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Chapter 11 Residential Environments and Obesity: What Can We Learn About Policy Interventions from Observational Studies? Jeffrey D. Morenoff,Ana V . Diez Roux, Ben B. Hansen, and Theresa L. Osypuk D o policy initiatives that are aimed at changing physical or social features of the residential environment have measurable impacts on health?1 It has become an increasingly popular view in the field of public health that physical and social features of the residential environment can affect health either directly (through contaminants in the air or water supply) or indirectly, by influencing behaviors related to health (such as physical activity, food intake, substance use, and utilization of medical care) or psychosocial factors (such as stress and social relationships that help cope with stress) that may be related to health through more complex causal chains (House 2002). Although few studies have examined the health impacts of policies specifically directed at residential environments, an increasingly large body of associational studies, many of them from social epidemiologists and sociologists, demonstrates that there is considerable variation in mortality and other health outcomes across local geographic areas. They show that this variation is related to area socioeconomic status (that is, poverty rates and other measures of disadvantage and affluence ), and the variation appears to be at least partly independent of personal measures of socioeconomic position (Diez Roux 2001; Morenoff and Lynch 2004). Living in impoverished neighborhoods appears to adversely affect health, independent of the negative health consequences of poverty per se (Robert 1998). However , there is less evidence on how impoverished neighborhoods produce these adverse effects or how they might be disrupted. We examine the neighborhood variation in outcomes related to obesity using data from a recent study of adult health in Chicago neighborhoods. We also consider how interventions targeting residential environment might affect obesity. We focus on obesity because the rapid rise in obesity rates in the United States over the / 309 past two decades (Mokdad et al. 1999) cannot be explained solely in terms of biological and genetic factors (French, Story, and Jeffery 2001; Hill and Peters 1998). Furthermore, prior theory and research has identified specific features of residential environments that might be causally linked to physical activity and food intake, both of which are proximal determinants of obesity. Obesity and physical activity are also two of the few health outcomes for which there is experimental evidence from the Moving to Opportunities (MTO) study of a connection to residential environment (Orr et al. 2003). Still, systematic evidence is lacking on the extent to which obesity and behaviors related to obesity vary across residential contexts, making the current study an important contribution to this literature. Our study is observational, as is much of the literature on which it builds. An important limitation of observational studies on residential environments and health is that people may self-select into neighborhoods on the basis of characteristics that are not measured or that are assessed with considerable measurement error. Neglecting these selection factors can lead to biased, and conceivably inflated, estimates of the causal effects of neighborhood residence on health (Kling, Liebman, and Katz 2007; Oakes 2004). Intervention studies yield stronger causal inferences but have limits. They are limited by costs and logistical challenges of implementing them; by ethical and political challenges inherent to imposing or selectively alleviating undesirable circumstances; and by the inherent difficulty of selectively intervening on factors of certain types, such as broadly shared attitudes and perceptions . Our empirical findings include some of this latter type, which are difficult to imagine emerging from a field experiment. Although it is important to bear in mind the limitations of observational studies, evidence relevant to residential-environment policies is too rare for observational evidence to be ignored. RESIDENTIAL ENVIRONMENTS AND OBESITY It is important to first consider the theoretical pathways through which residential environments are linked to obesity. One of the reasons we chose the case of obesity to illustrate the connections between health and residential environments is that it is easy to conceive of tangible ways in which neighborhoods might influence how physically active a person is and the quantity and type of food a person eats. If residential environments influence patterns of physical activity and eating, then we would expect these effects to manifest themselves rather quickly, even if a person has only lived in a particular neighborhood for a brief period of time, because behaviors can potentially be very responsive to changes in environmental conditions. However, we might not observe an immediate direct effect of...

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