffectbetweentheenvironmentandphysicalactivity.Fortytwopercent(42%)ofthe findingswererelatedtourbandesign,whileanother26%hadtodowithfacilityaccess. Approximately50%ofthefindingsinthosetwocategoriescombinedshowedpositive associations/effectsbetweenfeaturesoftheurbanenvironmentandphysicalactivity.These findingsoriginatedfromanumberofstudies(forexample,Craigetal.;135DeBourdeaudhuij, SallisandSaelens;136Franketal.;137Humpeletal.138andKingetal.139)andappeartodocument afairlyconsistentrelationshipbetweenenvironmentandbehaviour.However,apartfrom afewstudies(forexample,Craigetal.;135Franketal.;137Kingetal.;139Estabrooks,Lee andGyurcsik140andGilesCortiandDonovan141),manyonlyassessedperceptionsofthe environmentinrelationtophysicalactivity.Whilethismaybeconsideredalimitation, arecentmetaanalysis62foundthattheperceivedpresenceofphysicalactivityfacilities, sidewalks,shopsandservicesandperceivingtrafficnottobeaproblemwereall positivelyassociatedwithphysicalactivity. Fewerfindings(n=18)fromonly10studieswereavailableforthephysicalsector.Similar tothoseforthephysicalsetting,supportwasfoundfortheroleofthebuiltenvironment inrelationtophysicalactivity.68,142,143Forinstance,Sinetal.144foundthatanimportant barriertoexerciseamongagroupofelderlyKoreanAmericanslivinginSeattlewasthe availabilityoftransportation. 24
Results
3.4.3 TheInfluenceoftheEconomicSettingandSectoronPhysicalActivity
Ofthe55findingsintheeconomicsettings,35(64%)showedsomeassociationbetween theurbanenvironmentandphysicalactivity.Notsurprisingly,adistinctassociation emergedbetweenSESandphysicalactivity,withlowerincomeindividualsreporting morebarriersandlessparticipationinphysicalactivity.145,146Furthermore,itappearsthat theavailability,perceptionanduseoffacilitiesandtrailsinneighbourhoodsaremoderated bySES.140,147ThesefindingscouldbeoneexplanationfortheverycommonSESgradient thatisobservedforphysicalactivity.148 Thoughmorefindings(n=72)wereavailablefortheeconomicsector,65%showedsome associationbetweentheenvironmentandphysicalactivity.Forinstance,inacostbenefit analysisofusingbike/pedestriantrailsinLincoln,Nebraska,Wangetal.149foundthat foreveryUS$1investmentintrailsforphysicalactivity,US$2.94indirectmedicalbenefit wouldbeaccrued.
3.4.4 TheInfluenceofthePoliticalSettingandSectoronPhysicalActivity
Thepoliticalsettingincluded17findings,77%ofwhichshowedanassociationbetween theurbanenvironmentandphysicalactivity.Thiswastheleastsupportivesettingorsector. Almosthalfofthefindings(47%)werefrominterventionstudies.Interestingly,changes inschoolenvironment,curricula,policiesandpracticeswereassociatedwithincreases inbothmoderateandvigorousphysicalactivityamongagroupofninthgradegirls.150 Thepoliticalsectorhadevenfewerfindings(n=4)fromjustthreestudies.143,151,152All findingsindicatedapositiveassociationbetweentheenvironmentandphysicalactivity. Forinstance,Pucher143attributedarecentresurgenceinbicyclinginGermanyentirelyto publicpoliciesthathavegreatlyenhancedthesafety,speed,andconvenienceofbicycling.
3.4.5 TheInfluenceoftheSocioCulturalSettingandSector onPhysicalActivity

Thesocioculturalsettingwassecondtothephysicalsettingintermsofthenumber offindings(n=135),approximately60%ofwhichshowedsomeassociationbetweenthe urbanenvironmentandphysicalactivity.Whilesocialsupportrelationsmadeupmore thanhalfofthefindings(n=72),suggestingthisisanareaofinterest,39%ofthosefindings wereofnoassociation.Studiesinvestigatingethnicityandcultureshowedamore consistentpatternofassociationsbetweenenvironmentandphysicalactivity.145,153,154 Forinstance,inastudyof117Chinesestudentsfromgrades9through12inNewYork City,YuandBerryman154foundthatacculturationhadasignificantpositivecorrelation withtotallevelofrecreationparticipation. Thesocioculturalsectorincluded35findings,with23%ofthoseshowingnoassociation betweentheurbanenvironmentandphysicalactivity.Notsurprisingly,physicalactivity wasnegativelyassociatedwiththeextenttowhichcarswereculturallyacceptedin Australia155andpositivelyrelatedtothepopularityofthegreenmovementinGermany.143 25
3.5
Data: Sedentary Behaviour
Thereviewincluded13studieswith36findingsrelatedtosedentarybehaviour(for example,TVviewing,timespentincar)andsomeaspectoftheurbanenvironment. Mostofthefindingsinvolvedadults(47%).Thedistributionoffindingsbysexwassimilar formales(31%),females(33%)orboth(31%).Ethnicity(50%)wasindistinguishable forthemajorityofthefindings.Approximately25%ofthefindingsonsedentarybehaviour showednoassociation. Thephysical(53%)andsociocultural(22%)settingsaccountedforalmostallofthefindings. Thirtytwopercent(32%)ofthephysicalsettingfindingsshowednoassociationwith sedentarybehaviour,whileanother53%showedanegativeassociation.Forsociocultural settings,13%ofthefindingswereofnoassociation,withtheother87%showingapositive association.Overall,itappearsthattheremaybesomeassociationbetweensomeaspects ofurbansettingsandsedentarybehaviour,butthefindingsandstudiesaretoofew tomakeanyfurthermeaningfulanalysis.
3.6
Levels of Evidence for Relationships Between Urban Environments and Obesogenic Behaviour or Body Weight
Findingsfromobservationalandexperimentalstudiesthatweredeemedtobeoffair togoodqualitywereaggregatedwithintypeandlevelofenvironmentaccordingtothe directionofthefinding.Becausewewereinterestedindeterminingifanyassociation/effect existedbetweentheenvironmentandbehaviourorbodyweight,regardlessofdirection, ourfocuswasonthefindingsofnoassociation.Specifically,wemadeadetermination ofourconfidenceintheevidencebasedupontheproportionoffindingswithnoassociations. Thefewerfindingsofnoassociation,themoreconfidentwewereintheevidence(thatis, Convincing<10%,Probable10%to29%,Possible30%to49%,Insufficient50%to89%, NoEvidence90%).Iftherewerefewerthan10findingsforaparticularrelationship, wedowngradedourlevelofconfidencetothenextlevel.Forinstance,iftherewereonly ninefindingswithlessthan10%noassociations,ourlevelofconfidencewascategorized asprobableinsteadofconvincing. Fortheobservationalfindings,weconcludedthattheevidencewasprobablefordiet andsedentarybehaviourforsettingsoverall(seeTable2).Theevidencewasprobablefor diet,sedentarybehaviourandobesity/healthyweightswithinthesocioculturalsettings; probablefordiet,physicalactivityandobesity/healthyweightsintheeconomicsettings; andprobablefordietwithinthephysicalsettings.Forsectors,theevidencewasprobable fordietandphysicalactivityoverall.Theevidencewasprobablefordiet,physicalactivity andobesity/healthyweightswithinthesocioculturalsectors;probablefordiet,physical activityandsedentarybehaviourintheeconomicsectors;andprobableforphysical activitywithinthephysicalsectors.Wehadlessconfidenceintheevidenceforsedentary behaviourinrelationtosectors. 26
Results
Table2
Levels of Evidencei for Observational Findingsii
Environment Type Overall
Food, Diet and Nutrition Probable
Physical Activity Possible
Sedentary Behaviour Probable
Body Weight Possible
Settings Physical Economic Political Socio-cultural
Probable Probable Probable No evidence Probable
Possible Possible Probable Possible Possible
Probable Possible No evidence No evidence Probable
Possible Possible Probable No evidence Probable
Sectors Physical Economic Political Socio-cultural
Probable Possible Probable No evidence Probable
Probable Probable Probable No evidence Probable
Possible No evidence Probable No evidence No evidence
Possible Possible Possible No evidence Probable
Apartfromdiet,thereappearstobelittleevidenceofexperimentaleffectsonobesogenic behaviourandbodyweight(seeTable3).Withindiet,itisonlyatthesettingslevel wherethereisanyevidenceofexperimentaleffects.Specifically,physicalandeconomic settingsappeartoshowsomepromiseforeffectiveinterventions.

Table3 Environment Type Overall Food, Diet and Nutrition Probable Physical Activity Possible Sedentary Behaviour Insufficient Body Weight Insufficient
Levels of Evidencei for Experimental Findingsii
Settings Physical Economic Political Socio-cultural
Probable Probable Probable No evidence Possible
Possible Possible Possible Insufficient Possible
Insufficient Insufficient No evidence No evidence No evidence
Insufficient Insufficient No evidence No evidence No evidence
Sectors Physical Economic Political Socio-cultural
No evidence No evidence No evidence No evidence No evidence
i. Referstoproportionoffindingswithnoassociation.Probable=10%to29%;possible=30%to 49%;insufficient=50%to89%;noevidence90%. ii. Includestudiesoffairandgoodquality.
27
Overall,wehavemoreconfidenceinobservationalfindings,particularlyatthesettings levelfordietandsedentarybehaviour.Somewhatsurprisingwasthelackofevidence foreffectiveenvironmentalinterventionstoaddressobesogenicbehaviourandbody weightinanurbancontext.
3.7
Policy Context
Togetasenseofthepolicycontextinwhichurbanenvironmentalinfluencesofobesity operate,wereviewedalimitednumberofsummarypolicydocumentsgeneratedwithin theCanadiancontext.Thesedocumentscanbedividedintothefollowingcategories: peerreviewedpublications,literaturesynthesesandreviews,summaryreportsandexpert fora.Atotalof10documentswerereviewed(seeAppendixF).Theanalysisofthese documentshasthreeprimaryfoci:issueframing,resultsandrecommendations.The intentionistolinkthesemorebroadlyfocuseddocumentstooursynthesisfindingsfrom theurbanobesity/healthyweightsliterature.
3.7.1 IssueFraming
Since1997,whenexpertsgatheredatthefirstWorldHealthOrganization(WHO)Expert ConsultationonObesity,overweightandobesityhavebeenrecognizedasarapidlygrowing threattothehealthofpopulations156onaglobalscale.156,157Insomecases,theterm epidemic156wasusedtocharacterizetheissue.Anumberofthedocumentsbroadened thedefinitionoftheproblembyidentifyingbothoverweightandunderweightextremes andassociatedbehavioursasequallyimportant.Forexample,HealthCanada158defined weightproblemstoincludeeatingdisorders,weightpreoccupationsandnegativebody image,andnotjustexcessweight.Excessivedietingresultingfromthepromotionand societalreinforcementofunhealthybodyimageswasseenasaparticularproblem.158,159 Increasedsedentaryactivityassociatedwithtechnologicaladvancementswasalsoidentified asacontributingfactor.Children,inparticular,wereidentifiedasanatriskpopulation requiringimmediateandsignificantattention. Withinthiscontext,thegrowingthreatthatoverweightandobesityposesforthechildren oftheworldhasbeenidentifiedasamajorpolicyissue.Therisingratesofoverweight andobesityamongchildren,inCanadaandworldwide,overthepast20yearshave significantpublichealthimplications.Recentthinkingsuggeststhatpriorityshould bedirectedatthepreventionofobesityininfantsandchildren.160 Whilemostoftheexistingandemergingresearchhasfocusedondevelopingabetter understandingofthedeterminantsandrootcausesofthedisease,161somerecentresearch hasalsofocusedonpossiblesolutions,withvaryingdegreesofsupportiveevidence.162 Implicitintheexistingandemergingknowledgeaboutobesityingeneral,andchildhood obesityspecifically,isincreasingrecognitionofthecomplexityoftheissueandtheneed forthecoordinatedinvolvementofarangeofpolicyactorsacrosssectorsandsettings tolinkindependentpoliciesandprocesses.157,161,163Leadershipfromhealthagenciesat federal,provincial/territorialandlocallevelshasbeenidentifiedaskeytoimplementing integrated,multisectoral,obesitypreventionstrategiesbecauseoftheiruniquepotential 28
Results
forcrosssectoranalysisofthecostsandbenefitsofpublicpolicies.162Thepublicpolicy environmentisfrequentlycitedasacriticallocationforsolutionstotheobesityepidemic.163 Anadequateunderstandingofthestructuresandprocessesthroughwhichpublicpolicies haveeitherapositiveornegativeimpactneedstobecapturedinordertoinformand inspirethoseresponsibleforpolicy.163 Obesityisassociatedwithanumberofhealth160andeconomicconsequences.Although alargenumberofpolicyresponseshavebeenidentified,relativelyfewhavebeen systematicallytested.Thus,inadditiontoagapinknowledgeaboutthecomplex relationshipsamongfactorscontributingtoobesity,thereisalsoaknowledgegap intheimpactofpossiblepolicyresponses.
3.7.2 PossiblePolicyResponsesiii
Giventhatobesityisaffectedbyacomplexsetofpersonalandenvironmentalfactors, thepossiblepolicyresponsesarebroadanddiverse.Althoughmostdocumentsdidnot attempttoprioritizepossiblepolicyresponses,theGroupedetravailprovincialsurla problmatiquedupoids(GTPPP)159suggestedthatausefulstartingpointmightbethe creationofmultidisciplinaryteamstoaddresschronicdiseasesatthelocal,regionaland provinciallevels.Politicalwillwasseenasamajorfactorinensuringthatprogressismade. AppendixGsummarizesidentifiedpolicyoptionssynthesizedfromavarietyofCanadian documents.Policyoptionsarecategorizedaccordingtotheenvironment,thetypes ofpolicyinstruments(regulatory,expenditurebased,proceduralorinformationbased) andinfluenceonobesogenicbehaviour(diet,physicalactivity)orbodyweight.These policyoptions,crossreferencedwithlevelsofevidencefromthisreview,suggestthat sufficientevidenceexiststojustifythefollowingpossiblepolicyresponses:
EconomicEnvironments
Policiesthatpromoteeconomicaccesstohealthyfood,suchasproductionincentives andapricestructureforfoodthatfavourlowenergyandnutrientdensefoods;158,164 Policiesthatpromoteeconomicaccesstophysicalactivity,suchasfiscalmeasures involvingtaxreductionsforfeesrelatedtoparticipationinsports,159removalofsales taxfromexerciseequipment,164,165andtaxincentivesforemployerswhoprovidetheir employeeswithfitnessfacilities;164 Fiscalpoliciesthatdiscourageurbansprawlandencouragedensificationandactive commuting;164and Policiesthatsupportincomeequityandsupport,164,166giventheprobableinfluence ofeconomicsettingsonbodyweight.
iii. TheviewsexpressedinthisreportdonotnecessarilyrepresenttheviewsoftheCanadian PopulationHealthInitiativeortheCanadianInstituteforHealthInformation. 29
PhysicalEnvironments
Policiestoreviewmunicipalbylawsandfacilitateactivetransportbycreatingstreets thatincorporatepedestrianuseandbicyclefacilitiesandthatarecalmed(discourage highspeedvehicletraffic);164,166 Developmentplansthatencouragetheuseofactivetransportation,familyoriented parksandsportsfacilitiesforadults;159,164 Collaborationwithprivateandpublicsectoremployerstodevelopaworkplace environmentthatpromoteshealthyweights;164,167 Policiestosupportcomprehensiveschoolhealthinitiatives;167 Policiestosupporttheavailabilityofawiderselectionofhealthyfoodchoicesin schools,worksites,restaurants,fastfoodfranchisesandothercommunitysettings;158 Policiestoincreasecommunityaccesstoexercisefacilities,suchasthoseinschools, toenhanceopportunitiesforadultsandchildrentoparticipateinregularphysical activity;158and Policiestoregulateportionsizeanddisclosureofnutritionalcontentonsnacks andfastfoodsatpointofsaleandonproductlabels.164
SocioCulturalEnvironments
Policiesthatregulatetheadvertisingandpromotionoffoodsforchildren;159,164,165,167,168and Policiestoencouragelargescalecommunitybasedprogrammodelsthatsupport healthyweightactivitiesbasedonstrongcommunityinvolvement,158includingbutnot limitedtoethniccommunities.
PoliticalEnvironment
Policiestomonitortheimpactonobesityandhealthofdecisionsinnonhealthsectors, suchaseducation,transportation,foodandrecreation.166
3.8
Results of Online Stakeholder Survey
AsstatedintheMethodologysection,wesurveyedagroupofover90decisionmakersand researcherswhoattendedathinktanksessiononobesityrelatedpolicyresearchpriorities. Individualsrepresentingregionalhealthauthorities,provincialandfederalorganizations andacademicsattendedthistwodayevent.Thosestakeholdersinterestedinourresearch projectrespondedtoawebbasedquestionnaire(AppendixD).Thefirstquestioninthe stakeholdersurveyaskedrespondentstolistuptothreefactorsthataremostlikelytohave animpactonhealthyweightsinanurbanenvironment.All24respondentsfilledinthis questionandsuppliedthreefactorseachforatotalof72totalanswers(thoughsixanswers wereplacedintwodifferentcategoriesandonewasnotcategorizedduetolackof information,foratotalof77responses).
30
Results
Redefiningtherespondentsanswersinouradaptedsettingsandsectorsframework7posed somechallenges,asnotalloftheanswersgivenfellneatlyintoonecategory(forexample, somecouldfitinmorethanonecategory).However,anattemptwasmadetocategorize theresponsesinoursettingsandsectorsframeworktomakeamoreappropriatecomparison betweenstakeholderresponsesandwhatwasfoundinthesystematicreview. Mostrespondentsanswersweregroupedwithinthesettingsratherthanthebroadersectors category(seeAppendixH).Thissuggeststhatrespondentsmayfeelthemoreimmediate surroundingsratherthanbroadersocietaltrendsand/orpolicieshaveagreaterimpact onhealthyweights.Thephysicalsettingwasthecategoryforthemostresponses(n=33; 43%).Mostoftheseresponsesincludedpresenceofsidewalks,pathways,recreation facilitiesandfoodoutlets.Itshouldnotbesurprisingthatphysicalsettingswasthemost commonresponsecategorysincethequestion,whichcontainedthephraseurban environment,mayhaveledpeopletothinkimmediatelyaboutthebuiltenvironment. Relatedtothephysicalsettingisthephysicalsector,whichwasthenextmostcommon responsecategory(n=19;25%).Theresponsesinthisgroupincludedanyurbandesign orbuiltenvironmentanswers,alongwithpublictransportation.Thesocioculturalsetting wasthenextmostcommoncategory(n=9;12%),whereresponsesvariedconsiderably. Listedinthiscategoryweresocialnetworks,safety(notspecifictosafetyofaphysical setting),education,worklifebalance,individualattitudesandcaruse(signifyingthe choicetouseautomobiles).Fiveresponses(6%)weregroupedtotheeconomicsector andincludedsocioeconomicthemesaswellasenergyprices.Thepoliticalsectorwas thenextmostcommonresponsecategory(n=4;5%),whereresponsesincludedpolicies orzoningaroundlanduseplanningthatsupportcardependence.Theeconomicsetting alsoincludedfourresponses(5%)thatdealtmainlywiththeaffordabilityoffoodoptions. Tworesponses(3%)werecategorizedinthesocioculturalsector,whererespondentslisted sedentarylifestylesandaculturethatsupportscardependency.Finally,oneresponse(1%) wasinthepoliticalsettingscategoryandincludededucationgiveninschoolsaround healthyweights. Thesecondquestionaskedwhetherthefactorslistedinquestiononeweremodifiable byapolicyresponse.All24respondentsfilledinthisquestion,althoughsomeresponses wereputintotwocategoriesforatotalof77answers.Themajorityofrespondentsstated thatthefactorsweremodifiablebyapolicyresponse(69of77answers;90%). Similartothefirstquestion,thesettingsandsectorsframeworkwasusedtodetermine whichoftheresponsesinquestion2weremodifiablebyapolicyresponse.Mostofthe responsescategorizedinphysicalsettings(32of33;97%)werethoughttobemodifiable. Thesefactorsrepresentedtheaccessibilityoffitnessandnutritionoptionsgenerallyinthe localenvironment.Onerespondentwasnotsurewhethertheavailabilityofcaloriedense foodwasmodifiable. Thefactorsintheeconomicsetting(4of4;100%)andpoliticalsetting(1of1;100%)were thoughttobemodifiable.Onlysixofnineresponses(67%)inthesocioculturalsetting werethoughttobemodifiablebyapolicyresponse.Tworesponsesfocusedonthetheme ofsafetyandsecurity,andonerespondentwasnotsureifsocialsupportwasmodifiable. 31
All17(100%)responsesinthephysicalsectorwerethoughttobemodifiablebyapolicy response.Theseresponseswerecentredmostlyonurbandesignandpublictransportation. Fouroutoffive(80%)responsesintheeconomicsectorwerethoughttobemodifiable byapolicyresponse.(Onerespondentwasnotsureifsocioeconomiclevelswere modifiable.)All(4of4;100%)politicalsectorresponseswerethoughttobemodifiable andwerecentredonpoliciesandzoningoflanduse.Onlyoneoftwo(50%)responses inthesocioculturalsectorwasthoughttobemodifiable.(Onerespondentwasunsure whethersedentarylifestylesweremodifiable.) Baseduponresponsestoquestion2,factorsinthephysicalsettingsandsectorswere thoughttobeamenabletoapolicyresponse.Theonlyfactorsthoughttobeunmodifiable wererelatedtosafety.Stakeholdersrespondedstronglythatpolicychangesaffecting settingsandsectorscouldleadtohealthierbodyweights. Thethirdquestioninthesurveyaskedrespondentstolistuptothreepolicies/programs/ initiativesthatexistinurbanareastoassistpopulationsinachievinghealthybodyweights. Atotalof52responsesweretalliedforthisquestion.(Twowereclassifiedintomorethan onecategoryforatotalof54answers.)Theresponsestothisquestionweremorechallenging togroupintosettingsandsectorsbecausesomerespondentsgaveveryspecificinitiatives inageographicareaandothersgavebroaderfactorsthatweresimilartotheanswers foundinquestion1. Classifyingtheresponsesinquestion3intothesettingsandsectorsframeworkproduces amuchdifferentbreakdownthanwasseeninquestions1and2.Thecategorywiththe mostresponseswasinthepoliticalsector(n=18;33%)andtheresponsesvariedfrom specificinitiatives(forexample,QuebecCityssustainabledevelopmentplan,Healthy Ontario2010)tomoregenericanswers,suchaspoliciesfavouringachangeinretailmix orsnowclearingpolicies.Similarlythepoliticalsettinghadalargenumberofresponses (n=11;20%)thatincludedspecificpoliciesinworkplaces(forexample,BristolMyers Squibbsqualityoflifepolicy,physicaleducationinschools)tothemoregeneric(for example,communityuseofschools).Othercategoriesincludednineresponsesforphysical settings(17%),fiveforsocioculturalsectors(9%),fourforsocioculturalsettings(7%),four forphysicalsectors(7%),twoforeconomicsettings(4%)andoneforeconomicsectors(2%). Inconclusion,moststakeholdersrespondedthaturbandesignissuesandaccessibility ofphysicalactivityandnutritionopportunities(mainlyinthephysicalsettingandphysical sector)werethemostimportantfactorsinfluencinghealthybodyweightsinanurban environment.Moststakeholdersbelievedthatthemajorityoffactors,nomatterthespecific settingorsector,aremodifiablebyapolicyresponse,thoughthetypeofresponsewas notspecificallyaskedfor.Oftheinitiativesthatpeopleknewabout,mostwereclassified intothepoliticalsectorsandpoliticalsettings.
32
Conclusions
Conclusions
Inresponsetoourresearchquestion(thatis,towhatextentdostructuralorcommunity levelcharacteristicsofurbanenvironmentsencourageorinhibittheachievementofhealthy weights?),thisreviewrevealedsomeevidenceforassociationsbetweenaspectsoftheurban environmentandobesogenicbehaviourand/orobesity/healthyweights.Thestrongest levelsofevidencewereobservedforphysical(diet),economic(diet,physicalactivity, obesity/healthyweights)andsociocultural(diet,sedentarybehaviour,obesity/healthy weights)settings,andphysical(physicalactivity),economic(diet,physicalactivity, sedentarybehaviour)andsociocultural(diet,physicalactivity,obesity/healthyweights) sectors.Verylittleevidenceexistedfortheeffectivenessofinterventionsinachieving healthyweightsinanurbancontext(seetables2and3onpage27). Alargeproportionofthefindings,particularlyforphysicalactivityandsedentary behaviour,wereinthephysicalsettingsandsectors.Thoughthelevelofevidencewas probablefordiet(observationalandexperimental)andsedentarybehaviour(observational) inthephysicalsettings,lesssupportwasfoundforphysicalactivityandbodyweight. Accordingtothestakeholdersurveyofresearchersanddecisionmakers,urbandesign andaccessibilitytophysicalactivityandhealthynutritionopportunitieswerethemost importantfactorsinfluencinghealthybodyweightsinanurbanenvironment.Thus, somediscrepancyappearstoexistbetweentheperceptionsofthesedecisionmakersand thestateoftheevidencewithregardtotheroleofthephysicalenvironmentinrelation tohealthyweights.Foramorecompletesummaryontheroleofthebuiltenvironment, pleaserefertothereviewarticlesbySwinburnetal.,16FrankandEngelke,22Boothetal.38 andOgilvieetal.169Inparticular,thereviewbyBoothetal.38bringsattentiontothedifficulty incomparingresultsfromdifferentstudiesbecauseofthevariabilityinmethodsused. However,theirreviewofmostlycrosssectionalstudiesclearlysuggeststhatthebuilt environment,mostoftenassessedattheleveloftheneighbourhood,hasthepotentialto influencebodyweight.OursystematicreviewisingeneralagreementwithBoothetal.;38 however,itisimportanttonotethatalargeproportionofthefindingsweidentifieddid notreachstatisticalsignificance.Thismaysuggestthataccesstoasupportivephysicalsetting maybeadvantageous,butinsufficientbyitselftohaveasignificantimpactonobesity. Thoughexperimentalevidenceislacking,thestrengthoftheevidenceforeconomic settingsandsectorssuggeststhatinterventionsaimedatimprovingSESandeducation levelswithinurbanenvironmentsmayhelpaddressdisparitiesinobesogenicbehaviour andobesity. Perhapsoneofthemorestrikingfindingsinthisreviewwasthelackofevidenceforthe roleofpoliticalsettingsandsectorsinrelationtoobesity/healthyweightsintheurban context.Withregardtothepolicyanalysisconducted,alargenumberofpolicyresponses wereidentifiedinrelationtoobesityandtheenvironment,butrelativelyfewhavebeen systematicallytested.Thus,inadditiontoagapinknowledgeaboutthecomplex relationshipsamongfactorscontributingtoobesity,thereisalsoaknowledgegapabout theimpactofpossiblepolicyresponses. 33
Furthermore,aneedexistsforabetterunderstandingofhowtheurbanenvironmentmay influencetheprevalenceofobesity.Thismaybeparticularlytruefortheschoolsetting, whereseveralinterventionshaveimprovedphysicalactivityandnutritionknowledge/ behaviourswithouthavingasignificantimpactonobesity.Conversely,atleastonestudy achievedreductionsinBMIwithoutdemonstratingincreasedphysicalactivityorreduced dietaryfatintake.27Severalreviews,someofwhicharesystematic,havebeenrecently publishedinthisarea.170173Althoughthesereviewsarenotfocusedontheurban environment,theycanprovideimportantinsightonschoolbasedinterventions.
Limitations
Whiletheremaybeothers,thisreporthastwolimitationsthatshouldbementioned. First,theuseofavotecountingprocedureinwhichfindingswerecategorizedand aggregatedbaseduponstatisticalsignificanceanddirectionoftherelationship/change hasbeencriticizedinthepast.174Potentialconcernswiththisapproacharethat,regardless ofsamplesize,findingsfromvariousstudiesareattributedequalweightandthatstatistical significance,whichisheavilyinfluencedbysamplesize,istheonlyindicatorofworthiness ofafindingfromaquantitativestudy.Thus,somelargeandmeaningfulfindingsin quantitativestudiesmayhavebeenpassedoverbecausetheyarosefromsmallsample sizesandthusdidnotachievestatisticalsignificance.Ontheotherhand,thisapproach didallowfortheinclusionofqualitativedata,whichweseeasastrength.Second,because ourreviewincludedfourdependentoroutcomevariables(diet,physicalactivity, sedentarybehaviour,healthyweight)andmultiplelevelsoftheenvironment,studies oftencontributedmultiplefindingstotheanalysis.Thus,thefindingasopposedtothe studywastheunitofanalysis.Therefore,itispossiblethatastudycontributingnumerous findingsthatarerelatedtooneanother(thatis,samesample)withinanoutcome,and perhapsevenwithinthesameleveloftheenvironment(forexample,multiplemeasures ofthebuiltenvironment),couldskewtheresults.Thatis,whilewemayhavehad20or 30findingswithinaparticularleveloftheenvironmentforanoutcome,itispossiblethat thosefindingsweremostlyfromtwoorthreestudies.Fromastatisticalpointofview, thiswouldbeproblematicbecauseamajorassumptionofmoststatisticaltestsisthat findingswithinasampleareindependentofoneanother.Itisalsoproblematicbecause ourconfidenceinthelevelsofevidencewasbaseduponthenumberandproportionof findingsthatshowedsomeassociationbetweentheoutcomevariablesandlevelsofthe environment.Havingnumerousfindingsfromthesamestudywouldlimitourconfidence. Toaddressthisissue,wewerecautiousinourreportingifwesawthefindingsofone studydominatingtheresultsforaspecificleveloftheenvironment.
Summary
Insummary,someevidenceexistsforassociationsbetweenaspectsoftheurbanenvironment andobesogenicbehaviourand/orbodyweight,implicatinginterventionsinpolicyand practice.However,thelackofevidenceforeffectiveinterventionsandpolicyinitiatives suggestsaneedforresearchtofillknowledgegaps.
34
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137. L.D.Franketal.,LinkingObjectivelyMeasuredPhysicalActivityWithObjectively MeasuredUrbanForm:FindingsfromSMARTRAQ,AmericanJournalofPreventive Medicine28,2Suppl.2(2005):pp.117125. 138. N.Humpeletal.,PerceivedEnvironmentAttributes,ResidentialLocation,and WalkingforParticularPurposes,AmericanJournalofPreventiveMedicine26,2(2004): pp.119125. 139. W.C.Kingetal.,ObjectiveMeasuresofNeighborhoodEnvironmentandPhysical ActivityinOlderWomen,AmericanJournalofPreventiveMedicine28,5(2005): pp.461469. 140. P.A.Estabrooks,R.E.LeeandN.C.Gyurcsik,ResourcesforPhysicalActivity Participation:DoesAvailabilityandAccessibilityDifferbyNeighborhood SocioeconomicStatus?,AnnalsofBehavioralMedicine25(2003):pp.100104. 141. B.GilesCortiandR.J.Donovan,RelativeInfluencesofIndividual,Social Environmental,andPhysicalEnvironmentalCorrelatesofWalking,American JournalofPublicHealth93(2003):pp.15831589. 142. B.GilesCortietal.,IncreasingWalking:HowImportantIsDistanceTo, Attractiveness,andSizeofPublicOpenSpace?,AmericanJournalofPreventive Medicine28,2Suppl2(2005):pp.169176. 143. J.Pucher,BicyclingBoominGermany:ARevivalEngineeredbyPublicPolicy, TransportationQuarterly51,4(1997):pp.3146. 144. M.K.Sinetal.,FactorsInfluencingExerciseParticipationandQualityofLifeAmong ElderlyKoreanAmericans,JournalofCulturalDiversity11,4(2004):pp.139145. 145. A.A.Eyleretal.,PhysicalActivityandMinorityWomen:AQualitativeStudy, HealthEducationandBehavior25(1998):pp.640652. 146. J.S.Harrelletal.,LeisureTimeActivitiesofElementarySchoolChildren,Nursing Research46(1997):pp.246253. 147. B.GilesCortiandR.J.Donovan,SocioeconomicStatusDifferencesinRecreational PhysicalActivityLevelsandRealandPerceivedAccesstoaSupportivePhysical Environment,PreventiveMedicine35(2002):pp.601611. 148. M.Lindstrom,B.S.HansonandP.O.Ostergren,SocioeconomicDifferencesin LeisureTimePhysicalActivity:TheRoleofSocialParticipationandSocialCapitalin ShapingHealthRelatedBehaviour,SocialScience&Medicine52,3(2001):pp.441451. 149. G.Wangetal.,ACostBenefitAnalysisofPhysicalActivityUsingBike/Pedestrian Trails,HealthPromotionPractice6(2005):pp.174179.
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163. CanadianInstitutesofHealthResearch,Excellence,InnovationandAdvancement intheStudyofObesityandHealthyBodyWeightPilotProjectGrants(Ottawa: CanadianInstitutesofHealthResearch,2004),[online],lastmodifiedMarch30,2007, citedfrom<http://www.cihrirsc.gc.ca/e/4295.html>. 164. K.Raine,OverweightandObesityinCanada:APopulationHealthPerspective (Ottawa:CanadianInstituteforHealthInformation,2004),[online],from <http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=GR_1130_E>. 165. HeartandStrokeFoundationofCanada,InterventionsRelatedtoObesity:AState oftheEvidenceReview(Ottawa:HeartandStrokeFoundationofCanada,2005). 166. CanadianInstituteforHealthInformationandCanadianInstitutesofHealth Research,ObesityinCanada:IdentifyingPolicyPriorities(Ottawa:CanadianInstitute forHealthInformation,2003),[online],from<http://secure.cihi.ca/cihiweb/ dispPage.jsp?cw_page=GR_1066_E&cw_topic=1066>. 167. L.McLarenetal.,AreIntegratedApproachesWorkingtoPromoteHealthyWeightsand PreventObesityandChronicDisease(Calgary:UniversityofCalgary,2004). 168. RegisteredNursesAssociationofOntario,PrimaryPreventionofChildhoodObesity (Toronto:RegisteredNursesAssociationofOntario,2005). 169. D.Ogilvieetal.,PromotingWalkingandCyclingasanAlternativetoUsingCars: SystematicReview,BritishMedicalJournal329,7469(2004):p.763766. 170. T.Baranowskietal.,SchoolBasedObesityPrevention:ABlueprintforTaming theEpidemic,AmericanJournalofHealthBehavior26,6(2002):pp.486493. 171. D.L.Katzetal.,PublicHealthStrategiesforPreventingandControllingOverweight andObesityinSchoolandWorksiteSettings:AReportonRecommendationsofthe TaskForceonCommunityPreventiveServices,Morbidity&MortalityWeeklyReport: Recommendations&Reports54,RR10(2005):pp.112. 172. M.J.Muller,S.DanielzikandS.Pust,SchoolandFamilyBasedInterventions toPreventOverweightinChildren,ProceedingsoftheNutritionSociety64,2(2005): pp.249254. 173. C.D.Summerbelletal.,InterventionsforPreventingObesityinChildren, CochraneDatabaseofSystematicReviews,3(2005). 174. R.J.LightandD.B.Pillemer,SummingUp:TheScienceofReviewingResearch (Cambridge,MA:HarvardUniversityPress,1984).
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Appendix A: Project Flow Chart
Appendix A: Project Flow Chart

LiteratureDatabaseSearches
TitleScan Accepted ArticlesWithout AbstractsSeparated
ReTitleScanned Rejected
ReTitleScanned Accepted
HardCopy/ ElectronicArticles Retrieved AbstractScan Rejected
TitleScan Rejected AbstractScan AbstractScan AbstractScan Unknown/Follow Rejected,Kept Accepted UpRequired forConcept/Refs FullArticle FullArticle FollowUp FollowUp Accepted Rejected
ArticleFull Review ArticleRejected UponFullReview
FinalSystematically ReviewedArticles
ArticleRejectedbut KeptforConcept/Refs
Concept/Refs=ConceptualContentand/orReferences
49
Appendix B: Sample MEDLINE/HealthStar Search Strategy

1.obesity/orobesity,morbid/orbodyweight/ 2.bodymassindex/ 3.energyintake/ 4.motoractivity/orwalking/orbicycling/ 5.Exercise/ 6.leisureactivities/orrecreation/ 7.bodyweight/orbodyweightchanges/orweightgain/orweightloss/orthinness/ 8.diet/ 9.feedingbehavior/orfoodhabits/orfoodpreferences/ 10.fruits/orvegetables/ 11.carbonatedbeverages/ 12.dietaryfats/ordietarycarbohydrates/orcandy/ 13.menuplanning/ 14.or/113 15.(obes$orbodyweightorbodyweightoroverweight).ti,ab. 16.(physical$adj5(activ$orinactiv$orfitorfitness)).ti,ab. 17.sedentary.ti,ab. 18.(walk$orbicycl$).ti,ab. 19.((foodordiet$)and(choice$orchooseorprefer$orintakeorhabit$)).ti,ab. 20.(fruit$orvegetable$).ti,ab. 21.(carbonatedadj3(drink$orbeverage$)).ti,ab. 22.(softdrink$orsodaorpop).ti,ab. 23.(junkfood$orfastfood$orsnack$orcandyorhighfatorsugary).ti,ab. 24.portion$.ti,ab. 25.or/1524 26.14and25 27.*obesity/or*obesity,morbid/or*bodyweight/ 28.*bodymassindex/ 29.*energyintake/ 30.*motoractivity/or*running/or*swimming/or*walking/ 31.*Exercise/ 32.*leisureactivities/or*recreation/ 33.*bodyweight/or*bodyweightchanges/or*weightgain/or*weightloss/ or*thinness/ 34.*diet/or*feedingbehavior/or*foodhabits/or*foodpreferences/ 35.*fruits/or*vegetables/ 36.*dietaryfats/or*dietarycarbohydrates/or*candy/ 37.*menuplanning/ 38.or/2737 39.(obes$orbodyweightorbodyweightoroverweight).ti. 40.(activ$orinactiv$orfitorfitnessorsedentary).ti. 51
41.(walk$orbicycl$).ti. 42.((foodordiet$)and(choice$orchooseorprefer$orintakeorhabit$)).ti. 43.(junkfoodorfastfoodorsnack$orhighfatorsugary).ti. 44.(fruit$orvegetable$orsoftdrink$orsodaorpop).ti. 45.portion$.ti. 46.or/3945 47.26or38or46 48.healthpolicy/ornutritionpolicy/orpolicymaking/ 49.expPublicPolicy/ 50.exporganizationalpolicy/ 51.socialchange/ 52.expsocioeconomicfactors/oreducationalstatus/oremployment/orunemployment/ orexpworkplace/orfamilycharacteristics/orincome/oroccupations/orexppoverty/ orexpsocialclass/orsocialconditions/ 53.culture/oracculturation/ 54.socialmarketing/ormarketingofhealthservices/ 55.marketing/oradvertising/ 56.persuasivecommunication/ 57.Reimbursement,Incentive/ 58.expINSURANCE,HEALTH,REIMBURSEMENT/ 59.taxes/orincometax/ortaxexemption/ 60.expLEGISLATION,FOOD/ 61.liability,legal/ 62.politics/ 63.FoodIndustry/ 64.expFoodProcessingIndustry/ 65.foodpackaging/orfoodlabeling/ 66.FoodDispensers,Automatic/ 67.Restaurants/ 68.Curriculum/ 69.Schools/ 70.SchoolHealthServices/ 71.FoodServices/ 72.GovernmentPrograms/ 73.Financing,Government/ 74.NationalHealthPrograms/ 75.massmedia/ 76.socialplanning/orenvironmentdesign/ 77.SocialEnvironment/ 78.transportation/ormotorvehicles/ 79.humanengineering/ 80.(publictransitortransitsystem$orbusorbusesorbussing).ti. 81.((sociodemographic$ordemographic$orenvironment$)adj5(factor$orinfluence$ orbarrier$)).ti.
52
82.or/4881 83.urbanization/ 84.urbanpopulation/orurbanhealth/ 85.cityplanning/orurbanrenewal/ 86.residencecharacteristics/orgeographicinformationsystems/ 87.(urban$orcivicorcityorcitiesorsuburb$ormunicipal$orcommut$ orneighborhood$orneighbourhood$).ti,ab. 88.expSUBURBANHEALTHSERVICES/orexpSUBURBANHEALTH/ orexpSUBURBANPOPULATION/ 89.expUrbanHealthServices/ 90.or/8389 91.47and82and90 92.47and90 93.82or90 94.47and93 95.limit94tohumans
53
Appendix C: Article Coding Form and Reference Guide

Author(s): Title: Reviewer: Journal: DateofPublication:
Step1:MainCriteriaforAbstractScan
1. Doesthisarticlefocusononeormoreofthefollowingthemes:Diet/Food,Physical Activity,SedentaryBehaviour,HealthyWeights/Obesityastheypertaintoeffects onpopulations? Yes No Unknown/NeedsFollowUp 2. Areenvironmentalfactors(i.e.settings,sectors)addressed? Yes No Unknown/NeedsFollowUp 3. DoesthisarticleincludeUrbanpopulations? Yes No Unknown/NeedsFollowUp Keepforsuggestedreferences/followup
55
56
Ethnicity Phys Econ Poli S-C Detail Phys Econ Poli S-C Age SES SES Detail Environment Setting Environment Sector Detail Finding Direct.
Step2:FullReviewCodingandAssessment
4.
ArticleFindingsCodingForm
Study ID
Finding Behaviour Sex #
5.
StudyDesign: A1Systematicreviewswhichcontainatleastonerandomizedcontroltrial A2Othersystematicandhighqualityreviews B1Individualrandomizedcontrolledtrials;randomizedexperimentalstudies B2Nonrandomized,experimentalstudies B3Welldesigned,nonexperimentalstudies,controlledstatistically ifappropriate,alsoincludeswelldesignedqualitativestudies C1Descriptiveandotherresearch(e.g.conveniencesamples)notinB C2Casestudiesandexamplesofgoodpractice
6. ArticleFeatureQuality:PlaceanXintheboxthatbestdescribeseach articlesfeatures. Very Poor
StudyFeature 1.MethodandData 2.Sampling 3.DataAnalysis 4.EthicsandBias 5.Findings/Results 6.Transferability/ Generalizability Total
Good
Fair
Poor
Comment
57
CodingReferenceandDefinitions
MainCriteriaforAbstractScan
1. Doesthisarticlefocusononeormoreofthefollowingthemes:Diet/Food,Physical Activity,HealthyWeights/Obesityastheypertaintoeffectsonpopulations? Thisquestionisassessingwhetherthestudyinquestionisexaminingpopulation leveleffectsofoneofthelistedtopicareas.Literatureexcludedusingthiscriteria wouldincludethosethataddressthesetopicsindependentofpopulations(e.g. ChangesinNutrientContentofLettucefrom19752000)ornotexplicitlyfocused onpopulations(e.g.ASurveyofGradeSchoolPhysicalEducationPrograms). Includedstudiesshouldbeexplicitlyfocusedonobesity,butcanalsoexplore anyrelatedhealthconditions(i.e.cancers,cardiovasculardiseases,respiratory conditions,disabilities,etc.). 2. Areenvironmentalfactors(i.e.settings,sectors)addressed? Thisquestionexamineswhetherthestudyfocusesoncommunitylevelsettings orstructuralsectors.Theseincludephysicalenvironments,economicenvironments, politicalenvironmentsandsocioculturalenvironments.Examplesofpapersthat wouldbeacceptedmightbe:TheAccessibilityofGroceryStoresinanUrbanCentre; EconomicBarrierstoPhysicalActivity;DoesIncreasedStairwellLighting IncreaseUsageintheWorkplace?;or,TheImpactofaSchoolFeedingProgram onChildhoodObesity. Studiesnotincludedusingthiscriteriawouldbethoseinwhichthelocation orsettingofthestudyisnotaprimaryfocusofthework.Forexample,although aclinicaltrialmaytakeplaceinahospital,thestudywillnotbeincludedunless thehospital,asaworkplace,wasincludedinthestudyasaprimaryfocus.Similarly, apaperthatexaminesapopulationofchildrenrecruitedfromanelementaryschool wouldbeexcludedunlessthisenvironmentisaprimaryfocusforthepaper(e.g.The EffectofSchoolFoodPolicyonPurchasingBehaviourofJuniorHighStudents). 3. DoesthisarticleincludeUrbanPopulations? Fromtheabstract,itshouldbepossibletodeterminewhetherthepopulation ofinterestinastudyisfromanurbanarea.Often,researchbeingreportedwas conductedatuniversities,whicharegenerallylocatedinurbancentres.Ifnot,the papershouldspecifywhereithasbeenconducted.Iftheoriginofthepopulation isnotspecified,thestudywillneedtobefollowedup.
58
NotationInstructionsforAbstractScan
Consistencyinthenotationusedduringtheabstractscanstageisimportantifthereview istorunsmoothly.Eachreviewedabstractmustbemarkedinsuchawaythatitisclear whetherthearticlehasbeenrejected,accepted,orrequiresfollowup. Ensureallnotationisplacedtotheleftoftheabstract. List1,2and3tocorrespondwiththethreequestionsunderStep1ofthe AssessmentTool. Besideeachnumber,placeeitherYorYesforYes,NorNoforNo,orU/FU forUnknown/NeedsFollowUp,dependingontheappropriateassessmentforthat particularabstract.Pleasedonotusequestionmarks,oranyothermarksotherthan thoselistedaboveifyouareunsureoftheproperresponsetoaparticularquestion, markitasunknownanditwillbefollowedup. Underneaththesethreecriteria,clearlymarkanXifthearticleisbeingrejected; a ifthearticlehasbeenacceptedforfullreviewwithnoreservations;orFollowUp ifthearticleneedsfurtherreviewtodetermineitsstatus. Ifthearticlehasbeenrejectedorifitrequiresfollowup,writeaverybriefnote explainingthereasonforthisassessment.Forexample,Noenvironmentalfactors orNoeffectofdiet/obesity/physicalactivityonpopulationswouldbesufficienthere. Similarly,provideabriefnotedescribinganycriteriathatrequirefollowup,using asimilarformattothatdescribedabove. Ifthearticlehasbeenrejectedbutisperceivedasbeingvaluableintermsofitscontent, conceptualcontributiontothefield,potentialreferencesetc.,clearlynotethisunderneath theotherassessments.FollowupforsuggestedreferencesorFollowupforconceptual contentwouldbesufficienthere.
ConceptualFrameworkSectorsandSettings
Settings Forthisreview,settingsarecommunitylevelfactorsthatplayaroleininfluencingbody weightsintheurbanenvironment.Settingscanbeclassifiedintofourdistincttypes (physical,economic,political,sociocultural)definitionsandexamplespertainingtoeach ofthesetypesaregivenbelow. 1. Physical:Physicalenvironmentalfactorsrefertothebuiltenvironmentoftheurban area.Specificexamplesherewouldincludethedistributionoffoodandphysical activityamenities,includingtheplacementofgrocerystoresorrestaurantsand walking/bikingtrails,aswellasurbanplanningissuessuchaspublictransportation systems.Inmanycases,papersinthiscategorywillconcernthephysicalavailability oraccessibilityofaparticularamenity. Economic:Economicenvironmentalfactorsincorporateafinancialaspectintothe conceptsofavailabilityandaccessibility.Themostcommonthemeforthissetting istheaffordabilityofaparticularitem,beitfoodfromsupermarketsandrestaurants, orsourcesofphysicalactivitylikegymsorrecreationcentres. 59
2.
3.
Political:Politicalenvironmentalfactorsarethosethatexplorepoliciesatthemore personallyoriented(i.e.micro)levels.Thesecanincludefoodandphysicalactivity policiesatschools,workplaces,orevenofindividualpeople. SocioCultural:Socioculturalenvironmentalfactorsareslightlymoreambiguous, exploringtrends,perceptionsandfeelingstowardsfood,physicalactivityorobesity ataslightlybroaderlevel.Papersheremayexploreculturalbarrierstoparticipation inphysicalactivityorofpurchasinghealthyfoodsforaspecificethnicgroup,or theroleofthefamilyenvironmentinpromotinghealthyeatingorphysicalactivity. Particularattentionshouldbepaidtopapersfallingintothiscategoryintermsofthe distinctionbetweenthissettingandthebroaderstructuralsectorslistedbelow themaindifferenceisthatpapersinthiscategorywillpertaintoaspecificethnic grouporfamilyenvironment,forexample,insteadofbeingconcernedwithall familiesorallethnicities.
4.
Sectors Forthisreview,sectorsrefertobroaderstructuralfactorsthatsurroundthemorespecific settingsdescribedabove.Thesewillbepredominantlyconcernedwithpopulationlevel explorationsandanalysesofthefourenvironmenttypes. 1. Physical:Physicalenvironmentalsectorscanexplorethingssuchasgeneraltrends inurbanplanningrelativetophysicalactivityorfood;theroleoftechnologyand automationinpeoplesdailylives;ortheimpactoftransportationsystemsona populationlevel. Economic:Economicenvironmentalsectors,similartothedescriptionofeconomic settingsabove,concernsfinancialaspectsofobesity,physicalactivityand/oreatingat apopulationlevel.Forexample,papersheremayexploretheimpactofsocioeconomic statusonparticipationinphysicalactivityorfoodconsumptionpatterns,ormight provideananalysisofeconomicsubsidiesormarketforcesastheypertaintothe availabilityoffood. Political:Papersconcerningpoliticalenvironmentalsectorsarelikelytoexplore topicssuchastheimpactofspecificpoliciesonfoodcostsoravailability,funding decisionsforpopulationleveleducationprogramsorservices,orhowgovernment taxationorsubsidizationfactorsintoanyaspectofhealthyweights. SocioCultural:Examplesofsocioculturalenvironmentalsectorswouldincludethe impactofglobalizationorothermajorpopulationleveltrendsonobesity,orcultural acceptabilityofobesity.
2.
3.
4.
StudyDesign
SystematicReviewasynthesisoftheresultsofanumberofcomparablestudies todeterminetheoverallstateoftheliteratureforaparticulartopic.Metaanalysis isamethodofsystematicallyreviewingcomparablequantitativeliterature.
60
RandomizedControlTrials(RCTs)RCTsarethegoldstandardinmedicalandother typesofresearch.Subjectsarerandomlyassignedtoeitheratreatment(receiving experimentalcondition)orcontrol(receivingnotreatmentorstandardizedalternate treatment)group.Investigatorsandsubjectsareoftenblindedtowhichgrouptheyare assigned,inordertolimitoreliminatebias.Followingtheapplicationoftheexperimental treatment(s),thetwogroupsarefollowedupandcompared.RCTsaredesirablebecause theyminimizeexternalbiasesandallowformostofthedifferencestobeattributable toexperimentalconditions. ExperimentalStudiessimilartoRCTsdescribedabove,butwithoutmanyofthecontrols. Twoormoregroupsofsubjectsarecompared,butmaynotberandomlyassigned toexperimentalconditions;investigatorsandsubjectsmaynotbeblinded;samplesmay notberandomlychosenfromalargerpopulation.Anexperimentalstudylackingthese controlsmaybesusceptibletoconfoundingvariables,whichcanweakentherelationship betweentheactualexperimentalvariableandtheobservedoutcomes(i.e.differences betweenexperimentalconditionsmaynotbecausedbytheexperimentalcondition, butsomethingelse). NonexperimentalStudiesstudieswheretherearenocomparisonsbetweengroups onlyonegroupisobservedand/orgivenanexperimentaltreatment.Oftenagroup ofsubjectsisassessedonsomedimensionatthebeginningofthestudy(baseline),given anexperimentaltreatment,andthenassessedagainafterwards(prepostdesign).Acommon nonexperimentaldesignisthecrosssectionalapproach,whichtakesasnapshot ofseveraldifferentgroupsofsubjects(e.g.acrossagecategories,ethnicities,etc.)atthe sametimeusingthesamemethod.Oftenthesetypesofstudiesemergefromsecondary analysisofdatafromalargerpopulationsurvey,suchasNHANES(U.S.),Canadian CommunityHealthSurvey(CCHS;Canada),orsimilarlargescaleEuropeansurveys. Manyqualitativestudiesfallintothiscategoryaswell,includingobservations,interview studiesandcasestudies. Thesecondcategoryofnonexperimentalstudies(C1)includesdescriptiveresearchand lessstronglydesignedstudiesofthetypedescribedabove.Forexample,asmallonetime surveyorobservationthatdoesnotaccountformanypotentialbiases(e.g.population effects,timeofdayeffects)wouldbeincludedinthiscategory.Thesestudiesoftensample basedontheconvenienceofsolicitingparticipantswithsomedesiredcharacteristic(s), ratherthanfocusingoncontrollingthesebiasesthroughrandomselection.Another majordifferencebetweenthesestudiesandthoseinB3isthattheabilityofthereviewer tomakeanyconclusionsconcerningthevalidityandreliabilityofthestudyislimited asthenumberofpotentialbiasesincreases. CaseStudiesandExamplesofGoodPracticecasestudiesaregenerallyanindepth descriptionofasingleperson,placeorobject.Examplesofgoodpracticemightencompass casestudiesofrelevantpoliciesand/ordescriptionsofpracticallyappliedresearch.
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ArticleFeatureQualityAssessmentGuide
1. MethodandData:Isthemethodappropriateandclearlyexplained? Good Fair Poor Methodisappropriateanddescribedclearly(e.g.questionnaires included).Cleardetailsofthedatacollectionandrecording Methodappropriate,descriptioncouldbebetter.Datadescribed Questionablewhethermethodisappropriate.Methoddescribed inadequately.Littledescriptionofdata
VeryPoor NomentionofmethodAND/ORmethodinappropriateAND/OR nodetailsofdata 2. Sampling:Wasthesamplingstrategyappropriatetoaddresstheaims? Good Details(age/gender/race/context)ofwhowasstudiedandhowtheywere recruited.Whythisgroupwastargeted.Thesamplesizewasjustified forthestudy.Responseratesshownandexplained Samplesizejustified.Mostinformationgiven,butsomemissing Samplingmentionedbutfewdescriptivedetails
Fair Poor
VeryPoor Nodetailsofsample 3. DataAnalysis:Wasthedescriptionofthedataanalysissufficientlyrigorous? Good Cleardescriptionofhowanalysiswasdone.Qualitativestudies: Descriptionofhowthemesderived/respondentvalidationor triangulation.Quantitativestudies:Reasonsfortestsselectedhypothesis driven/numbersaddup/statisticalsignificancediscussed Descriptivediscussionofanalysis Minimaldetailsaboutanalysis
Fair Poor
VeryPoor Nodiscussionofanalysis 4. EthicsandBias:Haveethicalissuesbeenaddressed,andhasnecessaryethical approvalbeengained?Hastherelationshipbetweenresearchersandparticipants beenadequatelyconsidered?Assessmentshouldreflectboththedescriptionwithin thearticle,aswellashowtheseissuesactuallyaffectthearticlebeingassessed. Good Fair Poor Ethics:Wherenecessaryissuesofconfidentiality,sensitivityandconsent wereaddressed.Bias:Researcherwasreflexiveand/orawareofownbias Briefmentionofissues Lipservicewaspaidtoabove(i.e.theseissueswereacknowledged)
VeryPoor Nomentionofissues
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5.
Results:Isthereaclearstatementofthefindings? Good Findingsexplicit,easytounderstand,andinlogicalprogression.Tables, ifpresent,areexplainedintext.Resultsrelatedirectlytoaims.Sufficient dataarepresentedtosupportfindings Findingsmentionedbutmoreexplanationcouldbegiven.Datapresented relatedirectlytoresults Findingspresentedhaphazardly,notexplained,anddonotprogress logicallyfromresults
Fair Poor
VeryPoor Findingsnotmentionedordonotrelatetoaims 6. TransferabilityorGeneralizability:Arethefindingsofthisstudytransferable (generalizable)toawiderpopulation?LikeQuestion4,thisassessmentshouldfactor inboththedescriptioninthetextaswellaswhatthegeneralizability/transferability ofthearticleactuallyis. Good Fair Poor Contextandsettingofthestudyisdescribedsufficientlytoallowcomparison withothercontextsandsettings,plushighscoreinQuestion2 Somecontextandsettingdescribed,butmoreneededtoreplicateor comparethestudywithothers,PLUSfairscoreorhigherinQuestion2 Minimaldescriptionofcontext/setting
VeryPoor Nodescriptionofcontext/setting
ArticleCodingIndex
Note:Step1willnotbecoded,becauseallarticlesadvancingtothefullreviewstagewill allhavethesameresultsforthisstep. Step2:LiteratureCodingAssessment StudyDesign:A1=1,A2=2,B1=3,B2=4,B3=5,C1=6,C2=7 ArticleFeatureQuality:Eachofthesixarticlefeaturesshouldbecodedusingthe followingscaleGood=1,Fair=2,Poor=3,VeryPoor=4 Step3:FullArticleReviewCoding StudyID:thefirstauthorslastnameplusthelasttwodigitsoftheyearitwaspublished (e.g.Smith95). Finding#:foreachparticularstudy,theremaybeaseriesoffindingsthatarepresented. Becauseeachofthesefindingsistobecapturedseparately,anumberneedstobeassigned toeachonetokeeptheminorder.
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Behaviour:ThiscorrespondstothefourthemesofthereviewDiet/Nutrition(1), PhysicalActivity(2),Obesity/HealthyWeights(3),andSedentaryBehaviour(4). Sex:Male(1),Female(2),Both(3)orNotDistinguished/Applicable(4). Ethnicity:Theethnicityoftheparticipantsbeingresearchedinthestudy.Someexamples includeCaucasian/White(1),Black(2),Hispanic/Latino(3),Aboriginal/Native(4), Other(5)orNotDistinguished/Applicable(6). Age:Thegeneralageoftheparticipantsbeingresearched.Therangeofcodesincluded herewouldhaveYoungChildren(1),Adolescents/Teenagers(2),Adults(3),Older Adults(4),NotDistinguished/Applicable(5). SES:Thesocioeconomiccharacteristicofthefindingbeingreported.Codeswillinclude Income(1),Education(2),Employment(3),Composite/Index(4),orNotDistinguished/ Applicable(5)withspaceinthedetailcolumntoprovidemoreinformationaboutwhat isbeingexamined. EnvironmentSetting/Sector:Thissectionwillindicatewhichofthelistedsettingsand sectorsarebeingexaminedinthearticle.Placethenumeral1intheboxthatcorresponds totheenvironmentalsettingorsectorassociatedwiththatparticularfinding,andplace a0intheothersettingsandsectorstoshowthattheyarentbeingexamined.Inthe Detailbox,pleasenotethespecificsettingorsectorunderexamination(e.g.school). FindingDirection:Thisboxwillnotewhatthedirectionofthefindingis,asoutlined onpage7oftheprojectproposal.Thecodesherewillbeasfollows:NoAssociation(0); NegativeAssociation(1);Direct,positiveassociation(2);UshapedAssociation(3). GeneralNotesAboutCoding:Thegeneralformatforcodingastudybeginswith determininghowmanyfindingsneedtobereported.Oftentimesstudieswillreport resultsformorethanonegroupofparticipants(e.g.menandwomen;AfricanAmerican, CaucasianandHispanic),orformorethanonelevelofanalysis(e.g.multilevelstudies thatexamineparticipantswithinaneighbourhoodcontext).Thesestudiescansometimes includemorethanoneofthesedivisions(e.g.AfricanAmericanmen,AfricanAmerican women,Caucasianmen,Caucasianwomen);thus,findingsneedtobereportedforall ofthesepopulations.Alineinthecodingsheet(andsubsequently,inthedatabase)will becreatedforeachofthesedistinctpopulationsorenvironments;fortheexampleabove withAfricanAmericanandCaucasianwomenandmen,4linesonthecodingsheetmust beusedtoreportthisinformation.Shouldthesamepaperincludemultilevelmodeling, forexamplelookingatthesamepopulationattheindividualandcommunitylevels,8lines willneedtoberecorded. Thepointofconstructingthecodingthiswayistobeabletoempiricallyanalyzethe relationshipsbetweenanyoneofthelistedpopulationsand/orenvironmentalsettings (e.g.researchdemonstratesthatin7of10studies,thebodyweightofAboriginalmen isadverselyaffectedbythephysicalenvironment). 64
Someotherpoints: Anarticlewillsometimesreportmorethanonemeasureofthebehaviourinquestion (e.g.physicalactivityselfreports,accelerometers,etc.).Inacaselikethis,firstdetermine ifthereisageneralpatternacrossallmeasuresofthebehaviour(e.g.bothselfreports andaccelerometersresultinthesamedirection);ifthereisdiscordbetweentwo ormorebehaviourmeasures,separatethetwomeasuresintotwofindingsandmake anoteofthediscrepancyinthedatabaseinthedetailssectionoftheenvironmental setting/sector. Ifthereisnosignificancereportedforatrendpresentedinasetofresults,orifafinding isnotreportedassignificantinthetextofthearticle,reportthefindingdirection asnoassociation.Itislikelythatauthorswillhighlightthesignificantresultsoftheir workintheresultsordiscussionsectionsofthepaper,soreportfindingdirections basedonthisassumption.Shouldacaselikethisarise,besuretoratethequality ofthearticlesresultsaccordingly(i.e.lowerthaniftheresultswerecompletely reported/explained). Similarly,qualitativepapersdonothavetheluxuryofstatisticalsignificancetoaid indeterminingthedirectionofafinding.Forthesepapers,lookagaintotheresults anddiscussionsectionstoseewhattrendswerestrongenoughtobereported. Theissueofcodingsocioeconomicstatusispotentiallyproblematic.SinceSEScanbe researchedandreportedinmanydifferentwaysandonmanydifferentlevels,these guidelineswillundoubtedlybemodifiedasthereviewprogresses.However,hereare somebasicguidelines: Manystudies,especiallythosethatlookatmorepopulationlevelstatistics,usea compositeindicatororindextorepresentSES(e.g.deprivationindex).Anewcode hasbeencreatedtocapturethese,aswellasotherindicatorsofsocioeconomicstatus otherthanthetraditionalincome,educationandemployment. TherewassomeconfusionastohowSESshouldbecoded,andthislargelydepends onthewaySESisbeingexaminedinthestudy.IfSESisbeingreportedorcompared acrossanumberofgroupsandisthemajorfocusoftheanalysisbeingundertaken, itshouldbecodedasanenvironmentalsettingorsector.Morespecifically,inthe casethatSESisreportedasavariableacrossasampleofpeople,itisclassified asanenvironmentalsector.IfSESisonevariableofacrosssectionaltypedataset, itshouldbecodedintheSEScolumnusingoneofthepreviouslydefinedcodes (income,education,etc.).Forexample,ifSESisexaminedasacharacteristicofa neighbourhoodorcommunity,theSEScolumniswherethisshouldbecoded. Caseswillarisewheremorethanonelevelofresultswillbereported;forexample, genderstratifiedresultscouldbegivenforfemales,malesandforbothgroups together.Wewouldliketoonlycapturethemostdetailedlevelofresults,soonly thefemaleandmaleresultswillberecordedandnotthetwogroupstogether.
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Measuresofphysicalfitnessarenotbeingrecordedhere. Sedentarybehaviourisnotthesameasreversephysicalactivitythetwoare mutuallyexclusive.Assuch,anewcodehasbeencreatedtocapturestudiesthatlook atsedentarybehaviour. Variableslikerolemodeling,familyenvironmentandsupportiveenvironmentsshould becodedassocioculturalsectorsorsettings.
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Appendix D: Online Stakeholder Survey

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Appendix E: Bibliography of Assessed Literature

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Appendix F: Bibliography of Policy Documents
Appendix F: Bibliography of Policy Documents

Auld,M.C.andL.M.Powell.TheEconomicsofObesity:ResearchandPolicyImplications FromaCanadaU.S.Comparison,2005,[online],citedJanuary18,2006,from <http://jdi.econ.queensu.ca/Files/Conferences/HealthServicesconferencepapers/Auld_P owell_paper.pdf>. CanadianInstituteforHealthInformationandCanadianInstitutesofHealthResearch. ObesityinCanada:IdentifyingPolicyPriorities.Ottawa:CanadianInstituteforHealth Information,2003,[online],from<http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page= GR_1066_E&cw_topic=1066>. Groupedetravailprovincialsurlaproblmatiquedupoids.WeightProblemsinQuebec: GettingMobilized.Montral:AssociationpourlasantpubliqueduQubec,2004. HealthServicesandPromotionBranch.PromotingHealthyWeights:ADiscussionPaper. Ottawa:HealthandWelfareCanada,1988. HeartandStrokeFoundation.InterventionsRelatedtoObesity:AStateoftheEvidence Review.Ottawa:HeartandStrokeFoundation,2005. HeartandStrokeFoundation.TargetingFutureObesityResearch:CanadianExpertsIdentify CriticalKnowledgeGaps.Ottawa:HeartandStrokeFoundation,2005,[online],cited January25,2006,from<http://ww2.heartandstroke.ca/Page.asp?PageID=33& ArticleID=4279&Src=news&From=SubCategory>. McLaren,L.etal.AreIntegratedApproachesWorkingtoPromoteHealthyWeightsandPrevent ObesityandChronicDisease?Calgary:UniversityofCalgary,2004. Raine,K.OverweightandObesity:APopulationHealthPerspective.Ottawa:Canadian InstituteforHealthInformation,2004,[online],from<http://secure.cihi.ca/cihiweb/ dispPage.jsp?cw_page=GR_1130_E>. RegisteredNursesAssociationofOntario.PrimaryPreventionofChildhoodObesity. Toronto:RegisteredNursesAssociationofOntario,2005. Thomas,H.etal.EffectivenessofPhysicalActivityEnhancementandObesityPrevention ProgramsinChildrenandYouth.Ottawa:HealthCanada,2004.
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Appendix G: Potential Policy Instruments Categorized Using the ANGELO Framework
Appendix G: Potential Policy Instruments Categorized Using the ANGELO7 Framework

Physical Settings Policy options that seem Micro/meso environments primarily regulatory in nature: Review of PA municipal by-laws be undertaken to determine whether they encourage or discourage physical activity at the neighbourhood and broader urban levels166 Facilitate active PA transport by creating streets that incorporate pedestrian use and bicycle facilities and that are calmed (discourage high-speed vehicle traffic)164 Implement development plans that encourage the use of active transportation, family-oriented parks and sports facilities for adults159, 164 PA ELiv Economic EL Political or Policy EL Socio-Cultural Policy options that seem primarily procedural in nature: Help communities to set up babysitting services to make it easier for parents to make use of sports facilities or exercise159 PA EL
Provide incentives BW to promote healthy weight programs that are developed and implemented on an interagency and multidisciplinary basis158 Encourage largescale communitybased program models that support healthy weight activities based on strong community involvement158 Help start community programs for physical exercise and the adoption of realistic goals regarding weight and appearance159 BW
Increase PA community access to exercise facilities such as those in schools to enhance opportunities for adults and children to participate in regular physical activity158
PA, BW
(tablecontinuedonnextpage)
iv. TheEL(EvidenceLink)categorieslinktheidentifiedpolicyoptionswithevidencedescribed intables2and3onpage27. Notes: FDN=Food,DietandNutrition;PA=PhysicalActivity;S=SedentaryBehaviour;BW=BodyWeight. ReferencesforciteddocumentsappearintheReferenceList.
101
Physical
EL
Economic
EL
Political or Policy EL
Socio-Cultural
EL
BW Whole worksite interventions to facilitate health (incentive system)167
Encourage schools, All work-sites and community groups to develop and implement model programs promoting healthy weights158
Whole school interventions to facilitate health167 Encourage community-based demonstration projects, familycentred or at work-sites, with mutual aid or self-help groups158 Encourage voluntary organizations to develop programs and leadership training in promoting healthy weights158 Encourage workplace wellness and employee fitness programs that are supportive of the healthy weight concepts158 BW
Policy options that seem primarily informationbased: PA Encourage politicians, developers and consumers to consider the importance of the relationship between urban design and obesity166 Encourage FDN collaborative, community-based efforts to promote policies to support the availability of a wider selection of healthy food choices in schools, work-sites, restaurants, fastfood franchises and other community settings158 Work with private- All and public-sector employers to develop a workplace environment that promotes healthy weights164
BW
PA, BW
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Appendix G: Potential Policy Instruments Categorized Using the ANGELO Framework
Physical Transitional (That is, could be implemented in either settings or sectors)
EL
Economic Policy options that are based on expenditure instruments: Fiscal policies to facilitate healthy lifestyles (food and recreation)167
EL
Political or Policy EL Policy options that seem primarily informationbased:
Socio-Cultural
EL
PA, Determine the FDN impact on obesity and health of education initiatives, income support programs, and recreational initiatives166 Policy options that seem primarily regulatory in nature: FDN Regulating advertising time to ensure healthy foods receive equal time164 FDN A dialogue on the autonomy and authority of municipalities concerning obesity and health-related issues in Canada166 BW Encourage citizen BW groups to foster appropriate images of body shape in the media158 Policy options that seem primarily informationbased:
Sectors Macro environments or social structural conditions
Policy options that seem primarily regulatory in nature:
Policy options that are expenditurebased: Adopt fiscal measures involving tax reductions for fees related to participation in sports159
Municipalities be able to plan and raise revenue for sustainable urban design and transportation166
PA
Develop a tax (similar to the GST/HST) to subsidize the cost of low-energy nutritious foods164
Policies that support BW adequate income164
Support the adoption of regulations FDN Promote policies to increase the that encourage number of hours food producers and of physical activity manufacturers in schools159 to provide foods of lower energy value and high nutrient value158
PA
Taxation policies to PA promote physical activity; removal of sales tax from exercise equipment;164, 165 and tax incentives for employers who provide their employees with fitness facilities164
Regulation of FDN Start a campaign advertising and to change social promotion of foods standards leading for children (TV to the population's watching and understanding and advertising)158, 159, integration of the 164, 167, 168 idea of a healthy body weight159
BW
103
Physical Policy options that are expenditurebased: Taxes to discourage urban sprawl: congestion/ traffic taxes, rush-hour tolls, subdivision fees, and gasoline taxes to encourage densification and active commuting164
EL PA
Economic Policy options that are primarily informationbased: Explore food insecurity in relation to obesity166
EL
Political or Policy EL Restriction on junk food advertising during peak TV viewing times for children164, 167 FDN
Socio-Cultural
EL
BW
FDN Legislation to regulate portion size and disclosure of nutritional content on snacks and fast foods at point of sale and on product labels164
Research differences in obesity according to such factors as socio-economic status, region, and level of urbanization166 Determine the impact on obesity and health of education initiatives, income support programs, and recreational initiatives166
All FDN, Development of BW a national school health program modelled on a program originally developed and implemented in 1995 (Pan-Canadian Curriculum)166 All Development of an official body, based within a larger public health agency, for monitoring school health166 All
All Investigate the impact on obesity and health of decisions in nonhealth sectors, such as education, transportation, food, and recreation166
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Appendix H: Aggregate Results From Online Stakeholder Survey
Appendix H: Aggregate Results From Online Stakeholder Survey

Question1:Threefactorsthatimpacthealthyweightsinanurbanenvironment(Settings andSectorsanalysis)
Settings Physical No. of responses 33 Economic 4 Political 1 SocioCultural 9 Sectors Physical 19 Economic 5 Political 4 SocioCultural 2
Note:Atotalof77responsesareincluded.Oneresponsewasnotincluded(barriersto physicalactivity)becauseoflackofinformation.Sixresponseswereputintotwocategories. Question2:Arethefactorsinquestion1modifiablebyapolicyresponse?

Settings Physical Yes No Not sure No answer Total 32 0 1 0 33 Economic 4 0 0 0 4 Political 1 0 0 0 1 SocioCultural 6 2 1 0 9 Sectors Physical 17 0 0 2 19 Economic 4 0 1 0 5 Political 4 0 0 0 4 SocioCultural 1 0 1 0 2
Question3:Listupto3policies/programs/initiativesthatyouknowof:
Settings Physical No. of responses 9 Economic 2 Political 11 SocioCultural 4 Sectors Physical 4 Economic 1 Political 18 SocioCultural 5
Note:Tworesponseswereputintotwocategories,foratotalof54responses.
105
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State of The Evidence Review On Urban Health and Healthy Weights

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3.3.2 3.3.3 3.3.4 3.3.5 3.4

Data:PhysicalActivity.................................................................................... 24 3.4.1 3.4.2 3.4.3 3.4.4 3.4.5

3.5 3.6 3.7

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