The Public Health Prescription for Walkable

Communities

Deb Spicer

NYS Department of Health

Healthy Heart Program

Impact of Transportation and Land Use Patterns on Health

• Physical Activity and Obesity

• Asthma

• Injuries

• Loss of Function in Older Adults

• Heart Attacks

Underlying Causes of Death (US)

0%2%4%6%8%

10%12%14%16%18%20%

1993

2003

While most of the preventable causes of death declined, diet and physical inactivity increased 33%.

Source: Behavioral Risk Factor Surveillance System, CDC

(*BMI 30, or ~ 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. AdultsBRFSS, 2002

Source: Mokdad et al., Diabetes Care 2000;23:1278-83; J Am Med Assoc 2001;286:10.

Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS, 1990,1995 and 2001

1990 1995

2001

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Overweight and Obesity Among NYS Adults (2003 BRFSS)

42%29%

35%

21%

21%21%

0%

10%

20%

30%

40%

50%

60%

70%

Males Females Total

2000 BRFSS New York State

BMI >30BMI 25-30

63%

50%

56%

56% of NY Adults are Overweight or Obese

Obesity Among NYS Adults, By Ethncity2003, BRFSS

35% 38% 36%

20%30% 22%

0%

20%

40%

60%

80%

100%

White Black Hispanic

BMI > 30

BMI 25-30

55%68%

58%

Trends in Overweight and Obesity Among NYS Adults, BRFSS

10% 13% 14% 15% 16% 18% 20% 21%

33%34% 35% 38% 35%

39% 36% 35%

0%

10%

20%

30%

40%

50%

60%

1990 1992 1994 1996 1998 2000 2001 2003

OverweightObese

57%

42%

Obesity Rates by Ethnicity and Gender, US, NHANES 1999-2000

White Men 27.8%

African American Men 28.7%

White Women 30.8%

African American Women

50%

•Based on actual height and weight measurements (BRFSS is self-reported)

•Rate among AA women predicted to be 57% by 2010.

Estimated Medical Costs of Obesity in NYS

Total Pop Medicare Medicaid

% of Costs 5.5% 6.7% 9.5%

Estimated Annual Costs

$6.08 Bill $1.39 Bill $3.54 Bill

25% of increase in health care costs due to obesity

Current Recommendations for Physical Activity

• Adults– At least 30 minutes a day of Moderate activity, at

least 5 days a week.– Can be in 10 minute segments

• Elementary-Age Children– accumulate at least 60 minutes of activity on all

or most days of the week– up to several hours of intermittent activity every

day

What’s Moderate Activity?

• Brisk walking (3-4.5 mph)• Bicycling - on level terrain• Playing frisbee• Swimming - recreational (doesn’t have to be laps)• Dancing - anything but slow• Coaching a sport• Handling uncooperative young child (chasing,

dressing, etc.)

BRFSS Questions on Physical Activity

Through 2000• Two most frequent

types of leisure• Time/day; days/week• Appox 26% met

recommendations• No leisure time PA

After 2001• Moderate (other than

work); days/week, total time/day.

• Same with vigorous• Approx. 45% met

recommendations• No leisure time PA

Physical Activity Among NYS Adults, (BRFSS 2001)

% of adults meeting recommendations

45%38%

46%

29% 33%

0%

20%

40%

60%

80%

100%

MALES FEMALES WHITES AF AM Hispanic

Trends in No Leisure Time Physical Activity, NY

35% 35%39%

32% 32%30% 29%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1990 1992 1994 1996 1998 2000 2001

Percent of Adults With No Leisure Time Physical Activity 2001, BRFSS

26%34%

0%

10%

20%30%

40%

50%

60%

State NYC

Cost of Physical Inactivity in NYS

• Inactivity costs NYS $3 billion a year

• A 5% increase in physical activity rates in adults would save NY $180 million a year.

• Inactive adults have $330 more per year in direct medical costs than active adults (in 1987 dollars).

Most Frequent Leisure Time Physical Activities – NYS, 2000

Percentage Number

Walking 38% 5,215,725

Running 7% 966,023

Weight Lifting 6% 895,708

Gardening 5% 728,594

Bicycling 4% 602,380

Health Benefits of Walking

• 3 hrs/wk of brisk walking (3mph) reduced heart disease risk in women by 35-40%

• Older adults who walked at least 4 hrs/week were 31% less likely to be hospitalized for heart disease or stroke.

• Women who walked at least 1 hr/wk reduced risk of CHD by 50%. (amount more important than pace)

Health Benefits of Walking

• People with diabetes who walked for exercise at least 2 hours a week lowered their mortality rate from all causes by 39 percent.

• Older women who walked the most had 40% less cognitive decline over 6-8 years.

Successful Long Term Weight Loss

• National Weight Control Registry• Lost 66 pounds and maintained for 5.5 years• During weight loss:

– 89% used both diet and activity– 92% exercised at home

• During maintenance– walking most common type of activity

Walking Trips, US, 1977 - 1995

9.38.5

7.2

5.5

012345

6789

10

1977 1983 1990 1995

Per

cent

of T

rips

Why Don’t We Walk

• No place to walk• Can’t cross the street• Too far• Unpleasant• Dangerous• Time

Speed Kills

0% 20% 40% 60% 80% 100% 120%

20 mph

30 mph

40 mph

50 mph

Veh

icle

Spe

ed

% of Hit Pedestrian Who Will Die

Average Annual Hospitalization Costs for

Motor Vehicle Injuries, NYS, 1994-96

# % Total Cost %Bike 5,971 15% $45.7 M 10%Ped 12,964 33% $221.7M 49%Bike +Ped

18,935 48% $267.4M 59%

TotalMV

38,991 $452.3M

Healthy People 2010 Objectives

to at least 25% the percentage of trips of 1 mile or less that adults make by walking.

to at least 50% the percentage of trips to school (less than 1 mile) that youth make by walking

Making it easier to be active = Environmental Changes :

• Sidewalks and shoulders along roadways• Destinations to walk and bike to• Community trails - for walking, bicycling,

in-line skating, pushing a stroller.• Safe neighborhood playgrounds and parks

for kids and adults• Schools and malls open for walking• Attractive, well lit stairwells

Guide to Community Preventive Services – Promoting Physical Activity

• Insufficient Evidence– Classroom-based health education– Mass media (alone)– College health ed and PE– Family-based social support– Physician counseling

Guide to Community Preventive Services

– Promoting Physical Activity

• Recommended– Community-scale urban design and land use policies *– Street-scale urban design*– Community wide campaigns– PE– Social Support Interventions– Individually adapted health behavior change programs– More opportunities for PA

*to be published, fall 2004

Source: Switzerland Federal Office of Sports

Switzerland• Over 60% of adults meet PA recommendations• Daily commuting

– 32% walk (NY - 7%)

– 14% bicycle (NY - <1%)

• 20,000 miles of signed walking trails• 8 major bike routes (in a small country)• Town centers with pedestrian only zones• Bikes allowed on trains and buses

Impact of Environmental ChangesStair Use - 2000

• Baltimore subway station

• Observed 10,700 commuters (54% AA) choice of stairs or escalator

• Intervention: culturally specific sign - “No time for exercise? Try the stairs”

• Results: Increased stair use among AA from 10.2% to 16.2%.

Impact of Environmental ChangesTrail Use - 2000

• Telephone survey of adults in 12 rural counties in Missouri

• Trails associated with 8% overall increase in physical activity.

• Of those with access to a trail - 21% reported increased activity.

• Increase more likely among women, those with less education.–

Sprawl and HealthCompact Counties

(vs. sprawling)

Extremely compact (e.g. NYC) (vs. extreme sprawl)

Minutes walked per month

+14 min. +79 min

BMI - .17 -1.0

Weight - 6.3 pounds

Obesity – Odds Ratio

.90

Hypetertension .95

Ewing, 2003

Impact of Environment on Physical Activity in North Carolina (2003)

Odds Ratios

Any Activity Meets Recomm

Sidewalks 1.42 NS

Trails 1.62 1.49

Street Lights 1.57 NS

Access to PA 2.94 2.28

Huston, AJHP, 2003

Destinations and Physical Activity in Older Women in Pittsburgh(2003)

# of Destinations Within 20 Minutes Walk

Steps per Day

0 2745

1 3281

2-11 5714

King, AJHP, 2003

Obesity and Community DesignAtlanta, 2004

• Land use mix, residential density, street connectivity

• Land use mix most strongly correlated with obesity– ↑ 1 quartile → ↓ obesity risk by 12%

• ↑ car time by 1 hour → ↑ obesity by 6%• ↑ walk by 1 km/day →↓obesity by 5%

Frank, AJPM, 2004

Asthma and Traffic

• Atlanta - Summer Olympic Games, 1996, Reduced auto use by 22.5%

– Reduced hospitalizations for asthma by 41.6% among children 1-16 years old

• Erie County, 1990-1993.– Children living within 200 m of state road 2x as

likely to be hospitalized for asthma

Neighborhood Environment and Loss of

Physical Function in Older Adults

• Alameda County, CA; 55+; healthy at start, followed for 1 year; rated neighborhoods

• Living in problem neighborhoods - 2x as likely to have loss of overall function and 3x as likely to have loss of leg function.

• Noise, inadequate lighting and heavy traffic created highest risk.

Other Benefits of Walkable Communities

• Less reliance on cars – less traffic congestion, air pollution, noise

• Less crime – “Eyes on the street”, CPTED

• Better sense of community

• Economic benefits

• More independence for youth, seniors, people with disabilities, poor.

The Vision

• A Walkable Community is one where, on a hot summer’s day, a couple of 8-year old children can walk by themselves to a corner grocery store to get a popsicle.

Components of Walkable Communities

• Safe places to walk - sidewalks, shoulders, trails (engineering)

• Safe crossings - crosswalks, medians, signals, street design (engineering)

• Pleasant environs

• Safer driver and pedestrian behavior - (enforcement, education)

• Safe neighborhood (enforcement)

Components of Walkable Communities (cont)

• Traffic calming - narrow streets, on-street parking, trees, medians (engineering)

• Destinations - mixed land use, higher density housing, infill develop.,location of schools and parks, vibrant downtowns

• Attitudes - accepting walking as a viable means of transportation (encouragement)

Lewiston, NY - Before and After

Community Structure and Physical Activity

Growth of the Movement

• Initial focus on transportation

• Land use may have more effect

• Health and Built Environment

• Health Impact Assessments

Role of Public Health in Walkable Communities

• Don’t have to be technical experts

• Use our current skills

• Create Demand - for walking– Normalize Walking– Change social norms around walking

Role of Public Health (Cont)

• Create Demand - for walkable environments– educate public and decision makers– develop/nurture pedestrian advisory groups– policies and ordinances– hold events– get media attention– get walkers to public hearings

Walkable Community – The Role of Public Health

Increase Walking Walkable Communities

(Opportunities)Local Decision Makers

Influential Citizens

Trained Professionals

BC Walks

Long Term Outcomes

Intermediate Outcomes Short Term OutcomesHealthy Heart Program

Normalize Walking

(Attitudes)

State Policies

•Walkable Communities SlideShow• State Pedestrian Conference•Walk to School Week•Presentations•Walkable CommunitiesWorkshops•Communication campaign•Healthy Heart Contractors•Initiative for Healthy Infra.•Parks & Trails NY• Umbrella for pedestriangroups

NYS DOH Initiatives to Promote Walkable Communities

• 17 local Healthy Heart Program contractors-many work on bike/ped issues– Initiative for Healthy Infrastructure (SUNY Albany), Parks and Trails

NY, Transportation Alternatives• 9 new worksite and school contractors• 4 Steps to a Healthier US counties – Chautauqua, Broome, Rockland,

Jefferson. • Cardiovascular Health In NYS – A Plan for 2004 – 2010• Developing a state Obesity Prevention Plan • Walkable Communities Workshops• Walk to School Week/Safe Routes to School• State Pedestrian Conference• BC Walks, America on the Move• NYS Physical Activity Coalition (www.nysphysicalactivity.org)

Healthy Infrastructure Symposium, 2005

• Propose solutions to key issues that support improved environments

• Friday, March 18; 9:00 – 4:00, SUNY Albany

• Pre-symposium workgroups

• www.albany.edu/~ihi

What You Can Do

• Join local bike/ped task force

• Attend training sessions

• Attend public hearings on street redesigns

• Link with “smart growth” groups

• Organize Walk Our Children to School Week event

• Get on my Electronic PA Newsletter list

• Check out web sites

Walkable CommunitesWeb Sites

• NYS Physical Activity Coalition: www.nysphysicalactivity.org

• National Center for Bicycling and Walking: www.bikefed.org

• Pedestrian Information Center: www.walkinginfo.org• NY Parks and Conservation Assoc (trail maps):

www.nypca.org• Walk to School Day: www.walktoschool-usa.org• Active Living by Design: www.activelivingbydesign.org• America Walks (advocacy groups):

www.americawalks.org

Summary

• We need to be more active

• Walking is the easiest way for most people to be more active

• Walking has many benefits

• We need to have safer, more pleasant places to walk.