1. Moore, Justin B. PhD, MS

Article Content

It would appear that in the last century, public health in the United States has come full circle. As any student of the history of public health can attest, the greatest challenges to the nation's health in the early 1900s were predominantly related to the control of infectious diseases. The solutions to these challenges tended to be related to a two-pronged approach that involved changing the environment (eg, sanitation) while concurrently working at the individual level (eg, immunization, screening). While the leading causes of death over this span of over a century have shifted dramatically away from infectious diseases toward chronic diseases related to lifestyle, the solution still rests in a modification of the environment in conjunction with individually targeted intervention. A perfect example of this is tobacco use. A dramatic reduction in smoking behavior in the 1990s appears to have translated to a reduction in cancer deaths, first observed in 2000.1 If one examines the recommendations set forth in the Guide to Community Preventive Services regarding tobacco prevention and reduction, one can clearly see an ecological approach in place. The Task Force recommended intervening at multiple levels that included policy, environment, and interpersonal and intrapersonal approaches. However, despite the success of this ecological approach to reduce initiation and increase cession of tobacco use, the vast majority of interventions to promote physical activity are at the interpersonal and intrapersonal levels.


Since the Healthy People report in 1979, much attention has focused on personal behavior choices, with the understanding that these choices exist in the context of one's environment and socioeconomic status. Since that time, interventions targeting some specific behaviors such as tobacco use have shifted from this intrapersonal focus to a more ecological approach that targets behavior at multiple levels. Physical activity interventions have unfortunately remained largely targeted at the "lower levels" of the model due to factors inherent to the behavior itself. Foremost is that physical activity is very different from tobacco use in that for one to be healthier, one must engage in a behavior rather than avoid or cease a behavior. Physical activity is different from healthy eating in that one must monitor a necessary behavior to eat more healthily, but the behavior of eating is ongoing if one is to sustain life. To the contrary, one must actively seek out physical activity in the modern world as our communities and jobs have become increasingly sedentary. However, despite obvious differences, physical activity has much in common with healthy eating, in that the environment has changed drastically over the last 50 years to discourage both practices. The rise of fast food, the lack of access to produce in the inner cities, the increase of marketing of fat and sugary foods have coincided with the rise of suburban flight, increased automation of jobs, and increased automobile ownership. These environmental changes have worked in collusion to produce the highest obesity rates in history. If there is to be sustained change, public health professionals need to work together to develop multilevel interventions that start with environmental changes and end with intraindividual level programming, not the other way around.


In the last decade, considerable progress has been made in this direction. The Robert Wood Johnson Foundation (RWJF) has led much of this progress by funding Active Living Research and Active Living by Design, which continues to fund built-environment/ physical activity research and community projects that promote physical activity, respectively. Thanks to funding from these programs and other governmental sources, the knowledge base has grown substantially. In 2006, Heath and colleagues published an article on behalf of the Task Force on Community Preventive Services that reported "strong" or "sufficient evidence" to support three "Environmental and policy approaches to increasing physical activity" and concluded that "implementing these policies and practices at the community-level should be a priority of public health practitioners and community decision makers."2(pS55) However, the authors of this article astutely point out that very little guidance has been given to public health researchers and practitioners on how to actually implement these recommendations or even which specific changes to employ.


As we move forward, it is of the utmost importance to remember that this is a collaborative effort if lasting and substantial changes are going to be made in the behaviors of the communities that we serve. As with tobacco cessation efforts, we must layer our programming in a manner that will saturate the social environment while simultaneously modifying the built environment to complement these programs. For example, children are much more likely to achieve the recommended 60 minutes of physical activity3 if they can walk to school, have recess, receive quality physical education, and have access to active after-school programming, green spaces, recreation activities, bike lanes, and walking trails. This ecological approach is paramount, as it is very likely that the achievement of an active lifestyle for all will come from the cumulative effect of our efforts being greater than the sum of our individual contributions. As you will see, the articles comprising this special issue examining the built environment and health highlight how far this concept has advanced.




1. Thun MJ, Henley SJ, Burns D, Jemal A, Shanks TG, Calle EE. Lung cancer death rates in lifelong nonsmokers. J Natl Cancer Inst. 2006;98(10):691-699. [Context Link]


2. Heath GW, Brownson RC, Kruger J, et al. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review. J Phys Activity Health. 2006;3(1):S55-S76. [Context Link]


3. Strong WB, Malina RM, Blimkie CJ, et al. Evidence based physical activity for school-age youth. J Pediatr. 2005;146(6):732-737. [Context Link]