Getting on the Land Use Diet

Created by Andrea Trabelsi and Justin Dahlheimer

National concerns with health problems and rising health care costs have led leaders and citizens alike in search of new ways to promote healthier lifestyles and get at the health care dilemma through prevention.  While people's lifestyles certainly impact their health, even the most health-conscious people are bound by their surrounding environment, especially outside of the home. Land use decisions impact our health on a daily basis.  The following list is a summary of land use impacts on public health pulled from the Eastern Neighborhood Community Health Impact Assessment Final Report (2007).

  • Relatively expensive housing may force low-income tenants to use more of their resources to obtain shelter, leaving less for other necessities such as food.
  • Overcrowded housing conditions contribute to mortality rates, infectious disease risk, and respiratory infections.
  • Children living in homeless shelters have been found to suffer from depression, have a behavioral problem, or have severe academic delay.
  • Residential segregation is associated with teenage childbearing, tuberculosis, cardiovascular disease, availability of food establishments serving healthy foods, and exposure to toxic air pollutants.
  • Segregated neighborhoods have been shown to have fewer assets and resources, such as schools, public transportation, food retailers and libraries, than non segregated neighborhoods and a host of unwanted land uses such as power plants, solid and hazardous waste sites, and bus yards.
  • Substandard housing conditions can increase the risk of injury through exposed heating sources, unprotected upper-story windows and low sill heights, slippery surfaces, and breakable window glass in sites with a high likelihood of contact, and poorly designed stairs with inadequate lighting.

  • Living in proximity to high-traffic density or flow results in reduced lung function and increased asthma hospitalizations, asthma symptoms, bronchitis symptoms, and medical visits.
  • Sidewalk cleanliness and width, street design for pedestrian safety and speed control, and street lighting influence levels of pedestrian walkability and neighborhood crime and safety.
  • Walking or biking to work helps meet minimum requirements for physical activity.
  • People walk on average 70 minutes longer in pedestrian-oriented communities
  • Chronic noise exposure can adversely affect sleep, school and work performance, and cardiovascular disease.
  • Both the number of neighborhood parks in proximity to one's residence and the types of amenities at the park predict the duration of physical activity in children.
  • Living in proximity to green space is associated with reduced self-reported health symptoms, better self-rated health, and higher scores on general health questionnaires.

  • Vehicle miles traveled are directly proportional to air pollution and greenhouse gas emissions.
  • Exposure to air pollution contributes to the development of cardiovascular diseases, heart disease, and stroke.
  • Areas with high levels of vehicle miles traveled per capita also tend to have higher accident and injury rates.
  • Compact areas with lower levels of vehicle miles traveled per capita tend to have lower accident and injury rates.
  • Proximity to transit links is associated with reduced vehicle trips and improved access to social, medical, employment-related, and recreational activities.

Communities have been urging developers to consider these elements.  The use of Health Impact Assessments (HIA) to measure the health impacts of land use projects are gaining traction (see this recent article for more information) in the United States.  San Francisco has led the way with HIAs.  San Francisco's Department of Public Health has developed a Healthy Development Measurement Tool to provide a comprehensive evaluation of health needs in urban development plans and projects.

While most agree that planning healthier communities is something we should strive for, how would we go about ensuring it is built into local power structures? Discuss strategies and practices communities could implement to consider the health impacts of land use decisions.   


Other than through indirect encouragement such as raising issue awareness, the best approach to contribute to the health of a community might be through government policies and creative incentives. The state of Maryland has helped lead the way with the advancement of smart growth ( Maryland Department of Planning ). Maryland Smart Growth encompasses a number of state laws and programs passed by the Maryland legislature beginning in 1997. One of which, the 1997 Smart Growth Act, directs state funding into already developed areas and areas planed for growth. The act’s intent is to discourage sprawl by denying state subsidies that may promote sprawl, and use that money towards the revitalization of older communities and inner suburbs. Another example is the Live Near Your Work Program, where state grants match contributions by businesses and local governments that assist with house purchases. This program aims to stabilize targeted neighborhoods by promoting homeownership, and to reduce an employee’s commute. Such initiatives might not be embraced by the entire community; however, they have proven to slow the declining health of Maryland’s communities.

I agree with Greg that policies and incentives may be an effective way to create incentives to change.

One way to encourage healthier lifestyles would be to implement zoning changes that encourage healthier land uses. For example, more efforts could be made to ensure that residential areas are not in close proximity to land uses that would be unsuitable for residential housing-such as near industrial properties that may house factories or wastewater treatment plants or other such facilities. Additionally, if there was enough money in the municipal or state budget, incentives such as tax credits could be implemented to reward improvements made to substandard conditions such as unsafe stairways, inadequate windows and bad or unsafe lighting.

Municipalities could encourage the use of Business Improvement Districts to finance improvements such as lighting, streetscape, and other sidewalk and street improvements to improve walkability and encourage pedestrian traffic/business in the area. Additionally, policies could be implemented to limit the amount of parking in an area to encourage other methods of access, including transit, bicycling, or walking.

I agree that the HIA considerations and the Live Near Your Work, and similar initiatives, are great programs that can and do encourage a healthier style of development. I want to put in a plug for dense mixed use and (might I call it) anti-vehicular development.

I've been in Tucson AZ (and now am in Tempe AZ) for the last part of the week, and my visit to the University consequently turned into a "Livability Evaluation". I learned from the students and snow birds and permanent residents here, as well as in my own observations, that there are two forces that encourage a less-healthful style of living here, in terms of the city planning.

1) While it is possible to walk to most places in the middle section of the city or in your own "neighborhood" community (small sects with a shopping center next to a gated community), the distance can be somewhat daunting, especially if you have time constraints. Things are very spread out, there is very little mixed use, and while the weather is nice, no one wants to carry their groceries back a mile and half from the grocery store in the summer months.

2) All roads here are built for easy mobility - I experienced very little congestion. No wonder, since all main throroughfares are at least 4 lanes (many times 6 lanes) wide with turning lanes. Residential streets could easily carry 5 cars abreast. And unless you are satisfied with the small central-University area, you will want a car to capture the wonders that make up the remaining 85% of the city of Tucson, evenly and thinly spread out in the valley for you to hunt for. The easy roads offer a perfect incentive to never really walk. In fact, for me to even get a glimpse of this city, I was in my car 95% of the time. The only incentive here is that it is nice weather.

Development policies that ensure practical mixed use development (by practical, I mean, residential doubled with small grocery/convenience stores, attractive (local?) cafes, stores, etc.), policies that allow for and even encourage smaller blocks with greater access to denser commercial areas, ...

In general, to get people walking and biking and using transit, there needs to be carrots: accessible areas in close proximation that people want and need to go for a variety of reasons, places that are safe to be in out of your car, etc. ...and sticks: places with limit parking but that are safe places of high activity, roads that make cars feel outnumbered and encumbered by pedestrians or bikes... It is a task not only of getting people out of cars, but giving them a sweeter alternative and a place to go once out.

In an incremental way, I feel that the use of Health Impact Assessments (HIAs) would be a sensible way to introduce health issues into the land use and public policy discourse. In my mind, the concept of considering the importance of health in land use and zoning decisions is outside of many people's conventional thinking. More specifically, in terms of policies and incentives, I feel that the promotion of bike and pedestrian forms of transportation is a crucial component of developing healthy communities. Particularly in regions with mild and warm climates, limiting driving and facilitating walking and biking would likely lead to less polluted air and a generally more active public. In addition, cities could consider posing limits on energy production that causes pollution or offering incentives to firms using solar, wind, and safe and healthy forms of energy.

As others have mentioned, creating incentives and policies that take into account health factors is one of the best ways to create healthier communities. I recently read an article on environmental impact assessment for San Francisco that is somewhat similar to the link posted above. The article mentions the importance of building tools that will accurately predict future health effects and concerns. The more information that is known about potentially unhealthy urban factors, the more priority planners and city officials will give to curbing these health concerns. The article also brought up the importance of public participation. Public participation accomplishes a variety of things. It creates an awareness for health issues in the urban setting. It can also bring to light problems that officials may have overlooked, as well as potentially provide solutions to these problems. It is a combination of health impact assessments, policy changes, and public awareness that will create healthier communities for the future.

I believe one of the best ways to encourage a healthy urban form is ensuring access to food. This is especially important for low-income residents who often live in food deserts where the only place to obtain food is through expensive and unhealthy convenience stores. I saw that the cited study mentioned affordable housing as a factor in healthy living because low-income families have less money to spend on food, but worse yet is not being able to obtain healthy food. Cities can help by zoning for neighborhood grocery stores and providing tax incentives for grocery stores to locate in low-income neighborhoods.

One thing to add that addresses healthy living being built into local power structures could include standards to ensure that food deserts do not exist in any part of the city, but specifically in low-income neighborhoods that are most typically affected. Being able to bike and walk safely is crucial, but I would add that proximity to fresh produce is also essential to build healthy communities. I am not exactly sure where this would be - comprehensive plan or city planning guidelines, or what the verbiage would look like, but I definitely think that addressing food deserts and making it a priority at the local level to address this issue is critical.

DANG IT! I was too slow in writing my post, Brad beat me to the punch!

We should not mandate HIA-type assessment into the planning approval process because of the potential for unintended side effects and contradiction. We want this ideal of dense areas to promote transit but much of existing zoning and code law tends to favor the negative "unhealthy" type of density that we might have seen pre-highways. Parking requirements are rather intense but rightly so, especially if we want a threshold of middle to upper income residents to ensure building longevity and income mix. Similarly, we want density along corridors, yet those corridors are essentially where the majority of bad air pollution is produced. There are many contradicting statements in the list. What struck me the most is that the list essentially advocates for decentralization of business centers. In the condition of sprawl (which most of America is in), to solve this quandary, we must essentially focus energy on building new downtowns, new industrial and commercial areas in suburban sub-regions in order to achieve ideal home-to-work distances. In the case of the San Francisco region, the increasing dependence on the Bay Bridge to connect the eastern region is not a sustainable solution.

So in analyzing the list, I feel the appropriate way to go about this is to engage the relevant city departments to have a policy shift. Licensing and code regulation work directly in affecting the function and quality of buildings and businesses. They could address design issues more adequately by refining and revamping existing code. They also should start inventing code for new unconventional types of housing which may have evolved through the private market. Code also needs to start mandating efficient technologies and tight building materials which protect inhabitants from polluting air.

On getting more grocery and food operations, health and regulatory certainly needs to ease restrictions on small businesses which particularly have limitations in urban environments. They need to be less adversarial and more cooperating, helping find innovative ways to protect public health and feed the masses.

Planning may have the ultimate goal in say making sure there are parks and separating uses but it can't control for everything. Only megalopolis regions have residents who can live 30-40 minutes away from their work and never use a car. So instead the general national focus should be on making individual buildings and businesses become more attuned to health and sustainability. On the front then, the "economic development" departments need to take on the main cause and influence the private market for the public good.

As planners I think that we are inclined to build ordinances and planning hurdles to people to encourage the kind of development we want without actually having to develop things ourselves. But in order to really make change in the local power structure is to encourage education in as many forms and can be done. In part is it our education here, we should be learning about how to plan for these problems. In my neighborhood there is an environmentally focused elementary school, these are education opportunities that will in the long run change our local power structure.

Substandard housing is something that we currently have regulations and laws to address, and as we all know many properties fall through he cracks. Local governmental budgets do not allow for enough inspectors to make an impact on substandard rental units and housing. Couple that lack of governmental budget with the lack of property budget to make improvements and housing can easily drift into disrepair. Looking to tax incentives may not work when dealing with populations who may not benefit from them (elderly and disabled who do not have taxable income). I believe that stronger partnerships need to be formed between the municipalities and non-profits which assist in housing repairs (such as United Way’s work with local trade unions to repair and upgrade homes in need)

As for the health issues that accompany the industrial areas of our community makes me wonder if that is the bigger issue that needs to be address… not the placement of those districts within our city. Stronger pollution control needs to be enacted, just because the pollutant is not in my back yard it doesn’t meant that it won’t affect my water supply. Ownership to the level of environmental health hazards need to be placed on the polluters, not the public.

Access to food is also critical. I agree with Brad that zoning can make a difference in this arena. Limiting the amount of fast food restaurants that can occupy certain areas while zoning for more grocery stores makes sense.

I think pushing transit to develop dense, mixed-use and walkable neighborhoods while getting people out of their cars is the best way to produce substantial results for a health urban form. Building transit such as light rail, street car or expanding bike lanes provides people with alternatives to driving their car. Owning a car in urban centers is more so a hassle with parking and traffic but people don't have any alternatives.

The problem here in Minnesota is the weather which works against us. For roughly 7 to 8 months out of the year, the weather can be cold and deter people from walking places and taking transit. As in the case of Tucson that Michelle illustrated, I think pushing transit development along with HIA-type assessments can work best in cities with nearly year round mild weather. My brother lives in Phoenix and has said the exact same, there is very little congestion because almost every road is grossly over built, retail and commercial and all services are spread out to the point where you can't walk and have to either drive or bike, but bike lanes are not widespread. One of the main causes of healthy problems in the United States is the lack of exercise among the general populace. Coupled with people constantly driving producing air pollution and other negative externalities, the overall health deteriorates. Cities with mild weather are the best scenarios to develop transit and walkable neighborhoods. Other than their own laziness and not so stellar transit service, people would have no excuse to choose car over walking if they lived in a mixed-use and compact neighborhood with excellent transit service and nearly year round mild weather.

Planners should provide people with options. Planning for healthier communities is a great way to provide communities and individuals with options to live a healthier life. Community design policies promote and allow for people to bike and walk instead of drive. Cities should consider the the use of pedestrian overlay zones in mix-use districts- which limit parking requirements. Downtown areas should take away all parking requirements.

I agree with others regarding access to food. I live next to the St Paul farmers market and have been able to eat very well for very cheap. Not that its gone, it's very hard to eat well in Lowertown without driving to town. The few grocery stores in the area have limited hours and overpriced, packaged and canned foods. My other option is the SuperAmerica a few blocks away.

While Lowertown is definitely not a poor or blighted area, it shares some of the characteristics as a low-income area. In the case of Lowertown, I'm hoping demand will bring in a grocer with better options. I think planners can and are helping by incentives to do this with more accessible public transit - especially the light rail and the promotion of a more vibrant, livable community.

HIA's and their relationship to planning are not only about urban environments and getting people out of their cars and on to the walking paths, important as those goals are to planners and the health care industry. Long-range planning needs to make sure that new technology has been thoroughly investigated so that we are not adding to health issues in certain locations while we solve them elsewhere. As planners in cities, towns and energy companies scramble to meet deadlines like Minnesota's 25% (energy from renewable sources) by '25, we will start to see more experimental technology being promoted, including the location of some LULU anaerobic digesters in the countryside (which benefit urban businesses like RockTen in St.Paul), but may have odor or other deleterious health effects for locals. Wind power may need to be used in areas of the state (like the perimeter of the Twin Cities) with medium quality wind speeds, which require the use of lower speed wind turbines to be effective. These turbines vibrate, causing sleep disruption-sometimes necessitating the limiting of times of use. Also, the slower speed wind power has been shown to create a strobe effect that disturbs some people (headaches) and may need to be located far enough away from housing in order to eliminate a "shadow" effect from the turbines. In other words, we need to anticipate future health effects in cities AND rural areas from our planning solutions, not just retro-fit urban areas for walkability.

I would like to endorse Daniel's point of view. Transit in the shape of walk & bike able streets (not like the streets of Phoenix), and LRT, BRT or street cars. Because all the three categories of land use impacts on health point to high VMT, congestion etc and the most effective way to mitigate congestion and arrest the upward trend of VMT is supporting and promoting transit in all its forms, but at the convinience of people.

But in our effort to promote transit and increasing the density, we need to beware of not creating congested neighborhoods i.e. highly densified. Because then we might be compromising on housing quality.

For sustainable development, we, as planners, would like to strike balance between density and housing quality.

I think the HIA could be integrated into some of our pre-existing planning approaches as a tool to measure health impacts alongside some of the existing measurements for things like environmental impacts.

While I'd be reticent to require a HIA for every new project in a city, at least without a lot more thought about what that would look like, I can see making it a requirement potentially for certain projects. HIA's could, for example, be required by state law to be part of any environmental review - such as an Environmental Assessment Worksheet or Environmental Impact Statement. Such review is usually triggered in Minnesota at least when a project reaches a certain size, or is expected to have a pronounced impact on particular environmental or cultural resources. Already, EAWs and EISs are supposed to measure at least some of the same factors - pollution, for example - that an HIA would measure. So an HIA could be used to help expand that analysis, particularly if required by law.

Likewise, it seems that individual cities could require HIAs of developments that they fund with city resources. St. Paul and Minneapolis, for example, require all residential developments that they fund to have at least 20% of the housing be affordable to residents at 30% and 50% of Metro Median Income, and require certain standards of the contractors who work on those projects (fair labor standards). It only seems fair that if you get public resources, you work to be at least reasonably responsive to health concerns. It needn't be burdensome, and in fact would only be a good thing if it really were constructed to be useful to jump-starting a conversation with the developer. HIA's seem not to be about creating mandates, but simply identifying possible improvements, and as such, if they were constructed right, it would be hard to argue they would bog down the development process much at all.

I suppose a final option would be to elevate the profile of an HIA "rewards" system. Much as LEED certification allows for a positive reinforcement of environmental standards, an HIA system could parallel LEED to give an overall healthiness rating. Many of the factors already overlap, so maybe there could be a way to integrate the two as well.

One of the challenges in building healthy communities is access to food. As Adam talks about, I concur there is a relative lack of access to food in downtown St. Paul, where I also live. At the same time, we've worked to live without driving much of anywhere, which also has health benefits. And so working to provide the sorts of amenities - like fresh local food - in the communities that can support other health goals seems a win-win.

It need not really be said, but the rate of obesity has been increasing at a very high rate over the past several decades. This problem among others is in part due to the increased reliance on the automobile, less reliance on transit and overall less physical activity along with a lowered friction of distance. Some of the health problems associated with increased rates of obesity, diabetes and heart disease are also the product of cheap bulk transportation with a heavy reliance on cheaper to manufacturing and transport of processed foods. These foods are often loaded with highly concentrated sugars and fats that are widely available at low cost. Layout of and design of current urban development has helped to encourage unhealthy lifestyles. Changing many of the negative social by products of sparsely populated auto-centric urban areas will not occur in many already existing built up areas. Retro fitting these areas with mass transit, sidewalks and close proximity to work and commerce would require in many cases mass infrastructural changes along with changes in zoning. There can only be mitigation of the lack of accessibility in these in the near future.

A better solution is to re-concentrate zoning laws at the regional level by local, state and federal levels in areas yet to developed that mandates communities to build where accessibility is available at all levels. New communities would be required in some significant fashion to design communities that are accessible by walking, bicycle, transit and autos. Accessibility would emphasize pedestrian friendly streets that would be built as complete streets or streets that are accessible to multiple modes of transportation. Incentives for this approach could engender additional support to developers via tax incentives. State, federal and local government incentives that are mandated following the principles of smart growth and new urbanism would likely augment future development in a pattern that supports healthier lifestyles and overall efficiency.

Smarter growth may help free overused financial resources that currently support sprawl type development. Policies that limit sprawl type development by state and local subsidies as some have suggested, could be reinvested into the current built up community to enhance health and livability of existing communities.

Planners must learn to work with Departments of Public Health and similar type departments or organizations to consider what aspects of the in depth list they wish to tackle. Having interviewed a practicing planner who had dealt with the DPH's involvement in a Small Area Plan, I walked away with the impression that neither party knows what to expect out of the other in terms of promoting community health in the context of land use planning. I think the problem is, as Eric mentioned, is the great amount of contradictory goals and issues in the list. We want dense walkable neighborhoods, but we don't want traffic or noise. We want cheap housing, but not low quality or cramped housing.... With so many things to consider, I feel policy makers, planners, and health officials must be specific and unified about what they want to focus on or they risk doing nothing by trying to do everything.

Implementing a HIA component into the planning process sounds like a good idea, but I have reservations about implementing yet another series of criteria into a complex process. At what point does incorporating HIA strategies into local power structures start leading down the road to "Nanny state" policies? Caution should be implemented to avoid implementing policies that stop encouraging personal behavior (or creating environments conducive to it) and mandating such behavior.

Incorporating HIA components into the planning process will involve a critical review of *what* the planning process in an area can do for the general public health. Daniel touched on Minnesota winters - which aren't exactly encouraging to walking everywhere, IMO. Other climates have the reverse - incineratingly hot and humid summers, for example. A one-size fits all policy would not work, so any HIA implementation would be need to be tailored to the locality.

The best way to quickly implement health assessment tools into the urban fabric is to tap into existing programs that have captured the attention of the public due to extensive marketing tools. For example, incorporating choices in lifestyle regarding where you live could be wrapped into programs such as the "Do" program... perhaps called "Locate" to emphasize choices of mixed use residence to encourage a walkable lifestyle.

The other group that planners need to ally with in order to implement true change in livability and health measures are the developers themselves. Engaging this business community with up-to-date information on emerging preferences for healthy lifestyles, continuing the trend seen in public spaces with changes in smoking laws will convey that health issues have crept into consumer habits and reveal an opportunity for economic capital.

I see connections between the goals of Health Impact Assessments and the goals of environmental justice advocates. Environmental justice advocates bring to light the social and economic inequalities resulting from unequal development and land use. Often intense or hazardous land uses are located in struggling neighborhoods, neighborhoods which might not have the political or economic currency to fend off negative development types. In the same vein, positive land uses are commonly situated in stable or affluent neighborhoods (neighborhoods capable of lobbying for or funding beneficial land uses). Environmental justice advocates have had success in affecting development policy by arguing that inequalities resulting from unequal development bear weight when it comes to upholding civil rights afforded by the constitution.

Building HIAs into the power structure of a community may be difficult when only making an argument for better health or positive economic benefits. It would be easy for developers to argue the economic benefits aren't sufficient, or that negative economic impacts outweigh what they might see as only moderate health effects. By taking it a step further, and connecting health considerations (addressed through the use of HIAs) with civil rights considerations, we can start to give HIAs "political claws." This would best be done through the application of HIAs that carefully assess, record, and publicize negative health effects on minority populations in particular.

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