Int. J. Environ. Res. P ublic H ealth2011, 8, 3953-3978; doi:10.

3390/ijerph8103953
OE A C S P N C ES

International Journal of E vironm tal R n en esearch and P ublic H ealth

ISSN1660-4601 w w dpi.com w .m /journal/ijerph Article

AM ltilevel A alysis of N u n eighbourhood B ilt and Social u E nvironm ts and A en dult Self-R eported P ysical A h ctivity and B y M In od ass dex in O ttaw C ada a, an
Stephanie A P . rince 1,2,*, E lizabeth A K . ristjansson3, K atherine R ussell4, Jean-M ichel B illette5, M ichael Saw 6, A ira A 4, M S. T blay2,7,8 and D ada m li ark rem enis P rudhom e7 m
1

Population H ealth Program Facultyof G , raduate S tudies, U niversity of O ttaw 1 S art S a, tew treet, O ttaw O a, ntarioK 6N C IN 5, anada H ealthy A ctive Living and O besity R esearch G roup, C hildrens H ospital of Eastern O ntario, 401 Sm R yth oad, O a, O ttaw ntarioK 8L1, C 1H anada; E-M m ail: trem blay@ cheo.on.ca School of Psychology U , niversity of O ttaw 136 Jean Jacques Lussier, O a, ttaw O a, ntarioK 6N 1N 5, C anada; E-M kristjan@ ail: uottaw a.ca O ttaw Public H a ealth, C of O ity ttaw 100 C a, onstellation C rescent, O a, O ttaw ntario K 6C 2G 8, C anada; E-M ails: K atherine.R ussell@ ottaw a.ca (K .); A ira.A ottaw .R m li@ a.ca (A .) .A M icrodata A ccess D ivision, Statistics C anada, 65 U niversity Street, O a, O ttaw ntario K 6N 1N 5, C anada; E-M jbillet2@ ail: uottaw a.ca L aboratory for A pplied G atics and G Science (L G ISS), D eom IS A G epartm of G ent eography , U niversity of O ttaw 60 U a, niversity Private, O a, O ttaw ntario K 6N C 1N 5, anada; E-M m ada@ ail: saw uottaw a.ca F aculty of H ealth Sciences, U niversity of O ttaw 451 Sm th R a, y oad, O a, O ttaw ntario K 8M 1H 5, C anada; E-M denisp@ ail: uottaw a.ca F aculty of M edicine, U niversity of O a, 451 S yth R ttaw m oad, O a, O ttaw ntarioK 8M C 1H 5, anada

* A uthor to w homcorrespondence should be addressed; E-M s.prince.w ail: are@ ail.com gm ; Tel.: +1-613-737-7600(ext. 4191); F +1-613-738-4800. ax: Received: 6 July 2011; in revised form 27 Septem 2011/ Accepted: 4 O : ber ctober 2011 / P ublished: 14 O ctober 2011

A bstract: C anadian research exam ining the com bined effects of social and built environm ents on physical activity (PA and obesity is lim ) ited. The purpose of this study w to determ the relationships am as ine ong built and social environm ents and PA and

Int. J. Environ. Res. P ublic H ealth 2011, 8 overw eight/obesity in 85 O a neighbourhoods. Self-reported PA height and w ttaw , eight w ere collected from 3,883 adults using the International PA Q uestionnaire from the 2003-2007 sam ples of the R apid R Factor Surveillance System D on neighbourhood isk . ata characteristics w obtained from the O ere ttaw N a eighbourhood S tudy; a large study of neighbourhoods and health in O ttaw Tw a. o-level binom logistic regression m ial odels stratified by sex w used to exam the relationships of environm ere ine ental and individual variables w PA and overw ith eight/obesity w hile using survey w eights. R esults identified that approxim ately half of the adults w ere insufficiently active or overw eight/obese. M ultilevel m odels identified that for every additional convenience store, m w tw en ere o tim m likely to be physically active (O es ore R= 2.08, 95% C 1.72, 2.43) and w every I: ith additional specialty food store w en w alm tw tim m likely to be overw om ere ost o es ore eight or obese (O = 1.77, 95% C 1.33, 2.20). H R I: igher green space w associated w a as ith reduced likelihood of PA (O = 0.93, 95% C 0.86, 0.99) and increased odds of R I: overw eight and obesity in m (O = 1.10, 95% C 1.01, 1.19), and decreased odds of en R I: overw eight/obesity in w en (O = 0.66, 95% C 0.44, 0.89). In m neighbourhood om R I: en, socioeconom scores, voting rates and sense of com unity belonging w ic m ere all significantly associated w overw ith eight/obesity. Intraclass coefficients w ere low but , identified that the m ajority of neighbourhood variation in outcom w explained by the es as m odels. Findings identified that green space, food landscapes and social cohesiveness m ay play different roles on PA and overw eight/obesity in m and w en and future en om prospective studies are needed. K ords: physical activity; obesity; neighbourhood; environm population health eyw ent;

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1. Introduction Physical inactivity is a know risk factor for several chronic illnesses as w as prem n ell ature m ortality [1]. Even w physical activitys (PA know protective effects, average C ith ) n anadian levels continue to fall short of recom endations. D from the 2009 C m ata anadian C m om unity H ealth Survey (C H show that 51% of C C S) ed anadian w en and 44% of m reported that they w om en ere inactive (<1.5 kcalkg-1day-1) in their leisure tim [2]. In addition, 59%of C e anadian m and 44% of en w en reported that they w overw om ere eight or obese [3]. H istorically, studies of PA have focused on individual dem ographic factors such as age, sex, education, and incom [4]. H ever, these factors cannot fully explain the rise in the rates of phys e ow ical inactivity and obesity seen in the last few decades [5] and the social and built environm ents have be en posited as possible contributors to current trends [6]. M of the previous w on the association betw the built environm and PAhas focused on uch ork een ent self-report m ethods of perceived access to the environm [7]. G ent enerally results show that higher , perceived access to recreation resources is associated w an increased likelihood of PA but w ith , ith m ixed evidence [8]. O bjectively m easured studies w also m ere ixed, but generally reported positive associations betw een PA and num ber of, and distance to, w alking/bike paths; recreation/fitness

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facilities; and parks and green spaces [4,7,9]. W results are also heterogenous, studies suggest that hile overw eight and obesity are generally related to low access to environm er ental supports [10]. W hile the built environm m have an independent effect on PA and overw ent ay eight/obesity the , social environm has the capacity to m ent ediate the effects of the built environm and exerts its ow ent n influence through such factors as recreation and urban planning policies and funding, safety of facilities and resources, and social support for healthy behaviours such as regular PA N . eighbourhoo d social factors are often assessed using area-level m easures such as average incom levels or area e deprivation [11]. Several studies have reported inverse relationships betw een area deprivation and access to PA facilities [12-14]. Evidence also suggests that area deprivation is associated w high ith er rates of inactivity [14-16] and obesity [17,18]. In addition, research has show that other social fa n ctors such as neighbourhood social capital, social cohesion and safety also have the capacity to influence levels of PA[19-22]. R esearch exam ining the influences of the built and social environm ents on rates of PA has largely occurred in non-C anadian populations [23]. Furtherm ore, sex-based analyses are often lacking in these studies [24] and conclusions regarding possible sex differences in environm ental determ inants are not yet possible [25]. T address gaps in previous research this study assessed objectively m o easured built and social environm ental factors and their relationships w self-reported PA and overw ith eight/obesity using a sex-specific m ultilevel m odel w hile controlling for individual-level variables in a large rando m sam of adults w ple ithin the C of O a. O hypothesis w that inactivity and overw ity ttaw ur as eight/obesity rates w ould be highest in neighbourhood environm ents that w not conducive for recreational PA ere , such as areas w a low num of facilities, parks, and w ith ber alking paths, lim ited green space, or w here crim rates w higher, and w e ere here socioeconom status and social capital w low ic ere er. 2. M ethods A m ultilevel fram ork w used to exam ew as ine the associations betw een individual- and neighbourhood-level characteristics w PA and overw ith eight/obesity levels in 85 C of O a ity ttaw neighbourhoods. The study received ethical approval fromthe U niversity of O ttaw H as ealth Science R esearch Ethics B oard (#H 10-08-11) and the C of O a Public H ity ttaw ealth R esearch Ethics B oard(#128-09). 2.1. Rapid Risk F actor Surveillance System(RRF SS) The R F (w w R SS w .rrfss.on.ca) is an annual cross-sectional survey used to gather surveillance data of im portance to public health in O ntario m unicipalities. The R FSS survey em R ployed m odified random digit dialling to produce a sam of households. A ple pproxim ately 85% of the com pleted interview form a sam representative of the O a population. The other 15% of the sam s ed ple ttaw ple com prised an over-sam of parts of the city that according to Statistics C ple anada, have a higher concentration of people w a F ith rench m other tongue. W ithin households, interview w com s ere pleted w an ith R espondents w w unable to speak English or ho ere F rench, w w ho ere physically or m entally incapacitated or living in institutions, w ere excluded fromparticipation.

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Five years of data from R F (2003-2007 sam R SS ples) w com ere bined to create a dataset of 5,025 respondents. Survey year aggregation allow for m accurate m ed ore odel estim ates. Pregnant w en, om respondents m issing any of the variables (not including sense of com unity belonging) used in the m m odels, those living outside of the defined study neighbourhoods, and neighbourhoods w a cell ith count of less than five w ere excluded from the analyses. A fter excluding these cases, the final unw eighted sam used for analyses w 3,383 respondents. The distribution of the sam across the ple as ple five survey years is as follow 714 (21% in 2003; 745 (22% in 2004; 689 (20% in 2005; 613 (18% s: ) ) ) ) in 2006; and 622 (18% in 2007. The response rates for the survey years are as follow 60% (2003); ) s: 59%(2004); 64%(2005); 66%(2006); and 59%(2007). 2.2. O a N ttaw eighbourhood Study (O S) N B uilt and social environm ent characteristics w ere collected by the O S; a large study of N neighbourhoods and health outcom in O es ttaw C a, anada. B riefly, neighbourhoods w defined based ere on natural barriers, sim ilarity in socioeconom and dem ics ographics, O ttaw M a ultiple Listing Services (real estate) m aps, and participatory m apping feedback from com unity m bers and m em experts [26]. M neighbourhoods contained >4000 people. O ost bjectively m easured built environm ent data w ere collected from 2006 to 2008 using the follow ing m ethods: 1) 2006 C anadian census household data; 2) G data from D TI Spatial Inc., the C of O a, and the N IS M ity ttaw ational C apital C m om ission (N C 3) telephone contact w businesses; 4) w C ); ith eb-based research (e.g., C anada 411, w ebsites, G oogle M aps); 5) team know ledge of local resources; and 6) field research and validation (e.g., car, w alking, bicycle). A further in-depth description of m ethods related to the O S N and its derived variables is available elsew here [26]. 2.3. N eighbourhood Environm ents The neighbourhood built environm related to recreation and food availability w assessed using ent as objective variables geocoded to the 85 O a neighbourhoods fromthe O S. ttaw N 2.3.1. R ecreation Environm ent R ecreational facilities w defined using the N ere orth A erican Industry C m lassification System C anada (N IC C A S) ode 71 [27]. F the purposes of the O S, recreation facilities w or N ere only considered if they provided activities for free or at m inim cost (non-com ercial) and included al m com unity centers providing free access to facilities. The set of recreation m m easures by neighbourhood included total bike and w path length (km coun per 1,000 people of indoor alk ), ts 2 recreation facilities, w inter outdoor facilities, sum er outdoor facilities, park area (km), and area of m 2 green space (km). The neighbourhood recreation variables w derived using a com ere bination of G IS capabilities, including address geocoding, spatial query union and intersection overlay to integrate , recreation data found in the num erous layers fromthe N C D TI Spatial Inc., Statistics C C , M anada 2006 R oad N ork File, and the C of O etw ity ttaw [28]. O note, green space m a f anaged by the C of O a ity ttaw or the N C w further defined as a park and included in park area, w C as hile non-m anaged areas w ere captured by green space. A of the environm data except for path length w presented per 1,000 ll ent ere

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people in the neighbourhood to better capture the dem on the facilities rather than raw counts. T and he recreation environm data w added to the m ent ere odels as continuous variables. 2.3.2. F ood Environm ent W ithin the O S, objective m N easures of the food environm w identified and classified into five ent ere types of food retail outlets according to the N IC [27]. The O S com A S N piled data fromD TI C M anada Inc., the O a R ttaw etail Survey, C anada 411 B usiness, and w pages of m eb ajor grocery store, convenience store and fast food chains in O ttaw in addition to field research and local know a ledge. The food retail outlets w exam ere ined using density (i.e., counts per 1,000 people) and included grocery, convenience and specialty food stores, as w as fast food and full service restaurants. ell G rocery stores (N IC code 445110) included both superm A S arkets and grocery stores w a general ith line of foods and a full line of fruits, vegetables and fresh m eats. Specialty stores (N IC code 44 A S 51) concentrated on specialised food types such as m stores, seafood stores, fruit and vegetable stor eat es, bakeries, candy and nut stores, dairy stores, bulk food stores, organic food stores, health food stores, and ethnic food stores. C onvenience stores (N IC codes 44512, 445120 and 44711) had a lim A S ited line of convenience products (e.g., m snack food, dried/canned food) and included gas bars w a ilk, ith convenience store. F food outlets (N IC code 722210) provided lim service including ordering ast A S ited at a counter and paying for food before its delivery and included m food courts, pizzerias, and all donut and coffee shops. O utlets found in cinem and tem as porary in nature (i.e., chip w agons and hot dog stands) w excluded. R ere estaurants (N IC code 722110) provided full service, including table A S ordering from a w aiter/w aitress and paying for the m at its com eal pletion. Included w ere hotel restaurants, buffets and bars that served food, m a and papa establishm am ents (provided they w ere licensed registered business) w hile cafeterias, catering com panies, and country/private clubs w ere excluded. The food environm data w added to the m ent ere odels as continuous variables. 2.3.3. Social Environm ent The neighbourhood social environm w exam ent as ined using a neighbourhood socio-econom ic status (SES) index, voting rates, crim rates, and sense of com unity belonging. The neighbourhood e m SES index, w developed using principal com as ponents analysis and includes percent of households below the low -incom cut-off (L O [29], average household incom percent of unem e IC ) e, ployed residents, percent of residents w less than a high school education, and percent of single-parent ith fam ilies. The variables w selected based on their established relationships w health and their ere ith availability at the neighbourhood level in the 2006 C anadian C ensus. The SES index w t-scored to as represent a m ean of 50 w a standard deviation of 10; higher scores indicate low SES. Social ith er capital has been described as elem ents of com unity organization such as civic participationand sens m e of trust betw citizens that contributes to the m een utual benefit of the com unitythat can be related to m health status [30]. V oting rates m represent a com unitys sense of engagem in the com on ay m ent m good [31]. Furtherm ore, higher voter participation has been show to correspond to greater trust and n socialization betw citizens [31]. S een ocial capital w evaluated by proxy using councillor voting rates as from the 2006 O ttaw m a unicipal election and by aggregated neighbourhood values for self-reported strong sense of com unity belonging from four cycles (years 2000/01, 2003, 2005, 2007) of the m

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C H Sense of com unity belonging w ascertained using one question on the C H w C S. m as C S hereby respondents w asked how they w ere ould describe their sense of belonging to their local com unity. m R espondents w categorized into tw groups: very strong and som hat strong; and som hat w ere o ew ew eak or very w eak [32]. N eighbourhood safety w evaluated using C of O a P as ity ttaw olice 2006 crim e incidence rates for each neighbourhood aggregated to crim against property and crim against es es person follow the U ing niform C e R rim eporting (U R Survey version 2.2 [33]. D to population C ) ue m obility betw day, evening and w een eekends, population norm alized crim rates w e ould over-represent dow ntow core areas w lowpopulations in the central business district of O n ith ttaw and w therefo a ere re not calculated. The social environm data w analysed as continuous variables. ent ere 2.4. Individual-Level D ata 2.4.1. Physical A ctivity Previous w PA w self-reported using the short version of the International PA Q eek as uestionnaire (IPA ) collected w Q ithin the R F R SS. The IPA has been evaluated in 14 studies and found to have Q good test-retest reliability and a m odest Spearm correlation (r = 0.30) w PA m an ith easured by accelerom eter [34]. The IPA captures activity intensity inform Q ation across the dom ains of household and yard w ork activity, occupational activity, self-pow ered transport, and leisure-tim PA e . C putation of the total scores requires sum ation of the duration (in m om m inutes) and frequency (days) for all levels of activities (e.g., low m , edium high). PA w analysed as a binom outcom w lo , as ial e ith w and m oderate reporting of PA (insufficiently active) com pared to high levels of PA (active). These cut-offs w recom ended by the IPA U G ere m Q ser uide as higher thresholds of use for distinguishing differences at the population level [35]. O utliers (>960 m inutes/day) w not included in the sam . ere ple 2.4.2. O verw eight and O besity H eight and w eight w ere self-reported and used to calculate body m ass index (B I) as M 2 w eight (in kg) divided by height (in m). H ealth C anada B I guidelines for adults [36] w used to M ere 2 group individuals into the follow ing categories: underw eight (<18.5 kg/m), norm al 2 2 2 w eight (18.524.9 kg/m ), overw eight (25.029.9 kg/m ), and obese ( 30 kg/m ). B I w analysed M as as a binom outcom w under- and norm w ial e ith al eight com pared to those w reported as ho overw eight or obese. 2.5. C ovariates The m odels controlled for the follow covariates at the individual level: age category (1824, ing 2544, 4564, 65+ yearscategorized fromcontinuous response); education (<high school, high school graduate, som post-secondary school, post-secondary degree); household incom ( $29,999, e e $30,000), sm oking status (daily, occasional, form never); and season of collection (sum er, fall, er, m w inter, spring). A covariates w ll ere added to the m odels as categorical variables and all w ere self-reported in the R F except for season w R SS hich w derived fromthe survey com as pletion date. T he covariates w all added to the m ere odel for their potential to influence PAor overw eight/obesity and f or their bivariate association w several of the built and social environm ith ental variables.

Int. J. Environ. Res. P ublic H ealth 2011, 8 2.6. Statistical Analysis

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A descriptive and com ll parative analyses w conducted using SA version 9.1 (SA Institute, ere S, S Inc., C ary, N ) incorporating appropriate survey w C eights. M eans and standard deviations of all exposure and outcom variables w calculated. T-tests and chi-square tests w used to identify e ere ere significant differences betw m een ales and fem ales for all individual variables. Sex-specific binary logistic regression m odels w used to assess th relationships of environm l ere e enta and individual variables w the outcom of PAand overw ith es eight/obesity. V ariables w conceptually ere chosen for inclusion in the m odels based on their relationships w PA and overw ith eight/obesity as reported in the literature and on their availability in the R FSS and the O S. The m R N odels w built to ere distinguish betw een tw levels: neighbourhood and individual. A o nalyses w stratified by sex to ere control for differences in PAlevels and overw eight/obesity in m ales and fem ales. This study had 100% pow to detect associations at the individual level and 63% er -75% pow to detect associations at the er neighbourhood level. A six-step m odeling strategy w em as ployed to investigate the built and social environm ents separately then together, and finally to look at the relationships once individual variables and se , ason w controlled for. The first step com ere prised of identifying the null m odel or a description of the variance in the outcom explained at the tw levels as captured by the intraclass correlation es o coefficient (IC ). The second step involved the inclusion of all the built environm variables C ent (recreation and food). The social environm variables w added by them ent ere selves in the third, the built and social environm variables w added in the fourth, all of the individual-level variables ent ere w added in the fifth step, and finally season w added to produce the final full m ere as odel. A ll regressions w estim ere ated by residual iterated generalized least squares (R L and started w 1 IG S) ith st order M arginal Q uasi-likelihood then proceeded to 2nd order Penalized Q uasi-likelihood m ethods using M iN (R Lw elease 2.21) [37]. Survey w eights (standardized in M w ) generated from the L iN R F R SS w ere used at the individual level, w hereas design w eights w ere not available for the neighbourhood level; therefore, level 2 w eights w ere set equal to one. O dds ratios (O ) and R their 95% confidence intervals (C w estim I) ere ated from regression coefficients and their standard errors. The IC w calculated using a latent variable m C as ethod proposed by M erlo and colleagues [38]. 3. R esults 3.1. Sam C ple haracteristics U pon com bining the four years of R FSS data, a total of 5,025 respondents w R ere identified from85 neighbourhoods in the C of O ity ttaw A excluding respondents w w pregnant at the a. fter ho ere tim of response (n = 51), had m e issing inform ation on PA (n = 308), B I (n = 194), M education (n = 16), household incom (n = 632) or sm e oking status (n = 6), living outside the 89 predefined O S neighbourhoods (n =362), residing in neighbourhoods w N ithout councilor voting rates (n = 70), or from neighbourhoods w a cell count of less than five (n = 3), the final unw ith eighted sam used for analyses w 3,383 respondents, w 3,514 in the w ple as ith eighted sam (survey w ple eights). Sam distribution am ple ong the neighbourhoods ranged from5 to 210 respondents per neighbourhood, how ever, standardized survey w eights w appliedin the m ere ulti-level m odels.

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A sensitivity analysis for m issing incom w perform on outcom and individual-level e as ed es variables. R esults identified that those m issing household incom inform e ation w m likely to ha ere ore ve a low education and be younger. N other individual variables w show to differ betw incom er o ere n een e responders and non-responders. Table 1 provides descriptive characteristics for the w eighted sam ple. Just over half (54% of the ) sam w fem ple as ale. C pared w w en, m w significantly m likely to be classified as om ith om en ere ore overw eight or obese, highlyphysically active, and report higher incom levels. Significant differences e in the proportion of m and fem respondents to R FSS w observed across all seasons of data ale ale R ere collection. T able 1. W eighted sam characteristics. ple T otal (n = 3,514) A category, n (% ge ) 1824 years 2544 years 4564 years 65+ y ears B ody m index category, n (% ass ) U nderw eight/N al w orm eight O verw eight/O bese L evel of physical activity, n (% ) Insufficiently active A ctive E ducation, n (% ) D not graduate fromhigh school id G raduated fromhigh school Som post-high school education e C ollege/university diplom a/degree H ousehold incom n (% e, ) $29,999 $30,000 Sm oking status, n (% ) D aily O ccasional F er orm N ever Season of data collection, n (% ) Sum er m F all W inter Spring 401 (11% ) 1,490 (42% ) 1,456 (41% ) 167 (5% ) 1,688 (48% ) 1,826 (52% ) 1,706 (49% ) 1,808 (51% ) 191 (5% ) 528 (15% ) 409 (12% ) 2,386 (68% ) 393 (11% ) 3,121 (89% ) 474 (14% ) 156 (4% ) 1,022 (29% ) 1,862 (53% ) 907 (26% ) 886 (25% ) 794 (23% ) 927 (26% ) M en (n = 1,632) 177 (11% ) 700 (43% ) 664 (41% ) 91 (5% ) 556 (34% * ) 1,076 (66% * ) 755 (46% ** ) 877 (54% ** ) 106 (6% ** ) 243 (15% ) 195 (12% ) 1,088 (67% ) 140 (9% * ) 1,492 (91% * ) 237 (15% ) 84 (5% ) 494 (30% ) 817 (50% ) 438 (27% ** ) 388 (24% ** ) 399 (24% ** ) 407 (25% ** ) W en om (n = 1,882) 224 (12% ) 790 (42% ) 791 (42% ) 77 (4% ) 1,132 (60% * ) 750 (40% * ) 951 (51% ** ) 931 (49% ** ) 85 (5% ** ) 285 (15% ) 214 (11% ) 1,298 (69% ) 252 (13% * ) 1,630 (87% * ) 237 (13% ) 72 (4% ) 529 (28% ) 1044 (55% ) 469 (25% ** ) 498 (26% ** ) 395 (21% ** ) 520 (28% ** )

D are presented as frequencies and p ata roportio u ns nless otherw stated. ise Proportio are significantly different b een m ns etw ales and fem at *p<0.001, **p<0.05. ales

Int. J. Environ. Res. P ublic H ealth 2011, 8 3.2. N eighbourhood Environm ents

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Table 2 provides descriptive characteristics of the 85 neighbourhood environm ents. O verall the neighbourhoods in the study had m sum er outdoor recreation facilities than w ore m inter and indoor facilities, and had m uch higher ratios of park area than open green space. F food outlets and ast restaurants w the m abundant food resources w ere ost hile grocery stores w the least abundant. W ere hile there is a w range betw the m ide een inim and m um axim neighbourhood values, the m um edian of the SES index score is low than the indexs average, m er eaning that there w m neighbourhoods w ere ore ith incom higher than the average. Figure 1 provides a visual representation of the O S neighbourhood es N boundaries for the C of O ity ttaw and the relationship betw neighbourhood SE and the density of a een S recreation resources. F igure 1. O ttaw N a eighbourhood S tudy m including neighbourhood boundaries, SES ap index and recreation facility density.

*N the S index is reverse co w higher index scores m ote: ES ded ith eaning low incom lev er e els.

Int. J. Environ. Res. P ublic H ealth 2011, 8 T able 2. N eighbourhood characteristics (N=85). M SD ean R ecreation environm ent
Indoor recreation facilities per 1,000 people O utdo orW inter per 1,000 people O utdo orSum er per 1,000 people m 2 Park area (km) per 1,000 people B ike/w alking path length (km ) 2 G reen space (km) per 1,000 people F ood environm ent G rocery sto per 1,000 people res Fast food outlets per 1,000 people C onvenience stores per 1,000 peo ple R estaurants per 1,000 people Specialty food sto per 1,000 people res Social en vironm ent Socioeconom index (t-score)* ic Strong sense of belong (% ing )* C ouncillor voting rates (% ) Founded offences of property and violen crim (counts in 2006) t e 0.17 0.16 0.29 0.17 3.93 2.01 39.75 44 .95 11.54 16.24 0.63 3.48 0.12 0.15 1.24 2.20 0.53 0.40 0.97 1.79 0.38 0.60 41.75, 48.69, 57.73 56.00, 60.90, 63 .70 46.70 8.25 455.01 440.48 00.64 01.10 013.98 2.09329.42 0140.83 0.0132.09 00.87 017.93 01.99 014.76 04.03 36.0077.69 36.7077.90 32.06100 .00

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R ange (m inm ax)

72.003019.00

*Q uartile 1, M edian, Q uartile 3 .

3.3. M ultilevel Analysis Table 3provides final m ultilevel m ultivariate m odel results for the relationships betw individual een and neighbourhood level exposures and individual level PAand overw eight/obesity . 3.3.1. Physical A ctivity M odels N m ull odels (not show revealed no significant variability across neighbourhoods for level of PA n) . The IC s of the null PA m C odels w low for both fem ere ales (IC = 0.01) and m C ales (IC = 0.01) C indicating that a low proportion of the individual variation in level of PA could be explained by neighbourhood-level characteristics. Initial PA m odels including only the built environm variables ent show ed significantly increased odds for PA w ith higher num bers of restaurants in fem ales (O R= 1.25, 95% C 1.06, 1.45) and convenience stores in m I: ales (O R= 1.51, 95% C 1.23, I: 1.79). C ontrary to our hy pothesis, the likelihood of being physically active w low for m in as er en neighbourhoods w a higher green space area (O = 0.90, 95% C 0.84, 0.96). These associations ith R I: rem ained significant and in the sam direction follow e ing the addition of the social environm ent variables, individual-level variables, and season. F m higher neighbourhood sense of belonging or en, w significantly associated w increased odds of PA only after the inclusion of the built as ith environm variables (O ent R= 1.02, 95%C 1.001, 1.03) and rem I: ained significant in the final m odels. N significant associations w found betw social environm variables and fem PA Season o ere een ent ale . w a significant predictor of m as ens PA but not w ens PA , om .

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F m w or en, inter and spring m onths w associated w significantly low levels of PA Final ere ith er . m odels identified that no individual-level characteristics w significantly associated w m P . ere ith ale A H ever, final fem m ow ale odels identified that those classified in the higher incom group had a 50% e greater likelihood of being active. 3.3.2. O verw eight/O besity M odels N m ull odels (not show identified a significant variance in the likelihood of being overw n) eight or obese across neighbourhoods. A lthough low the IC s in the null m , C odel tended to be slightly higher for overw eight/obesity than they w for PA (IC male = 0.05 and IC female = 0.02) (Table 4). N ere C C o significant associations w observed betw any of the built environm characteristics and m ere een ent ale overw eight/obesity rates in built environm ent-only m odels. H ever, after the addition of the social ow environm variables, a higher proportion of restaurants w significantly associated w low odd ent as ith er s (O = 0.72, 95% C 0.56, 0.91) and a higher green space (O = 1.12, 95% C 1.03, 1.23) w R I: R I: as significantly associated w higher odds of being overw ith eight/obese. F m or ales, a decreased likeliho od of overw eight/obesity w associated w living in neighbourhoods w higher voting rates in the as ith ith social environm m ent odel. W the built environm variables w added to the social environm hen ent ere ent m odel, m ales w also m likely to be overw ere ore eight/obese in neighbourhoods w a higher sense of ith com unity belonging and less likely living in neighbourhoods w a low SES. The odds rem m ith er ained alm identical w the addition of season and individual-level covariates. Final m ost ith odels identified that increasing age above 24 years and being an occasional sm oker com pared to a daily sm oker w ere associated w greater odds of being overw ith eight or obese. Initial fem m ale odels w only the built environm variables show that w en w m ith ent ed om ere ore likely to be overw eight or obese if living in neighbourhoods w higher num ith bers of sum er outdoor m recreation facilities (O = 1.09, 95% C 1.03, 1.16) and specialty stores (O = 1.65, 95% C 1.06, R I: R I: 2.57) and greater bike and w path length (O alk R=1.01, 95%C 1.001, 1.02). They w less likely to I: ere be overw eight or obese if living in neighbourhoods w m green space area (O ith ore R= 0.73, 95% C I: 0.58, 0.89), park area (O = 0.99, 95% C 0.99, 0.99) and restaurants (O = 0.78, 95% C 0.69, R I: R I: 0.99). A of these associations rem ll ained significant and in the sam direction in the final m e odel w ith the exception of bike and w alkpath lengthand park area w hich lost significance follow ingthe addition of the individual-level variables. N significant associations w o ere observed betw een the social environm and fem overw ent ale eight/obesity Final m . odels identified that increasing age above 24 years w associated w greater odds and being a college/university graduate w associated w a as ith as ith low likelihood of being overw er eight or obese. 4. D iscussion This study investigated the influences of objectively m easured recreation, food and social environm ents as they relate to levels of PAand overw eight/obesity in a large representative sam of ple adults living in the C of O ity ttaw In addition to exam a. ining m ultiple environm ental determ inants concurrently the study used neighbourhoods that are relatively hom , ogeneous in term of s socio-econom In contrast to census tract delineations usually seen in the C ics. anadian literature onthis topic, the O S neighbourhoods are thought to better represent natural areas w w N ith hich residents

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identify and provided a scale that is adequate to study the differences in health outcom w es ithin the urban environm ent. The studys findings are sim to other C ilar anadian studies in w hich significant differences w ere observed betw een neighbourhoods/areas for PA levels [39] and rates of overw eight/obesity [40,41]. F indings identified that higher green space w negatively associated w as ith PA and positively associated w overw ith eight/obesity in m ales. A recent study in the N etherlands by M and colleagues also revealed a negative association betw aas een green space and w alking and cy cling in leisure tim in both m e ales and fem ales. Interestingly, in that sam study, green space w e as not significantly associated w ith m eeting PA recom endations, playing sports or actively m com uting [42]. The negative association in m m ales m perhaps be attributed to low m ay otivation for using green space. G reen spaces lack specificity for use related to PA unlike bike/w paths for alk com uting or parks for play and as such, their use for PA purposes m be low than that of other m ay er facilities. In addition, it has been show that w en are m likely to visit areas like playgrounds n om ore w here they can supervise children as opposed to m w use m form facilities like basketball en ho ore al courts and soccer fields w here they can engage in m vigorous types of PA[43]. ore In contrast to m ales, the fem ales in our sam w ple ere less likely to be overw eight/obese in neighbourhoods w high green space and m likely w a greater num of sum er outdoor ith ore ith ber m facilities. The sex differences in green space and facility association w overw ith eight/obesity rates w as not clear. It is possible that the preference for use of green space and facilities differs by sex, but unfortunately this study w unable to test this hypothesis. A as nother C anadian study show that livin ed g in proxim to greater num ity bers of parks and parkland w m positively associated w PA am as ore ith ong w en than m [44]. It m be that the sum er facilities are m geared tow om en ay m ore ards y oung children and m ales. It is also possible that w en visit these venues w their children w om ith here they in turnsit to w atch them play. C ontrolling for the presence of young children m help to tease out th ay is relationship, but this data w not available for this analysis. A review of parks and recreation se as ttings identified that these settings are m com only associated w w ore m ith alking w less clear relationships ith for m oderate- and vigorous-intensity PA [45]. It is likely that the differences observed across studie s are attributable to the variation in m easurem used for both the environm and PA variables, and ent ent the definition of neighbourhood w ithin a study. Interestingly, w hile the food environm w originally intended as a proxy for food consum ent as ption for our covariates specifically in the overw eight m odels, it em erged as a possible determ inant of PA In . m ales, a higher num of convenience stores and in fem ber ales, a higher num of restaurants in the ber neighbourhood w significantly associated w higher odds of PA It is likely that these food outlets ere ith . are m representative of the density of am ore enities in the neighbourhood and m act as a proxy for ay m ixed-land use and w alkabilityw hich has been previously show to be associated w PA[9]. F n ith uture research w ould benefit fromthe use of a m easure of land use for testing this hypothesis. The m ajority of research to date has focused on the food environm as it relates to B I and body w ent M eight status [46]. In the present study, fem ales had increased odds of being overw eight/obese w living in hen neighbourhoods w a greater num of specialty food stores w ith ber hile m ales had low odds living in er neighbourhoods w a higher num ith bers of restaurants. The present findings are sim ilar to those reported by B lack and colleagues w used sim m ho ilar easures of the environm in their m ent ultilevel exam ination of N Y ew ork C neighbourhoods and the odds of obesity. In their study, a greater ity

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availability of restaurants w also significantly associated w low odds of obesity [47]. The fe ale as ith er m findings w also sim to U studies of adults looking at the relationship betw various food ere ilar .S. een outlets including convenience stores and B I [48-50]. These previous studies dem M onstrated that the presence of convenience stores com pared to no stores w significantly associated w a higher as ith prevalence of overw eight and obesity W these studies did not perform sex-specific analyses they . hile did control for sex in their m odels [48-50]. P erhaps the reason w there w hy ere no significant associations betw the other food outlets like grocery stores and fast food outlets in our study w een as related to both their variability am ongst neighbourhoods and the ratio of the poor nutrition resourc es such as fast-food restaurants and convenience stores to healthy resources such as superm arkets and specialty food stores. A recent C anadian study dem onstrated that a low ratio of fast-food restauran er ts and convenience stores to grocery stores and produce vendors near peoples hom w associated es as w low odds of being obese [51]. ith er Surprisingly, the social environm had no im ent pact on fem PA or overw ale eight/obesity status. H ever in m ow ales, a stronger neighbourhood sense of com unity belonging w significantly m as associated w being physically active and low neighbourhood SES and higher voting rates w ith er ere significantly associated w low odds for overw ith er eight and obesity. O ften, low individual level SES has been associated w low rates of PA and higher rates of obesity [4,52]. S ith er tudies that have used aggregated indices, area-level m easures of deprivation or area-level SES have reported positive associations betw higher neighbourhood levels of deprivation and higher rates of inactivity [11] a een nd higher B I or rates of obesity [53]. H ever, the m M ow ajority of research on this relationship has been conducted in the U w .S. here the incline of the social gradient m be steeper than in C ay anada. In addition, there is evidence to suggest that sex-differences exist for area SESand health [52,54]. H arrington and Elliott reported on data from the O ntario H eart H ealth Survey collected in 1992, their analysis looked at both a com bined and m and fem specific m ale ale odels. Sim to the current ilar study, factors in the social environm including proportion of hom ners versus renters, incom ent eow e inequality neighbourhood education, average household incom proportion of households below the , e, L O and unem IC , ploym rate w not significantly related to B I in the com ent ere M bined or m ale-fem ale specific m odels. A verage dw elling value w the only significant social variable and w only as as significant in the fem and com ale bined m odels, identifying that low average dw er elling value w as associated w higher B I versus the highest average dw ith M elling value [41]. B erry and colleagues also exam ined the issue of neighbourhood S on B I in a cross-sectional sam of com ES M ple bined m and ale fem participants w ale ithin the C of Edm ity onton, A lberta, C anada [55]. Their analysis also em ployed m ultilevel m odeling and controlled for PAas assessed by the IPA , how Q ever, it included other factors not captured w ithin the R F R SS such as fruit and vegetable consum ption and reasons for neighbourhood selection (e.g., proxim to job, proxim to outdoor recreation resource, etc.). ity ity Findings identified that participants residing in low SES neighbourhoods had greater B Is than those M in the m edium or high SES neighbourhoods [55]. It appears that an inverse relationship m exist ay betw area level SES and B I in C een M anadian populations and these relationships m be influenced ay by sex. L er neighbourhood SE w associated w low odds of overw ow S as ith er eight/obesity in m only. In en addition, m w m likely than w en to be overw en ere ore om eight or obese. It is possible that the higher prevalence of overw eight/obesity is partially responsible for these findings, but it is also possible that

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the low SES scores are proxy m er easures of factors in the built environm such as increased relian ent ce on active transportation. Previous research has also show a positive association betw public tra n een nsit use and PA[56]. F studies have exam ew ined the influence of social factors other than neighbourhood S ES. Findings of the present study support the notion that high social cohesion or sense of com unity belonging is m associated w a greater likelihood of PA [57-59]. O ith ther research has show that relationships n betw een crim and PA m differ depending on w e ay hether the crim is perceived or objectively e m easured [22,60]. Sim to other objectively m ilar easured research [19,47], the present investigation identified no significant associations betw crim and PAor overw een e eight/obesity. The present study has lim itations that should be recognized. First, the neighbourhood-level indicators w all collected betw 2006 and 2008 w ere een hile the individual-level data com prised of the com bination of five surveys spanning years 2003 to 2007. The tem porality of the data collection periods m bias the results w ay hereby individuals w not exposed to the sam environm ere e ents at every survey tim point. W e hile this bias m be present, O a level estim ay ttaw ates rem ained relatively stable across this tim period (data w originally collected in 2006 and re-assessed in 2008). Second, the e ere food outlet density variables used w based on a per capita m ere easure, it is im portant to distinguish that defining food outlet density m easures in per land area m easures m produce a different estim ay ated relationship betw B I and food outlet density as seen in previous research[61]. Thirdly, the study een M w unable to control for the fact that individuals m have responded in m as ay ultiple cycles of the R FSS R resulting in an individuals over-representation, how ever, this bias is likely overcom by the large e sam size. A fourth lim ple itation is that the individual-level variables w self-reported and eviden ere ce suggests that self-report m easures specifically for PA differ significantly from their objective m easures [62]. W hile it w ould have been preferable to use direct m easures to exam these ine relationships, there is no know large dataset for the O n ttaw area and collection of these m a easures on such a large scale w ould be very tim and cost intensive. The self-report m e easures allow for the ed capture of data on a large scale and the use of the higher PA cut-point (level 3 versus 1 and 2) m ay have helpedto identify individuals w are truly active. ho O of the m ne ajor lim itations of this study is its cross-sectional nature; thus it w unable to captu as re causality in the relationships of the built and social environm ents w PA and overw ith eight/obesity. M of the previous research has also relied on cross-sectional designs due to the sheer costs ost associated w tracking such a large group of individuals over tim D to the nature of our ith e. ue secondary data sources w w unable to control for several im e ere portant individual variables includin g intrapersonal factors (e.g., intention and attitudes), interpersonal factors (e.g., social support for PA ), diet, sedentary behaviour, and num of children. L ber astly, it w not possible to assess neighbourhood as preferences and the likelihood that people self-selected into their respective neighbourhoods. It is possible that individuals w are m active select to live in neighbourhoods that are supportive of ho ore their lifestyles. W hile the study did not assess preference, it w able to control for clustering a the as t neighbourhood level using the hierarchical m odeling approach. Further, the aggregate-level unit of analysis (neighbourhoods) is distinct from the sam pling units utilized in the survey sam pling fram e. W hile survey w eights do adjust for the com plex survey design, they fall short of accounting for differential sam pling across neighbourhoods and m polarize them in a w that doesnt necessarily ay ay reflect the extent of the differences betw them In addition, the study w unable to account for the een . as

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fact that individuals w likely to cross neighbourhood boundaries to utilise other PA and food ere resources, and as such, neighbourhoods m not have truly represent their degree of exposure. ay 5. C onclusions The results of this study suggest that in O a, C ttaw anada variation in PA and overw eight/obesity levels can be attributed to the neighbourhood of residence. Findings suggest that neighbourhood-level interventions that support PAand healthy w eight control m need to be gender tailored. F ay urtherm ore, the recreation environm m play less of a role in PA levels, specifically higher intensity PA than ent ay , access to am enities in the food environm ent, a possible indicator of m ixed land use. The social environm ent, specifically neighbourhood-level sense of belonging, voting participation and SES m ay play m im ore portant roles in m outcom w ale es, hile individual-level SES m be m im ay ore portant for fem ales. Season, w hich had previously been ignored in m any m ultilevel exam inations of neighbourhood influences on PA appears to play an im , portant role for m PA perhaps due to gender ale , differences in preference for outdoor versus indoor location for PA A continues to be associated . ge w a greater likelihood of being overw ith eight or obese. To our know ledge, this study is the first to have exam ined the m ultilevel associations betw een individual PA levels and rates of overw eight/obesity w neighbourhood-level recreation, food and ith social environm ents and individual socio-dem ographics and season in a large randomsam of urbanple dw elling C anadians. O findings provide support for the grow research identifying that physical ur ing inactivity and obesity m be partially explained by neighbourhood-level exposures. Future researchin ay this area is necessary to identify w hether the relationships differ w objectively m ith easured PA and body com position, accoun ting for neighbourhood preferences an w d hether longitudinal associations exi st. C onflict of Interests A of the authors declare no com ll peting interests. A uthors C ontributions SA conceived the study, carried out the design, perform the analyses, and drafted and edited the P ed m anuscript. EA Kis a principal investigator w the O S and w responsible for the environm ith N as ental data; she participated in this studys design and coordination, provided analy tical input and helped draft and edit the m anuscript. K participated in the studys design, abstraction of data from the R R FSS, provided analy R tical input and aided w the editing of the m ith anuscript. J-M provided B analytical advice and interpretation and helped edit the m anuscript. M a principal investigator w Sis ith the O S and w responsible for the environm N as ental data, specifically the G com IS ponents; he also participated in the design of the study, provided m ethodological input, and assisted in the editingof the m anuscript. A participated in the studys design and coordination of data acquisition and edited the A m anuscript. M and D participated in the design of the study, provided m ST P ethodological input, and assisted in the editing of the m anuscript. A authors read and approved the final m ll anuscript.

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SA received funding in support of her doctoral w from the Social Sciences and H anities P ork um R esearch C ouncilD octoral A ard, O w ntario M inistries of O ntario G raduate Scholarships and a U niversity of O ttaw Excellence Scholarship and D a octoral R esearch A ard. The O a w ttaw N eighbourhood Study w funded by the C as anadian Institutes of H ealth R esearch (funding reference num 99345), the C plain L ber ham ocal H ealth Integration N ork, the O etw ttaw C a oalition of C m om unity H ealth, R esource C entres and U nited W O ay ttaw R a. andy M C eron H ar, am opgood and the O a ttaw Police Service are gratefully acknow ledged for the crim data used in this research. This research is a e contribution to the O a N ttaw eighbourhood S tudy (w w w .neighbourhoodstudy.ca) and the authors w ould like to thank all those involved in its inception and m aintenance including funders. R eferences and N otes 1. W arburton, D .E.R C .; harlesw orth, S Ivey, A N .; .; ettlefold, L B .; redin, S.S.D Asystem review . atic of the evidence for C anada's Physical A ctivity G uidelines for A dults. Int. J. Behav. N utr. P hys. Act. 2010, 7, 39. 2. Statistics C anada. Physical A ctivity D uring Leisure Tim 2009. C e, atalogue no. 82-625-X 2010002. M inister of Industry: O a, ttaw O , N C anada, 2010. A vailable online: http://w w w .statcan.gc.ca/pub/82-625-x/2010002/article/11267-eng.htm(accessed on 4 July2011). 3. Statistics C anada. O verw eight and O bese A dults (Self-R eported), 2009. C atalogue no. 82-625X 2010002. M inister of Industry: O a, O , C ttaw N anada, 2010. A vailable online: http://w w w .statcan.gc.ca/pub/82-625-x/2010002/article/11255-eng.htm(accessed on 4 July2011). 4. Trost, S.G O en, N B an, A Sallis, J.F.; B n, W C .; w .; aum .E.; row . orrelates of adults' participation in physical activity: review and update. M Sci. Sport. Exer. 2002, 34, 1996-2001. ed. 5. K atzm arzyk, P.T. The C anadian obesity epidem 1985-1998. C AJ2002, 166, 1039-1040. ic, M 6. H J.O Peters, J.C Environm ill, .; . ental contributions to the obesity epidem Science 1998, 280, ic. 1371-1374. 7. M orm cC ack, G G .; iles-C orti, B L .; ange, A Sm T.; M .; ith, artin, K Pikora, T.J. A update of .; n recent evidence of the relationship betw een objective and self-report m easures of the physical environm and physical activity behaviours. J. Sci. M Sport. 2004, 7, 81-92. ent ed. 8. R aine, K Spence, J.C C .; .; hurch, J.; B oul, N Slater, L M .; .; arko, J.; G ibbons, K H phill, E. .; em State of the evidence review on urban health and healthy w eights; C anadian Institute of H ealth Inform ation: O a, O , C ttaw N anada, 2008. 9. Saelens, B .; H .E andy, S.L. B environm correlates of w uilt ent alking: a review M Sci. Sports . ed. Exerc. 2008, 40, S550-S566. 10. Feng, J.; G lass, T.A C .; urriero, F.C Stew W .; Schw .; art, .F artz, B . The built environm and .S ent obesity: Asystem reviewof the epidem atic iologic evidence. H ealth P lace 2010, 16, 175-190. 11. M eill, L.H K cN .; reuter, M .; Subram .W anian, S.V Social environm and physical activity: A . ent reviewof concepts and evidence. Soc. Sci. M 2006, 63, 1011-1022. ed.

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12. A bercrom L .; Sallis, J.F.; C ay, T.L.; F bie, .C onw rank, L .; Saelens, B .; C .D .E hapm J.E. Incom an, e and racial disparities in access to public parks and private recreation facilities. Am J. Prev. M . ed. 2008, 34, 9-15. 13. Estabrooks, P.A L R .; ee, .E.; G yurcsik, N . R .C esources for physical activity participation: D oes availability and accessibility differ by neighborhood socioeconom status? Ann. Behav. M ic ed. 2003, 25, 100-104. 14. M oore, L .; D R .V iez oux, A .; Evenson, K .; M inn, A .V .R cG .P.; B rines, S.J. A vailability of recreational resources in m inority and low socioeconom status areas. Am J. P ic . rev. M 2008, ed. 34, 16-22. 15. G iles-C orti, B D .; onovan, R The relative influence of individual, social and physical .J. environm determ ent inants of physical activity. Soc. Sci. M 2002, 54, 1793-1812. ed. 16. R iva, M G .; auvin, L R .; ichard, L U of local area facilities for involvem in physical activity . se ent in C anada: Insights for developing environm ental and policy interventions. H ealth P ot. Int. rom 2007, 22, 227-235. 17. R egidor, E.; G utierrez-Fisac, J.L R .; onda, E.; C alle, M M .E.; artinez, D D inguez, V Im .; om . pact of cum ulative area-based adverse socioeconom environm on body m index and overw ic ent ass eight. J. Epidem C m H iol. om un. ealth2008, 62, 231-238. 18. R oss, N .; C .A rouse, D Trem .; blay, S.; K han, S.; Trem blay, M B .; erthelot, J.M B . ody m index ass in urban C anada: neighborhood and m etropolitan area effects. Am J. P . ublic H ealth 2007, 97, 500-508. 19. B K C all, .; leland, V Tim .J.; perio, A .; Salm J.; G .F on, iles-C orti, B C ford, D . L .; raw .A ove thy neighbour? A ssociations of social capital and crim w physical activity am e ith ongst w en. om Soc. Sci. M 2010, 71, 807-814. ed. 20. Fisher, K Li, F.Z N .J.; . eighborhood w alking and health status in older adults: A m ultilevel path analysis. J. Aging Phys. Act. 2004, 12, 273-273. 21. Lindstrom M H , .; anson, B O .S.; stergren, P.-O Socioeconom differences in leisure-tim physical . ic e activity: the role of social participation and social capital in shaping health related behaviour. Soc. Sci. M 2001, 52, 441-451. ed. 22. M inn, A Evenson, K .; H cG .P.; .R erring, A .; H .H uston, S.L R .; odriguez, D . The association of .A perceived and objectively m easured crim w physical activity: a cross-sectional analysis. e ith J. P hys. Act. H ealth2008, 5, 117-131. 23. H pel, N O en, N L um .; w .; eslie, E. Environm ental factors associated w adults' participation in ith physical activity: Areview Am J. P . . rev. M 2002, 22, 188-199. ed. 24. Sallis, J.F.; K J. Physical activity and the built environm Res. D 2006, 7, 1-8. err, ent. ig. 25. W endel-V W D os, .; room ers, M K ers, S.; B .; rem rug, J.; van Lenthe, F. Potential environm ental determ inants of physical activity in adults: a system review O atic . bes. Rev. 2007, 8, 425-440. 26. Parenteau, M .; Saw .-P ada, M K .; ristjansson, E.A C .; alhoun, M L .; eclair, S.; L abont, R R .; unnels, V M .; usiol, A H .; erold, S. D evelopm of neighborhoods to m ent easure spatial indicators of health. U RISA J. 2008, 20, 43-55.

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