Nonvolitional health

Growing up in Manhattan, Dr. Lynn Silver-Chalfin was afraid to take the stairs. No traumatic experiences informed this dread and, physically speaking, she was perfectly capable of walking up and down steps. Her trepidation was merely a product of life in the city. “Traditionally, the staircases in New York were locked, and that’s where your mother told you rapists lurked,” says Silver-Chalfin.

In 2004, after training as a pediatric surgeon at the Johns Hopkins University School of Medicine and over 15 years of public health work in South America, Silver-Chalfin came back to New York City as an assistant commissioner of the Department of Health and Mental Hygiene. Her focus was the prevention of chronic diseases. A big part of that task was battling obesity, an affliction affecting 21.7 percent of the city’s population at the time. The scope of this epidemic rendered traditional prevention practically useless. The changes the city needed were not going to come in the form of doctor’s wagging fingers at yearly check- ups.

More innovative interventions were needed.

This job was how Silver-Chalfin came to play an integral part in what could be called the nonvolitional health movement. The logic behind nonvolitional health is this: Make healthy options the most accessible ones and people’s health will improve. Such alterations may include widening sidewalks so people are more likely to use them or establishing farmer’s markets for better access to fresh food. In Silver-Chalfin’s hands, nonvolitional health meant limiting trans fats in New York City to 0.5 grams per serving or less and requiring calorie counts on restaurant menus.

Yet anyone familiar with New York’s recent attempt to ban large sugary beverages, which Silver-Chalfin also helped craft, knows at least one argument against nonvolitional health, often cited by its critics: It limits our ability to choose.

Nonvolitional implies passivity. What unifies all of the actions of the nonvolitional health movement is that they change the balance of healthy and unhealthy choices available to us before we even have to make a decision. This adjustment makes the subsequent selection of a healthier lifestyle option either unconscious (because it’s easier than the alternative) or compulsory (because it’s the only option).

Silver-Chalfin argues that nonvolitional health doesn’t affect our autonomy as much as certain groups, such as the agriculture industry and certain libertarians, have alleged. What controversy there is, she says, has been magnified by Big Agriculture, “I have no question that the food industry is encouraging it,” says Silver-Chalfin, “They want to have it their way and be able to manipulate the American diet however it’s most convenient.” For example, many people choose the drive-thru at McDonald’s because it’s become easier and cheaper than an hour of grocery shopping and cooking. Conversely, Silver-Chalfin says that her family’s recent move to Santa Rosa in Northern California has helped them eat more healthily than they did in New York because they have greater access to high-quality, fresh produce. Whether it’s nonvolitional health laws or fast food availability, diet choices are almost always under some kind of outside influence, says Silver-Chalfin.

New York City, largely undeterred by complaints about undue restriction, has been exploring different forms of nonvolitional health for years. In 2006, the city hosted the first Fit City Conference, a collaboration between the American Institute of Architecture’s New York chapter and the New York City Department of Health and Mental Hygiene. The purpose of this conference was to discuss how the city’s design could affect physical activity and food choice. Fit City was successful enough to warrant a second conference, but its impact remained relatively contained. Then, in his closing remarks at the 2^nd annual meeting, David Burney, Commissioner of the Department of Design and Construction, declared that he would begin work on guidelines that detailed the principles of active design.

The New York City Active Design Guidelines were released in January 2010. One hundred thirty-five pages long and freely available online, this booklet contains over 100 specific strategies for improving the health impact of the city’s built environment (the elements of our surroundings that we create, like buildings, roadways, and sidewalks). Since some of these recommendations are more common sense than common science — like making sidewalks wider in areas people are more likely to linger — each is labeled with the level of empirical support it has. Unlike Silver-Chalfin’s food-based regulations, the Active Design Guidelines only address details of the built environment. But in the same way that her laws encourage healthier food choices, these guidelines show architects and urban designers ways that their structures can promote health through encouraging increased physical activity and easy access to healthy foods and beverages.

One topic covered extensively by the guidelines is, of course, stairs. After all, New York has an abundance of people who share Silver-Chalfin’s step-avoidant history. Office fire drills in the city will sometimes make occupants go down a couple flights just so they can get familiar with the stairwell.  On August 23, 2011, many people took their first (and perhaps only) trip down their buildings’ steps during the magnitude 5.8 earthquake that swayed the city’s skyscrapers. To combat the supremacy of elevators and escalators in the city, the guidelines have developed a variety of recommendations, which run the gamut in complexity and cost.

Among the simplest promotions of active design are the city’s stair prompt posters. Lime green with white stick figures, they say, “Burn Calories, Not Electricity.” These signs don’t force anyone out of the elevator, but studies have found that similar prompts — placed in areas where people are deciding between the stairs and the escalator or elevator — increased stair use, although the extent of the effect varied widely. While these prompts seemed to have small individual impacts, the hope is that those will add up as thousands of the prompts have been posted around the city and are still freely available to anyone who requests them via 311, New York City’s information hotline.

More involved stairwell interventions include painting the walls inviting colors, hanging up art, and playing music, which research has suggested make stairs more appealing. The most complex suggestions are structural. These include making staircases that are architecturally appealing, since research has found that these attention-grabbing structures promote stair use — particularly when they are visible, easy to access, and aesthetically consistent with the rest of the structure. The guidelines also encourage using stairways to join commonly-used floors. After all, if someone could walk down the hall and take two flights of stairs to the lunchroom, they might not use the elevator at the other end of the building.

Of course, the guidelines address more than stairs. To promote cycling, they suggest better bike lane signage along with improved interconnectedness and continuity of the lanes. They give specific tips for building pedestrian plazas, like those seen in Times Square and Madison Square Park, to encourage outdoor activity and provide rest areas for carless commuters. These plazas are also desirable because they contribute to the city’s imageability, defined by the guidelines as “the quality of a place that makes it distinct, recognizable and memorable.”

The guidelines also contain structural ways to improve nutrition, such as identifying food deserts — places where people have limited access to fresh foods — and creating incentives for supermarkets or farmer’s markets entering those areas. Even installing drinking fountains, according to the guidelines, promotes more physical activity and less high-calorie drink consumption.

Specific places, such as High Line Park and the Museum of Modern Art, are also highlighted in the booklet as good examples of active design. These structures are lauded for their appealing views and walkability. Such elements make people want to stroll around at these locations, all the while burning calories in an enjoyable, unobtrusive way. The variety of these case studies reveals how the guidelines are applicable to many different architectural styles throughout the city.

“We want to ensure that active design is incorporated in as many buildings, streets and neighborhood projects as is possible, because that’s the way we’re going to get population impact,” says Karen Lee, Director of Built Environment and Healthy Housing, a program within the Bureau of Chronic Disease Prevention and Tobacco Control. As the world’s fattest nation, with 34 percent of all adults suffering from obesity, the U.S. will require population-level change in order to win the battle of the bulge. This reality plays an integral part of a compromise within nonvolitional health. Most of these interventions are not about the individual, but instead about entire communities. Studies of stair prompts similar to those produced by the New York City Health Department say that they increase stair use from around 5 percent to 7.5 percent per person. For a single person that may not seem like much, but considered overall, this is a 50 percent increase, which researchers think is a very good reason to promote these signs.

Of course, there is no sure-fire way to combat obesity on this scale, but science shows that addressing our surroundings is a decent place to start. “Today, in our modern world, we have sort of flipped things on their head,” says Professor Bill Leonard, the Director of Global Health Studies Program and Chair of the Department of Anthropology at Northwestern University. “We now have readily available calories all over the place and we have to do little or no work whatsoever to get those calories, leading us to the predicament we’re in at the moment.”

Our species spent the majority of its evolutionary history enduring substantial physical demands, like spearing birds of prey and bringing down mammoths, to obtain food. There were seasonal scarcities our bodies had to adjust to, and about 2 million years ago we developed giant, energy-sucking brains that practically necessitated the addition of energy-rich meat into our diets.

The problem is, the extreme feast/famine conditions our ancestors dealt with favored fat storage as a way to survive periods when calories were less available. So, evolution and natural selection favored individuals who could make the most of their meals. According to the Thrifty Gene Hypothesis, which is well-regarded by many scientists studying the impact of evolution on humans’ health, individuals still vary in their capacity to store calories. The idea is that “thrifty” genes equal more efficient calorie storage and use. For most people today — who aren’t as active as our ancestors — that means more fat. However, just because some people lack especially thrifty DNA, doesn’t mean they’re immune from obesity. “Human physiology, in general, is designed to be thrifty,” says Leonard.

Yet Leonard doesn’t recommend intensive exercise or extreme dieting. The most plausible solutions, according to him, are much more subtle. His studies of ancient human ancestors, modern-day hunter-gatherers in the Amazon, and Siberian herders have all made one aspect of our fitness especially clear. “Slow and steady wins the race in this,” he says. None of the people Leonard has observed are sitting around for eight hours and then running a 10K. Instead, they maintain a steady, moderate level of physical activity and equally sensible diets. Informed by his research, Leonard suggests walking and biking instead of driving and, again, taking the stairs more often in order to improve our health. These are the same simple fixes supported by many experts and nonvolitional health measures are trying to make them even simpler. Ironically, this simple fix has quite a few implementation complications to overcome.

Many developers and businesses that would be responsible for making the changes suggested by the nonvolitional health movement are worried about the cost. On a societal level, the savings from reduced obesity rates are huge. A five percent drop in our nation’s average Body Mass Index (a tool used to estimate body fat) by 2030 could cut medical costs by 6.5 to 7.9 percent per state. In California alone that would amount to about $81.7 billion saved. But the costs on an individual business level are more complex. That is where Mariela Alfonzo comes in.

A petite woman with welcoming eyes, Alfonzo looks young enough to be a college freshman, but her speech reveals her to be a passionate, well-seasoned academic. In addition to being an adjunct faculty member in NYU-Poly’s Technology, Culture and Society Department, Alfonzo is the founder and president of Urban Imprint, an urban design consultation firm born from her doctoral research at UC Irvine. One particular service her company provides is called State of Place, a diagnostic tool that evaluates a neighborhood’s walkability, what it can do to improve it, and the return on investment that can be expected from different improvements.

“It’s really pushing the envelope of getting people to think more broadly about the economic impact, because I feel that that’s an easier conversation to have,” says Alfonzo.

State of Place’s recommendations can be designed for any budget, whether someone has only sweat equity or infinite resources. Just adding a new coat of paint or organizing a neighborhood playground clean-up can have positive effects on the feel of a neighborhood, according to Alfonzo’s tool. Such suggestions fall very much in line with the city’s own built environment advice. Director of Built Environment Karen Lee says even drawing hopscotch squares on an otherwise featureless park can encourage children to be more active.

Neither economics nor health was a primary concern for Alfonzo when she was undertaking the research that is now the foundation of her company. Instead, she was interested in overall quality of life.

This interest was triggered by her experience growing up in Westchester, a neighborhood in Miami that Alfonzo describes as an endless array of strip malls with narrow sidewalks bordering a 6-lane highway. Being entrenched in Westchester’s inherent structural flaws sent Alfonzo on a mission to figure out what makes people feel the way they do about their neighborhoods.

Through her work, she has identified many different elements of a neighborhood that affect people’s desire to spend time there. For example, elements that people tend to like include appropriately-sized trees, safe traffic crossings, blocks that house a variety of buildings, and signs for businesses that add character and a sense of uniqueness.

“I tell my students that a good street is the one that hugs you,” says Alfonzo.

She sees examples of this “hugability” in diverse neighborhoods throughout Manhattan. She says that NoHo’s wide sidewalks, narrow streets, and eclectic facades have a certain welcoming embrace. She also admires the design of Tompkins Square Park, where hipsters, immigrants, and young families cross paths as they play chess and handball and mingle with pets in the dog park. This stands out in contrast to single structures that dominate and dull an entire block and office parks that discourage use by the general public.

While most of Alfonzo’s recommendations for improvement apply to buildings that are already established (a practice she focuses on for its inherent sustainability advantages), many of the suggestions from the Active Design Guidelines are most cost-effective when they are considered prior to construction, says Lee.  As a result, builders who learn of the guidelines after completing their projects are often frustrated by their inability to take full advantage of the advice after-the-fact.

Lee says that two years of intensive collaboration with the Mayor’s Office for People with Disabilities, the Department of Buildings, and various public and private construction and building organizations made the Active Design guidelines realistic for most projects. However, a central concern about the guidelines is their feasibility for affordable housing construction. According to current studies, when the Active Design guidelines are applied to affordable housing projects from the start, its suggestions don’t add any extra costs, says Lee. They may even save money. Even now, Via Verde, an apartment complex being developed in the South Bronx, has been heralded as a model for collaboration between affordable housing development and active design.

Although she touts it as a selling point for her services, the possible cost-effectiveness of active design actually worries Alfonzo. Her apprehension is that change in the name of enhanced urban design can lead to gentrification. If the modifications to a neighborhood make it too desirable, wealthy tenants may end up ousting low-income and working class residents. This means that the people who are often the intended targets of nonvolitional health interventions are also the most likely to be chased away to other, less healthy neighborhoods.

“Urban design is only one part of the puzzle of how a city works, and it’s limited in both what it can do and what it can avoid,” says Alfonzo. Having been in this business for some time, she is well aware that concerns about gentrification tend to be rather low on developers’ lists of priorities. To address this problem, Alfonzo encourages incremental changes and suggests that the planning process involves someone who understands the potential impact different changes will have on the residents. Improvements supported through grassroots campaigns can also work well, says Alfonzo.

At this point, much of the noticeable use of nonvolitional health measures is being done through government programs and legislation. “A healthier food industry in the future needs a government that’s going to play an active role in that,” says Silver-Chalfin. She sees the potential role of the government in this area as comparable to its current functions with regards to food safety. Others, however, are less convinced of our government’s capabilities.

New York University School of Law Professor Richard Epstein, (who was contacted via email for this piece) is known for his support of minimal government regulation. He says that subsidized care may justify the state’s preoccupation with people’s health — because it means the state is incurring the costs of healthcare outcomes — but he questions the government’s ability to address these concerns appropriately. While acknowledging the possible value of nonvolitional health programs, he says that they should be run privately, not by the government.

In addition to her concerns that top-down legislation could overlook the lower class, Alfonso says she would like to see more intricate evidence-based approaches supporting government actions. On a smaller scale, she says an experimental version of the soft drink ban might have been a useful source of predictive data, for example. She understands all too well that such detailed research is often frustratingly time consuming but says this kind of experiment might have revealed unintentional consequences that may result from the ban.

The changes that nonvolitional health programs are putting into place are only beginning and pitfalls are to be expected. So far the improvements are subtle and the outlook is positive. According to a 2011 study published in the British Medical Journal, calorie postings on menus are used by 15 percent of people. That number may seem small, but people who allow these postings to inform their meal choices cut an average of 100 calories per meal. The New York City Health Department, with funding from the Clancy Foundation, has trained over 2,000 of its architects, builders, planners, and real estate professionals on the Active Design guidelines. According to Lee, post-training surveys have shown that 87 percent of the trainees say they plan to use active design strategies in the future. The city has also coordinated with the U.S. Green Building Council to get innovation credits for physical activity, which builders and architects can use toward LEED certification.

Even in the face of uncertainty, the nonvolitional health movement is growing. Active design, walkability and built environment have become common buzzwords within the architectural community. In 2010, Section 4205 of the federal Affordable Care Act made it a requirement for restaurant chains with more than 20 establishments to post calories for their standard menu items. Six states — California, Maine, Massachusetts, New Jersey, Oregon and Tennessee — currently have similar labeling laws.

Alfonzo says she has noticed a distinct demographic shift toward people being more concerned with the state of their health environment. “I think in the next several years, not only will it be really important for public officials and private sector to address this. It’ll be critical for them,” she says. Even the sprawled suburban city of Santa Rosa, California, where Silver-Chalfin now works as a county public health officer, is showing interest in improving its network of bike lanes and enhancing public transportation.

Continued squabbles over how it is implemented and who does it are inevitable, but the overall consensus on nonvolitional health seems to be that most of this is common sense finally being put to use. Still, just because the work is obvious, doesn’t mean it’s easy. “It’s going to be an on-going effort to try and build a society that’s healthy and fun,” says Silver-Chalfin. And yet it is also as simple as taking the stairs.