Eat Better, Move More, Work Together

By Marya Morris, FAICP

"Energy balance" is a phrase that doctors and nutritionists often use to advise patients on maintaining a healthful diet and getting regular physical activity. It is an equation of sorts that measures the number of calories, or energy, a person consumes relative to how much energy the person burns.

Increasingly, health care professionals aren't the only ones with skin in this particular game. In neighborhoods and towns everywhere, planners and public health officials are tackling energy balance at the neighborhood, community, and regional scales through targeted efforts to increase access to healthy foods and opportunities for regular physical activity.

In 2014, with funding from the Centers of Disease Control and Prevention, APA teamed up with the American Public Health Association to establish Plan4Health, a program that has delivered grants totaling $4.5 million to 35 U.S. communities. The funds support creative partnerships and build sustainable cross-sector coalitions that are committed to increasing health equity. APA members and their public health colleagues are key program leaders.

In many respects, Plan4Health is a manifestation of the growing movement to strengthen the intersection between planning and public health. By diving deep into community deliverables, Plan4Health coalitions are pursuing policy, systems, and strategies that will make real changes possible.

Numerous jurisdictions are already using planning to improve health outcomes, while others are just getting started. No matter where grant recipients fall on that spectrum, they all are taking big strides toward implementing plans that will create healthier communities for all residents.

Photo by Farakos/Thinkstock.

Laying the groundwork

Planners know that in order to implement good ideas, you first need a strong foundation. For Plan4Health grant recipients like the F.R.E.S.H. Coalition in Wisconsin and the Bike Ajo Coalition in Arizona, the basics of coalition building and local capacity building were the first order of business.

Residents of rural northeastern Wisconsin, many of whom live below the poverty line, have an unexpected problem: Agriculture is the area's main economic driver yet there is a shortage of healthy food available to local households. Access is particularly limited for members of the Ho-Chunk Nation, Menominee Indian Tribe, and Stockbridge-Munsee Band of Mohican Indians in Shawano and Menominee counties, where residents' rates of diabetes, coronary heart disease, and obesity are higher than the national averages.

Poor diets and a lack of healthy food options are in no small part to blame for the counties' poor health rankings (countyhealthrankings.org). In fact, only two Shawano County municipalities have full-service grocery stores and Menominee County has only one. Only 95 of the 1,200 farms in the area sell local products directly to customers.

In late 2015, a Plan4Health grant got the F. R.E.S.H Coalition (F.R.E.S.H. stands for Food, Resources, Education, Security, and Health) off the ground in an effort to improve access to healthy foods for residents in those counties.

In Ajo, Arizona, Bike Ajo worked with partners to provide 50 bicycles to the community in an effort to embrace cycling for health promotion, recreation, and as an economic driver. Photo courtesy Bike Ajo Coalition.

"Our first objective was to get an idea of what barriers people face to accessing healthy food," says Dan Robinson, the F.R.E.S.H. project coordinator, whose position is housed in the Shawano County Planning Department. That required surveying households to ask about food prices and preferences and shopping and consumption habits. The survey also is tracking how far away the households are located from fresh food.

"Our goal was to get 350 returned surveys, but we ended up with more than 750 usable returns," says Robinson. "We used every avenue imaginable to get people to respond." That meant going door to door and visiting WIC Clinics and food pantries, community dinners, back-to-school nights, the farmers market, and the county fair, and leveraging conventional advertising and social media tools. He notes that the coalition's success in getting the word out about the survey also helped educate the public about both the problem of food insecurity and the work of the project.

The survey results, along with data from grocery store and farm stand vendors and focus group feedback from food pantry patrons and workers, are currently being analyzed. In the meantime, the F. R.E.S.H. Coalition is working to broaden its membership and to provide training to the group's core leadership team on how to form a local food council. The final product will be a series of recommendations on how to increase food security in the region.

On the other side of the country, in Pima County, Arizona, grant funds also went toward building local capacity.

The county is nationally recognized for its bicycle and trail infrastructure, as well as its support system for bicycle commuters and recreational riders. But the benefits of those efforts were out of reach for residents of rural Pima County, where an obesity rate of 15 percent and a persistently high unemployment rate were the norm.

In 2015 the Pima County Bike and Pedestrian Program — part of the Pima County Department of Transportation and spearheaded by a planner — working with its partners at the University of Arizona School of Public Health, used a Plan4Health grant to establish a bicycle coalition and sustainable bicycling hub to educate, train, provide resources, and build a health-based partnership in the rural community of Ajo (pop. 3,000).

The Bike Ajo Coalition was modeled on existing efforts in two urban Tucson neighborhoods. It aims to promote biking, increase opportunities for physical activity, and develop corresponding diabetes prevention education and resources.

A community assessment in the initial months of the project identified safety and the lack of tools or skills to repair bikes as the two biggest barriers to Ajo residents embracing bicycling for transportation and recreation.

Ajo residents were generally supportive of the program concept from the start. "But when the bikes arrived, it was like a light switch got flipped, and now it's really taking off," says Martha Moore-Monroy, lecturer at the University of Arizona and the Plan4Health project manager.

The county purchased 600 helmets and 38 bikes for kids and Plan4Health supported the purchase of an additional 12 bikes for adults. Bicycle repair tools were purchased for use at the sustainable cycling hub (housed at the Desert Senita Community Health Center) and several community members have become League of American Cyclists-certified instructors and are trained to do bicycle repair.

The Plan4Health coalition in Thomas County, Kansas, is working to improve the food system in part through school and community gardens. Photo courtesy Thomas County Coalition.

Mapping a way forward

The Plan4Health project has helped some coalitions to scale up existing efforts and transfer their successful models to underserved neighborhoods.

In 2014, the National Region office of the Rails-to-Trails Conservancy in Baltimore and Bikemore, the region's bicycle and pedestrian advocacy group, were working together to identify missing segments in the region's 35-mile urban trail network.

"Through a mapping exercise it became clear that the gaps were in or adjacent to Baltimore's most economically disadvantaged neighborhoods," says Jim Brown, RTC's manager of trail development.

The team found that struggling neighborhoods on the west and east sides had neither trail connections nor ready access to parks and open spaces. "We knew we were on to something," says Brown. "Filling in these trail gaps could actually improve social and health equity in the city — it could be more than just another trail connection project."

Last September, with funding from Plan4Health, the newly formed Baltimore Greenway Trails Network Coalition launched a targeted community outreach pilot project that aims to eventually connect Druid Hill Park on Baltimore's west side to surrounding neighborhoods and the future trail system. Graham Coreil-Allen, a local artist, painted a symbolic decorative crosswalk across eight lanes of roadway to represent the safe passage that will link Druid Hill to the trail system.

Brown, who also serves as project manager for the Plan4Health grant, says the coalition's broader focus on health and equity has helped increase political support and funding for trail planning by bringing more voices than the "usual suspects" to the table, like community development organizations, commercial developers, and business leaders. Those groups already are invested in neighborhood revitalization in Baltimore and the trail links are a logical continuation of that work.

Mapping is also a key part of the planners' toolkit in Mecklenburg County, North Carolina, which is a national leader in assessing and mapping health disparities within its jurisdiction. Using the Charlotte Mecklenburg Quality of Life Explorer interactive mapping system, the county identified public health priority areas in which there is demonstrable health inequity compared with county averages. The determinants of health that were used include race/ ethnicity, economic characteristics and assistance, educational attainment, health and safety, housing, and transportation.

"Residents within the public heath priority areas in Mecklenburg County have a life expectancy that is seven years less than someone living elsewhere in the county. This clear picture of health inequity was the driver behind our project and the selection of healthy community strategies," says Michelle Nance, AICP, planning director for the Centralina Council of Governments and head of the Centralina Health Solutions Coalition, the Plan4Health grantee.

Physical proximity of neighborhoods to active living opportunities and healthy food options does not equate to access to such resources. In Mecklenberg County, the relatively high population density in the public health priority areas means people do live close to health care providers, public outdoor recreation, and grocery stores. But barriers to access in the form of safety, affordability, and quality still exist. In a positive vein, the "bones" to build access — sidewalks, transit service, and parks — are in place. The coalition is working with individual neighborhoods to further identify needs through community assessments and carry out walking and bicycling audits, shared use agreements, and park access audits.

"The most important thing our coalition can do now is to develop local neighborhood leadership to speak with their own voice, [and] understand the process for change," says Nance. "They will then be armed with the information needed to impact decisions that affect their streets and blocks and that will increase local opportunities for physical activity."

All about implementation

The Thomas County Coalition in Kansas addresses the dual objectives of increasing physical activity and encouraging healthy lifestyles.

Formed in 1996, the group's initial focus was on substance abuse prevention. In 2008 the focus shifted to promoting active living and healthy lifestyles. In the last decade the coalition spearheaded the construction of 2.2 miles of public walking trails, most of which are in the town of Colby (pop. 5,800), the county seat. With funding from a previous CDC grant, the coalition hired Vanessa Spartan, AICP, a bike and pedestrian consultant with Wilson & Company, Inc. in Phoenix, to prepare a Walking & Biking Master Plan that was adopted in June 2015.

The coalition's Plan4Health grant has enabled Colby to quickly move forward to implement the plan, which recommended a complete streets policy. Spartan was rehired to do that piece and it was adopted by the city council in October 2016.

Sue Evans, the Plan4Health project director in Thomas County, notes that the coalition's involvement in built environment interventions to improve health has spurred the city and county to start the process of updating their comprehensive plan and zoning and subdivision ordinances.

"We plan to be very involved in that, and will be at the table to ensure that health goals are included in every relevant aspect of the plan and ordinance," she says. "We want to make sure sidewalk infrastructure spending is spread into neighborhoods that have been overlooked and that new street and sidewalk standards accommodate unconventional modes like adult-sized tricycles and scooters."

In addition to encouraging active living, the Thomas County Coalition is assessing the "food and beverage" environment in public agency workplaces — city and county government, public schools, and the local community college — to identify how to make more healthy foods available and encourage healthier nutritional choices.

"Our core goals have been to improve access to and consumption of water in place of sugary beverages," says Evans. They are also supporting workplace wellness committees which are currently considering policies to present to their leadership on food and beverage issues, like what kinds of food are served at meetings, encouraging walking meetings, and substituting water in place of unhealthy drinks.

The overall vision for the Thomas County Coalition is to become the healthiest county in the state of Kansas, says Evans. According to the County Health Rankings, it is currently number two, behind only Johnson County in suburban Kansas City. By stretching and leveraging every grant dollar and engaging its many partners along the way, they just might make it.

Marya Morris, FAICP, is a planning and zoning consultant and a freelance writer based in Glencoe, Illinois. She is also a member of the Glencoe Plan Commission.