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Review

Thebenefitsofregularwalkingforhealth,
wellbeingandtheenvironment

C3CollaboratingforHealth*
September2012

Contents

Overview

Introduction

PartI:Evidencesupportingthebenefitsofwalkingonphysicalandmentalhealth

1.Theimpactofwalkingonphysicalhealth

a)Effectofwalkingonallcausemortality

b)EffectofwalkingonNCDs

2.Theimpactofwalkingonmentalhealth

3.Walkingguidelines

PartII:Thewalkingenvironment

11

1.Overcomingbarrierstowalking

11

2.Activetransport

14

3.Thebuiltenvironment

16

PartIII:Walkingandtheenvironment:awinwin

18

PartIV:Casestudies

20

1.Introduction

20

2.Casestudies:walkingprogrammes

20

3.Casestudies:thebuiltenvironment

28

AppendixI:Selectedliteratureonthehealthbenefitsofwalking

31

Table1a:Benefitsofwalkingfortype2diabetes

31

Table1b:Cardiovascularbenefitsofwalking

32

Table1c:Otherchronicdiseasebenefitsofwalking

33

Table2:Mentalhealthbenefitsofwalking

33

AppendixII:Thewalkingenvironment

35

Table3:Walkingandpedometers

35

Table4:Activetransport

36

Table5a:Selectedwalkingcampaignsfromaroundtheworld

37

Table5b:Onlinewalkingtools

38

AppendixIII:Levelsofevidenceandevidencegaps

41

Endnotes

42

C3CollaboratingforHealth
Director:ChristineHancock
FirstFloor,28MargaretStreet,LondonW1W8RZ,UnitedKingdom
Tel+44(0)2076374330;Fax+44(0)2076374336
C3CollaboratingforHealthisaregisteredcharity(no.1135930)
andacompanylimitedbyguarantee(no.6941278),registeredinEnglandandWales

www.c3health.org

Overview
Thepurposeofthisreviewistosummarisetheevidenceofthebenefitsofwalkingforphysicalandmental
health,aswellasthefeaturesofthebuiltenvironmentnecessarytofacilitateandencouragethisformof
physicalactivity.Casestudiesdemonstratingbestpracticesinavarietyofsociodemographicand
geographicalsettingswillbeusedtoexemplifythereallifepositiveeffectsofwalking.

PartIincludesasummaryanddetailedtablesofthefindingsofaliteraturereviewonthementaland
physicalbenefitsofwalking,whichformabodyofevidenceonthepositiveimpactthatwalkingcanhaveon
reducingtheburdenofnoncommunicablediseases(NCDs).
PartIIincludesasummaryofthefindingsofaliteraturereviewontheevidencearoundtheoverall
environmentnecessarytopromotewalking.Thissectionincludessummaryinformationfromstudies
relatedtoactivetransport(walkingandcycling),thebuiltenvironment,andtheenvironmentalbenefitsof
walkingovercarbonemittingformsoftransportation.
PartIIIpresentsaseriesofcasestudiestoserveasexemplarsforindividualsand/ororganisationsthatare
consideringincorporatinginterventionstopromotewalkingasaformofphysicalactivityinavarietyof
settings.Inadditiontocasestudiesthathavebeenexternallyevaluated,someexamplesareincludedthat
arenotgroundedinscientificevidencebutuseinterestingapproachesthatcouldbeusedtostart
discussionamongthemanygroupsofpeoplewhohaveaninfluenceoverthewalkingenvironment.

Introduction
TheworldiscurrentlyfacinganepidemicofrisingratesofNCDs,causedinpartbytherisingtrendin
obesityrates,correspondingtodecliningratesofphysicalactivity.1
Walkingisoneoftheleastexpensiveandmostbroadlyaccessibleformsof
physicalactivity.2Itisrarelyassociatedwithphysicalinjuryandcaneasilybe
adoptedbypeopleofallages,includingthosewhohaveneverparticipatedin
physicalactivity.3Studieshaveshownthatwalkinghashigherlevelsofadherence
thanotherformsofphysicalactivity,possiblybecauseitisconvenientand
overcomesmanyofthecommonlyperceivedbarrierstophysicalactivity:lackof
time,lackoffitnessorlackofskill.4
Walkingiscurrentlythemostpopularformofphysicalactivityintheworld,with
studiesfromtheUnitedKingdomandUnitedStatesdemonstratingthatthe
prevalenceofwalkingistwotothreetimeshigherthanthoseofthenextmost
frequentlyreportedactivities.5However,althoughwalkingispopularinthese
countriesandelsewhere,walkingrateshavedeclinedsteadilyoverthelast
severaldecades6forexample,theproportionofchildrenwalkingorcyclingto
schoolfellbetween1969and2009from48to13percentintheUnitedStates,7
and(amongprimaryschoolchildren)from62to50percentbetween1989and
2004intheUnitedKingdom.8
Thisreportprovidestheevidenceofhealthbenefitsofwalking,providingtherationaleforactionand
strategiesforincreasingwalkingratesamongdiversepopulations,asthiscanhelptolowerriskfactorsfor,
andratesof,NCDs.

www.c3health.org

PartI:Evidencesupportingthebenefitsofwalkingon
physicalandmentalhealth

1.Theimpactofwalkingonphysicalhealth
AsdetailedinC3CollaboratingforHealthsreviewofTheBenefitsofPhysicalActivityonHealthandWell
being,9thereexistsextensiveevidencesupportingthebenefitsofphysicalactivityonmanypartsofthe
body,whichcanresultinreducedriskofnoncommunicablediseases(NCDs).Physicalinactivityis
estimatedtocausearound5.3milliondeathseachyear,10andinmanycountriesthemajorityofpeopledo
notreachtheminimumlevelofphysicalactivityrecommendedforgoodhealthinEngland,forexample,
onlyaround42percentofmenand31percentofwomenreachedtherecommendationsin2008.11
WalkingintheUnitedKingdomfellbyalmost20percent,fromanaverageof408milesayeartojust314
miles,between1976and2009.12
Walkingisaparticularlyaccessibleformofphysicalactivity:itislowimpact,appropriateforallagegroups,
andisfree.NotonlyisitagoodwaytogetfromAtoBbriskwalkingspeedisabout3.5miles(5km)per
hourbutwalkingcanalsohelppeopletoavoidweightgainoverthelongterm.Evenslowwalkingburns
around114caloriespermilewalkedforsomeoneweighing200lb(91kg).13
Estimatingcaloriesburned:aroughestimate
Tocalculatethenumberofcaloriesburnedwalkingamileatcasualwalkingspeed(2mph),multiply
yourweightinpoundsby0.49,andforbriskwalking(3.5mph)multiplyitby0.57.

Studiesarenowemergingthatdifferentiatethespecific
physicalbenefitsofwalkingfromthebenefitsofhigher
intensityformsofexercise.

a)Effectofwalkingonallcausemortality
Recentstudieshaveshownanassociationbetweenwalkingand
areductionindeathsfromallcauses,rangingfrom1930per
centdependingonthefrequencyandlengthofwalking
activities.14Themostsignificantreductioninmortalitywas
associatedwithwalking20kmperweek(beyondstepstakenin
normaldaytodayactivities),whileareductionof19percent
wasassociatedwith2.5hoursofbriskwalkingperweek
(around12.5km,assumingwalkingatabout5km/hour).15
Whiletheusualrecommendationforphysicalactivityforadults
is30minutesatleastfivetimesaweek,16thehealthbenefitsof
briskwalkingbegintobeseenatlevelswellbelowthislevel.
Forexample,arecentstudyof400,000peoplefoundthatjust
15minutesadayofmoderateexercise(whichincludesbrisk
walking)canhavesignificanthealthbenefits,addingupto
threeyearstolifeexpectancy.Everyadditional15minutesof
dailyexercisereducedallcausedeathratesbyafurther4per
cent.17

Figure1:Theanatomyofwalking
www.c3health.org

b)EffectofwalkingonNCDs
WalkinghasbeenshowntohaveanimportantpreventiveeffectonmanyofthemajorNCDs,includingtype
2diabetes,cardiovasculardisease(CVDheartdiseaseandstroke)andmusculoskeletalconditionssuchas
backpain.

i)Type2diabetes
Type2diabetesisthechronicconditiononwhichtheeffectsofwalking(asopposedtogeneralphysical
activity)havebeenmostresearched.Walkinghasbeenshownto:

reducesignificantlytheriskofdevelopingtype2diabetes;

adultswithdiabeteswhowalkatleastamileeachdayarelessthanhalfaslikelyasinactiveadultswith
diabetestodiefromallcausescombined;

increasefitness(heartandrespiratorysystem)inadultswithtype2diabetes;and

effectivelycontrolfastingandpostwalkbloodsugarlevels.

Onedeathperyearfromallcausescouldbepreventedforevery61peoplewithtype1ortype2diabetes
whowalkatleasttwohoursperweek.
Table1ainAppendixIprovidesasnapshotoftheserelevantstudiesandtheirfindings,andfullreferences.

ii)Cardiovascularhealth
Theimpactofwalkingonthereductionoftheriskfactorsforcardiovasculardisease(CVD:heartdisease
andstroke)includingloweredbloodpressure,improvedbloodcholesterollevelsandreducedbodymass
index*hasbeenexaminedinseveralstudies,includingametaanalysisandasystematicreview.
Walkinghasbeendemonstratedto:

resultinreductionsinCVDrisk(especiallyforischaemicstroke),asaresultofduration,distance,energy
expenditureandpace(i.e.thebenefitsaredoseresponsivethebenefitsincreaseastheamountof
walkingincreases);

lowercoronaryheartdiseaserisk,withaslittleasonehourofwalkingperweek(includingthosewho
areoverweight,smokersorhavehighcholesterol)

walkingfor30minutesadayonfivedaysoftheweekcanleadtoareductionincoronaryheartdisease
riskof19percent;

lowerbloodpressure,althoughmoreresearchisneededtodeterminethespecificwalkingintensity
thatresultsinthegreatestbloodpressureimprovements;

increasemaximumaerobiccapacity(thecapacityofanindividual'sbodytotransportanduseoxygen
duringexercise)andaerobicendurance;

decreasebodyweight,BMI,bodyfatpercentageandwaistcircumference;

increaseHDL(good)cholesterol;and

increasemuscleendurance.

Inaddition,therearepotentialcostsavingstobemadeoneAustralianstudyestimatedthatifallinactive
adultAustralianswalkedforanhouradayonatleastfivedaysoftheweek,theannualcostsavingswould
beAus$419.9million.
Table1binAppendixIprovidesmoreinformationonthesefindings,andfullreferences.

Bodymassindexisdefinedasaperson'sweightinkilogramsdividedbythesquareofhis/herheightinmetres:kg/m2

www.c3health.org

iii)OtherNCDs
Physicalactivityhassignificantbenefitsinpreventingcancer,notablybreastcancer18(ariskreductionof
approximately2040percentforthosewhodovigorousphysicalactivityfor3060minutesonfivedays
eachweek)andcoloncancer(themostactivepeopleareat30percentlowerriskthantheleastfit).19
However,todatethereseemstohavebeenlittleresearchonthespecificbenefitsofwalkingoncancer
prevention.
Physicalactivitycanalsobeofgreatbenefittothoselivingwithandbeyondcancer,withpositiveeffectson
fatiguelevels,bodystrength,mentalhealth(forexample,anxietylevelsandselfesteem)andqualityof
life.20IntheUnitedKingdom,MacmillanCancerSupportsMoveMorecampaign21ishighlightingthe
benefitsofexerciseforcancersurvivors:22aMacmillansurveyofUKhealthprofessionalsworkingwith
peoplewithcancerfoundthataroundonein10ofthemstillthinkitismoreimportanttoencouragecancer
patientstorestupratherthantakeappropriatephysicalactivity,andoverhalf(72percentofGPs)speak
tononeorjustafewoftheirpatientsabouttheimportanceofphysicalactivity.23Cancersurvivorsshould
beadvisedtobuilduptheirphysicalactivitygradually,uptothelevelofthe
guidelinesforthegeneralpopulationandwalkingisideallysuitedtothis,as
highintensityexercisemayexacerbatesymptoms(suchasfatigueand
nausea.24MacmillanhasnowjoinedforceswithTheRamblersintheUnited
Kingdom,torunthenationalWalkingforHealthinitiative,whichisnowalso
focusingonencouragingcancersurvivorstowalkmore.25
Selectedstudieshavealsoexaminedtheimpactofwalkingonothertypesofchronicdisease,suchas
chroniclungdisease,arthritisandlowerbackpain.Walkinghasbeendemonstratedto:

halvetheriskofpeoplewithchroniclungdiseasebeingadmittedasanemergencyadmission26;

increaseaerobiccapacityandcapacityforfunctionalexerciseforpeoplewitharthritis;

reducepainforpeoplewitharthritisbybetweenaquarterandathird;and

havealowtomoderateeffectonthetreatmentoflowerbackpain(furtherresearchisneeded).

Table1cinAppendixIsummarisesthesepapers,andprovidesfullreferences.

www.c3health.org

2.Theimpactofwalkingonmentalhealth
Althoughthereisanemergingbodyofliteratureonthebenefitsofphysicalactivityformentalhealth,27few
publishedstudieshavedocumentedthespecificmentalhealthoutcomesfromwalking.Researchfindings
currentlyindicatethatwalkingcanrelievesymptomsofdepressionandanxiety,resultinginimprovements
inindividualqualityoflifeandreductionsinthemedicalcostsassociatedwithtreatingthesedisorders,28
andimprovecognitiveperformance(performanceinmentalprocessessuchasthinking,understandingand
remembering).29Thereisaneedformoreresearchintotherelationshipbetweenthesocialcontextof
walkinganditseffectonmentalhealthoutcomesforexample,itcanhelptoovercomesocialexclusion,
whichitselfhashealthconsequences.
Walkinghasbeenshownto:

reducephysicalsymptomsofanxietyassociatedwithminorstress;

increaseselfreportedenergylevelswhenolderadultssettheirownpace;

improvesleepquality;

elevateaffectiveresponse(e.g.pleasure),resultinginincreasedpsychologicalwellbeingforindividuals
withtype2diabetes;

beassociatedwithbettercognitiveperformanceatschool;

improvethecognitivefunctioningofolderadults(comparedtostretchingandtoning);

improvecognitiveperformanceandreducecognitivedeclineamongolderpeople;

increasethesizeofthehippocampusandprefrontalcortex,potentiallybeneficialformemory.

Table2inAppendixIprovidesmoredetailsonthestudiesexaminingtherelationshipbetweenwalkingand
mentalhealth,andfullreferences.
Thegreatestpsychologicalbenefitsofwalkinghavebeenfoundinsocialcontextswithspecificfeaturesof
theoutdoorenvironment(greeneryandwater),andwalkinghasagreateraffectiveandcognitive
restorativeaffectforadultsofpoormentalhealth(comparedtoadultsofgoodmentalhealth)inrural(as
opposedtourban)settings.30
UKmentalhealthcharityMINDranasmallstudyofgreenexercise(physicalactivityoutdoors),
questioningpeopleinvolvedingardening,conservationandcyclingaswellaswalkinggroups.90percent
ofthosesurveyedsaidthattheyfeelthatgreenexercisebenefitstheirphysicalhealthbutanevenhigher
proportion,94percent,feltthatitimprovestheirmentalhealth.31
Thislinkofmentalhealthwithexercisingingreenspaceisalsoshowninfigure2.

www.c3health.org

Figure2:Walkingingreenspace
benefitsforphysicalandmentalhealth

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3.Walkingguidelines
Physicalactivityguidelinesareusuallystatedintermsofintensity,durationandfrequencyforexample,a
commonguidelineisthatmoderateintensityphysicalactivityshouldbeperformedforaminimumof30
minutes(notnecessarilyinasingleboutof30minutesitcanbetakeninshortersessions)onfivedaysper
week.32Withtheincreasingpopularityofpedometersasmeansofmeasuringphysicalactivityintermsof
stepsperday,itisimportanttounderstandhowtheseguidelinestranslateintonumberofsteps.(SeeTable
3inAppendixIforasummaryofpedometerbasedwalkinginterventions.)

Moderateintensityphysicalactivity
Forgoodhealth,physicalactivityshouldbeofmoderateintensity.Forwalking,thisisatleast
100stepsperminute,equivalenttoapproximately3,000stepsperhalfhour33andtheCDC
suggestsaneasyruleofthumbforgauginglevelsofphysicalactivity,thetalktest:ifyou're
doingmoderateintensityactivityyoucantalk,butnotsing,duringtheactivity.Ifyou'redoing
vigorousintensityactivity,youwillnotbeabletosaymorethanafewwordswithoutpausing
forabreath.*

In2011,threereviewstudiesexaminingtherecommendednumberofdailystepsforadults,childrenand
specialpopulations,inordertodeterminehowmanystepsperdayareenough?34Theresearchersalso
identifiedtheminimumnumberofmoderatetovigorousstepsrecommendedformaleandfemalesata
varietyofagethresholds.Thesefindingsaresummarisedinfigure3.

Figure3:Recommendednumberofstepsperdaybyagegroup

http://www.cdc.gov/physicalactivity/everyone/measuring/index.html

www.c3health.org

Adultsusuallywalkbetween4,000and18,000stepsperday.Traditionalruralcommunities,suchasthe
Amish,areattheupperendofthisscale,whilesedentary,obeseadultswouldbeatthelowerendof
thescale.35Themajorityofpedometerbasedinterventionsresultinanincreaseof2,0002,500steps
perday.36Currently,Americanadultsaverage6,500stepsperday,acrossallpopulations.37

Officeworkerswhocurrentlyaverageapproximately7,000stepsperdaycanbenefitfrompedometer
basedinterventions,withonestudyevidencinganincreaseofmorethan3,000stepsperdayafterless
thanonemonthofparticipatingintheintervention38

Olderadultsandspecialpopulations(includingindividualssufferingfromchronicconditionsand
disabilities),currentlyaveragebetween2,0009,000steps/day,and1,2008,800steps/day
respectively.39Pedometerbasedinterventionshavedemonstratedonaverageanincreaseof775and
2,215stepsperdayamongolderadultsandspecialpopulations,respectively.40

Childrenbetweentheagesofsixand12typicallyaveragebetween10,000and16,000stepsperday,
whileadolescentsonlyaverageapproximately8,0009,000stepsperday.41
ChildrenfromNorthAmericatakefewerstepsthanchildrenfromotherregionsoftheworld.For
example,Americanboysandgirlstake9,500and7,900stepsperdayrespectively,whileAmishyoung
peoplewhotendtoabstainfrommoderntechnologyaverageover15,000stepsperday.42

Howactiveareyou?
Researchershavealsoestablishedpedometerdeterminedphysicalactivitythresholdsfor
adultscategorisedbytheiractivitylevel43:
<2,500steps/day(sedentarybasalactivity)
2,5004,999steps/day(limitedactivity)
5,0007,499steps/day(lowactive)
7,5009,999steps/day(somewhatactive)
10,00012,499steps/day(active)
12,500steps/day(highlyactive)

Theadviceonwalkingdependsontheageoftheindividual.Apersonwalkingat3mphusesaround30per
centoftheirmaximumenergyconsumptionwhentheyare25,butthisdecreasesby10percentadecade,
sosomeoneaged75walkingatthesamespeedusesup60percentofhisorhermaximumenergy.44
Asnotedinsection1,above,thehealthbenefitsofphysicalactivitybegintobeseenatlevelswellbelow
thatof30minutes/dayor10,000stepsaday,with15minutesadayofbriskwalkingaddinguptothree
yearstolifeexpectancy.45
Inaddition,peoplewhobegintodomorephysicalactivity
tendtogetatasteforit,andincreasetheirquota.46As
walkingisaparticularlyaccessiblewayofstartingphysical
activity,thissuggestsitcouldbeagoodwayinto
increasingphysicalactivity,withattendanthealth
benefits.AsMikeLoosemore,consultantinsportand
exercisemedicineattheInstituteofSport,Exerciseand
Health,UniversityCollegeLondon,hascommented,any
increaseinexerciseimprovesyourhealthandthiscan
actasagatewaytodoingmore.

10

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PartII:Thewalkingenvironment
1.Overcomingbarrierstowalking
i)Therangeofbarriers
Althoughitistheeasiestandmostaccessibleformofphysicalactivity,theremaystillbebarriers(realor
perceived)towalking.Thesecanincludeaperceivedlackoftime47(althoughinfactpeoplemaynotrealise
howlongittakestowalkshortdistances),lackofsafeandattractiveplacestowalk,andadverseweather
(eithertoohotortoocold).Thephysicalbarriersmaybesignificantlyincreasedforpeoplewhoaresocially
excluded,suchaselderlypeople,peoplewithdisabilitiesorparentswithsmallchildrenforexample,
steps,narrowpavementsandlackofplacestositdown.48Enablersofwalkingincludeimprovementstothe
builtenvironment(footpaths,seating),highlightingthesocialaspectsofwalking(throughwalkinggroups)
andtoolssuchassmartphonerouteplanners(whichreduceconcernsovergettinglost).
AsurveyofpeopleinLondonin2011specificallyaskedwhatfactorswouldencouragethemtowalkmore.
Responsesincludednewandimprovedwalksforpleasure(74percent),knowingthatwalkingwasasquick
asthebusforshortdistances(73percent),andifthereweremorefacilitiesinthelocalarea(61per
cent).49
Figure4(seenextpage)setsouttherangeofphysicalandperceptualbarriersandenablerstowalkingin
moredetail.

ii)Initiativestoovercomebarriers
Arangeofinitiativeshaveprovedsuccessfulinmotivatingindividualstoincreasetheirwalkingduration,
frequencyandintensity,helpingtoovercomethebarrierstowalking.Thiscanbethroughimprovingaccess
toactivetravelopportunitiesandimprovingthebuiltenvironment(seebelow),aswellasspecific,targeted
interventions(oftenincluding
pedometeruse).
Anexample:Walkit.com
Recentreviewshavefoundthat,in
ordertobeeffective,interventionsto
promotewalkingshouldbe50:

tailoredtopeoplesneeds;

targetedeitheratsedentary
individualsorindividualsalready
motivatedtochange;

individuallytailored:massmedia
campaignsmayincreaseknowledge
andawareness,butareunlikelyto
resultinbehaviourchange;

brief:telephonepromptshadequal
efficacytomoreindepthtelephone
counselling;

prescriptionstowalk57(instead
of35)daysperweekata
moderate(insteadofvigorous)
pace;

grouporiented:thesocialaspect
canincreaseadherencetoawalking
programme.

11

TheurbanwalkingrouteplannerWalkIt.com(availableonline
andasasmartphoneapp)facilitateswalkinginover40UKcities
byplottingthebestroute(whetherthefastestortheleast
polluted),calculatingthetimeitwilltaketowalk(atslow,
mediumorfastpace),caloriesburned,stepstaken,andthe
carbondioxideemissionsoffsetbywalkingratherthandriving.

www.c3health.org

Successfulwalkingcampaignsareoftenrunbyvolunteers.Forexample,theStockholmDiabetesPrevention
Programmeadvertisedinlocalmediatorecruitvolunteerstobeleadersofwalkinggroups,for811week
sessions.Manyleadersvolunteeredformultiplecampaigns.Thismethodofnewspaperrecruitment
resultedinattractingdiverseparticipants,onethirdofwhomhadnopreviousexerciseexperience,51
indicatingthatvolunteernetworkingcanbeaneffectivewayofreachingpreviouslyunderserved
populations.
Socialmediacanalsohelptoencouragewalkingforexample,theUSbasedSeeMommyRunisa
dedicatedsocialnetworktoestablishwalkingandrunninggroupsbyfacilitatingcommunicationbetween
likemindedpeopleinthelocalcommunity,andmediasuchasMapMyWalkallowuserstoshareroutes.
SeeTable5aforlinkstoavarietyofglobalandnationalwalkingcampaignsandinformation(including
challenges,workplacebasedinitiatives,andschoolprogrammes),andTable5bforonlinetoolsto
encouragewalking(bothtablesareinAppendixII).

iii)Messagingtoovercomebarriers
Clearmessagingonthebenefitsofwalkinggoingbeyondhealthmayalsohelptomotivatepeopleto
walkmore.Forexample,asurveyofLondonersin200852assessedthelevelofknowledgeaboutthe
benefitsofwalking(health,financial,etc.),andsuggestedthatthemostpowerfulmessagesforfuture
marketingofwalkingwerelikelytoincludemessagesaroundpollution(affectingfamilymembersaswellas
individualssurveyed)andtime,aswellashealth:

inheavytrafficjams,airqualitycanbepoorerinsidethecarthanoutside;

childrenwalkingtoschoolhelpsimproveairqualityaroundschools;

Walkingonemilein20minutesburnsthesamenumberofcaloriesasrunningonemilein10minutes.
Promotingwalking:theWestWing,walkingandhealth
EveryBodyWalk!aUSbasededucationalcampaigntoencouragewalkinghasproduceda
shortpublichealthadvertisement(May2012)bringingtogethermanyofthecastoftheWest
Wingtopromotethehealthbenefitsofwalkingusingofcourseawalkandtalkmeeting.53

12

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Figure4:Somebarrierstoandenablersofwalking
Barriers
Physicalbarriers

Lackofwalkingpaths/pavements
Poorqualitywalkingsurfaces
Highspeedtraffic
Airpollution/trafficfumes
Lackofattractiveplacestowalk(e.g.greenspace)
Toomanysteps
Fewplacestosit
Weather

Personal/perceptual
barriers

Unfit/healthproblems
Tootired
Lackoftime
Lackoffamilysupport
Unsafe:fearofinjury,crime(especiallyafterdark)andgettinglost
Boring
Someculturesmayseeexerciseasinappropriateforwomen/girls

Enablers
Physicalenablers

Personal/perceptual
enablers

Sources

Improvethenumberandqualityofwalkingpathsrequiresfundingfor
municipalimprovements,andmaybehelpedbypressurefromlocal
groups
Engineeringimprovementsroadsthatarewide,withsafeplacestocross,
trafficcalmingmeasures,andrampsratherthansteps
Improvementstofacilities,suchasseatinginparks
Iftheweatherisabarrier,buyappropriateclothingandwatchthe
weatherforecast,andwalkduringthemiddleofthedaywhenitiscold,
andintheearlymornings/lateeveningsinhotclimates
Startsmallevenwalkingforafewminutesisbetterthannothing,andit
isagreatwaytobuildupfitnesslevels
Walklocally:youwillgettoknowyourneighbourhoodgradually.Useyour
smartphonemaptohelptoovercomethefearofgettinglost
Takingmoreexercise,suchaswalking,mayhelpimprovesleeppatterns
andgiveyoumore,ratherthanless,energy
Walkingmaybequickerthanyouthinkforshorttrips(tryatoolsuchas
www.walkit.comtoworkouthowlongitwilltake)oraddshortwalksto
yourschedule,suchasparkingfurtherawayfromthebuilding,orgetting
offthebusastopearly
Walkingwithotherpeoplemakestheactivitysocial,andhelpsovercome
feelingunsafeorafraidofcrimeorjustbored
Socialmediacanhelptoidentifypeoplelocallywhomaybeinterestedin
settingupwalkinggroups
Dogwalkingcanalsobeastrongmotivator

54

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2.Activetransport
Associetieshavemodernised,increasedavailabilityofmotorvehicleshasresultedinadecreaseofwalking
asaprimarymeansoftransportation.Thistrendhasalsocorrespondedwithrisingglobalobesitylevels,as
increasedenergyexpenditureisrequiredforwalkingandcyclingcomparedtovehicleusage.Belletal.
conductedalongitudinalstudyinChinathatemphasisesthiscausallink.55Inthe1980s,veryfewpeoplein
Chinaownedamotorvehicle,andbetween1989and1997,14percentofChinesehouseholdsacquireda
motorvehicleresearchersfoundthat,afteradjustingfordiet,Chinesemenwhoacquiredamotorvehicle
weretwiceaslikelytobecomeobese,andexperiencedanaverage1.8kggreaterweightgainthantheir
nonvehicleowningpeers.56
Andcarsareoftenusedevenforveryshortjourneys.IntheUnitedStates,carsareusedfor55percentof
tripsthatareapproximately0.5kminlength,85percentoftripsthatare1.0kminlength,and>90percent
oflongertrips.57Onaverage,EuropeanswalkedalmostthreetimesmorethanAmericans(382kmversus
140kmperpersonperyear)andbicycledmore(188kmversus40kmperpersonperyear)in2000.58
Nationswiththehighestlevelsofactivetransportgenerallyhavethelowestratesofobesity.59
IntheUnitedStates,activetransportoptionsaremoreprevalentinoldercities,withmixedlanduse,
excellentpublictransportationsystems,andsidewalks.60AnAtlantabasedstudyfoundthateachadditional
kilometrewalkedperdaywasassociatedwitha4.8percentreductioninanindividualsprobabilityof
becomingobese,whereaseachhourspentdrivingwasassociatedwitha6percentincreaseinan
individualsprobabilityofbecomingobese.61
Inadditiontoreducingobesity,studieshaveshownthatactivetransportisassociatedwith:

reductioninriskofcardiovasculardisease

reductionofaround11percentwiththestrongestcorrelationamongwomen62;

reductionsintheriskofobesity

riskreductionofupto50percent63;

lowerlevelsoftriglycerides(thefatthatcancausehardeningandnarrowingofthearteries)64;

improvedHDL(good)andreducedLDL(bad)cholesterol65;

reductionsinBMI66;

reductionsinbloodpressure;and

reductionsinbloodsugarlevels.67

Table3inAppendixIIdetailsmanyofthebenefitsofactivetransport.
AUKstudyofpublictransportusersfoundthattwothirdswereactiveenoughthroughtheirdaily
transportationroutinestomeetgovernmentphysicalactivityrecommendations.68Themajorityof
individualsinthisstudyspentbetween20and60minutesperdayparticipatinginactivetransport.
Younger,lessaffluentpeoplewithoutaccesstoavehicledemonstratedthehighestlevelsofactive
transport.69Walkingasaformofactivetransportationhasdemonstratedgreaterlongtermsustainability
thancycling,especiallyamongobesewomen.70
Althoughwalkingratesinindustrialisedcountriesareonthewane,schoolbasedactivetransport
programmesaregainingpopularity.Casestudy2isanevidencebasedUKexampleofasuccessfulwalkto
schoolcampaign,andcasestudy6isaboutthewalkingschoolbusmovement.
Thepoliciesandinfrastructurechangesneededtofacilitateactivetransportarediscussedinthenext
section.Table4inAppendixIIsummarisesthekeystudiesrelatedtothehealthbenefitsofwalkingasa
formofactivetransport.

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Anexample:Walkingtubemap
ThistubemapshowscentralLondonsundergroundstationsbutwiththeapproximatenumberof
stepsneededtowalkbetweeneachone.Thisisparticularlyhelpfulasthediagrammatic
representationofthetubemapoftendoesnotreflecttheactualdistancebetweenstationsabove
ground,whichmay(asinthecaseofLeicesterSquareandCoventGarden,forexample)beveryclose
together.

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3.Thebuiltenvironment
Thereisasignificantamountofscientificliteratureexaminingtheaspectsofthebuiltenvironmentthat
createfavourableconditionsforwalking.AlistofthesestudiesisincludedinTable6inAppendixII.Itis
beyondthescopeofthispapertoprovideadetailedliteraturereviewofthesestudies,andthiswouldbe
anexcellenttopicforfutureanalysis.
Thefactorsofthebuiltenvironmentthathaveafavourableimpactonpedestrianactivityinclude71:

streetlightingandpavements;

availabilityofpublictransport;

streetconnectivity;

highhousingdensityandmixedlanduse;

carfreezones;

pedestriancrossingsandtrafficcalminginresidentialareas;

reductionsinmotorvehiclespeed;and

limitedormoreexpensiveparking.

Peoplewholiveinareaswithhighwalkabilityaremorelikelytoengageinactivetransportandaccessto
neighbourhoodamenitiessuchasshopsandparkswillalsostimulateactivetravel:individualswholivein
neighbourhoodswithhighwalkabilityparticipateinapproximately30minutesmoreactivetransporteach
week.72Therearetoolsforassessinglocalenvironmentsforfactorscontributingtohealthy(orunhealthy)
lifestyles(includingphysicalactivityopportunities),suchastheCommunityHealthEnvironmentScan
Survey(CHESS).73
AstudyoftheAtlantaareademonstratedthateachquartileincreaseinlandusemixwasassociatedwitha
12.2percentreductioninthelikelihoodofobesity,independentofgenderandethnicity.74Inaddition,
individualslivinginmixedlanduseneighbourhoodshavehigherlevelsofsocialcapital,astheyaremore
likelytoknowtheirneighbours,bepoliticallyandsociallyengaged,andmoretrustingthanpeoplelivingin
vehicleorientedsuburbs.75
Studieshavealsoshownaninversecorrelation
betweentrafficspeed/volume,andlevelsof
walking/cycling.76Thepromotionofwalking
andneighbourhoodwalkabilityhasthe
potentialtobenefitnotonlythehealthof
pedestrians,butalsothehealthofthebroader
naturalenvironment.

Anexample:WalkScore
WalkScore(http://www.walkscore.com/)isanonlinetool
withthestraplineDriveless.Livemore.Itaimstohelpin
ascertainingthewalkabilityofanarea,highlightingland
use(e.g.localshopsandrestaurants),greenspace,schools
andcommutingtimeincludinganestimateofthecostof
takingthecarfromhometowork.

Unfortunatelythereareveryfewpeer
reviewedstudieslookingattheenvironmental
benefitsofwalking.AstudyinKingCounty,
Washington,foundthata5percentincreasein
walkabilitywasassociatedwitha32.1percent
increaseinactivetravelanda5.5percentin
motorvehicleemissionofairpollutants.77
Thereisaneedforgovernmentpoliciesthat
prioritisepedestriansafetyandthe
developmentofcommunitieswithhigh
walkabilityasoneofthecomponentsinthe
fightagainstrisingratesofNCDs.Makingthe
economiccaseforsuchpolicies(thehealth
impactsofwhichwillbefeltoveralongperiod
oftime)canhelptostrengthenthecase.
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Theeconomicsofwalking
ThereisalsosomeevidencethatintheUnitedStateswheresuburbshaveoftenbeenaccessibleonlyby
carwalkableneighbourhoodsareincreasinglypopular(forexample,amongretiringbabyboomers),and
increasinglyexpensive.A2012reportfromtheBrookingsInstitute78showsthatinWashingtonDC(and
aftercontrollingforhouseholdincome),anincreaseinwalkabilityof20pointsonitsscale(outofarange
of94points)translatesintoan$8.88valuepremiuminofficerentsand$81.54/squarefootpremiumin
residentialhousingvalues.Thereportalsosuggestswalkabilityasamechanismtoincreaseaplacestriple
bottomline:profit(economics),people(equity)andplanet(environment)butnotesthattherearenot
yetclear,acceptedmetricstomeasurethebenefits.
However,atoolthatcanhelptoassesstheeconomicbenefitsofnewpedestrianandcyclingdevelopments
hasbeendevelopedbytheWorldHealthOrganisation:theHealthEconomicAssessmentTool(HEAT)for
walkingandcycling,79whichcanprovideanestimateoftheeconomicbenefitsaccruingasaresult
specificallyoflowerdeathratesamongmoreactivepopulations.Ithasbeendesignedtobeusedby
transportplanners,trafficengineersandspecialinterestgroupsworkingonwalkingandcycling,aswellas
beingofinteresttohealthpromotionexpertsandhealtheconomists.Itevaluatesthereducedmortality
frompastand/orcurrentlevelsofwalkingandcycling,andtheeconomicconsequencesofapotential
futurechangeinlevelsofwalkingandcycling.Itistobeusedtoassesshabitualbehaviour(e.g.regular
commuting)atpopulationlevelamongadultsitisnotappropriatetouseittolookatindividual
behaviour.80

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PartIII:Walkingandtheenvironment:awinwin
Increasinglevelsofwalking,inplaceoftakingthecarorotherformsofmotorisedtransport,canhave
benefitsforthehealthoftheenvironmentaswellasofindividuals.Reducedcarusedecreasesairpollution
levels,whichcanhavesignificantbenefitsforhealth,reducestrafficcongestionandaccidents,and
contributestoreducedtrafficnoise(throughlowertrafficvolume),whichisoneofthemostpervasive
formsofnoisepollution.
Theenvironmentalbenefitsarealsoimportant,aslowercaruseleadstolowercarbonemissions,
particulatelevels(pollution)intheair.Transportisamajoremitterofthesepollutants,responsibleforan
estimated45percentoftheozoneprecursorsand38percentoftheparticulatematteremittedin
Europe.82Pollutioncanbeparticularlyharmfultothehealthofchildrenandolderadults,andastrong
relationshiphasbeenshownbetweenlevelsofairborneparticles,sulphurdioxideandotherfossilfuel
emissions,andriskofearlydeathfromheartdisease,andrespiratoryillnessessuchasallergies,asthmaand
lungcancer.83
Goodmessagingandinformationontheimpact
ofwalkingontheenvironmentmayalso
encouragewalking.43percentof1,000
respondentstoasurveyin2011inLondon,for
example,citedknowingmoreabouttheimpactof
walkingontheircarbonfootprintasbeingafactor
thatcouldmotivethemtowalkmore.84Estimates
oncarbonemissionscanberoughlycalculated
usingonlinetoolsforexample,thewebsite
WalkIt.com(seep.11above)includesCO2
emissionsavoidedbywalking:around0.2kgof
CO2isavoidedforeachmilewalkedratherthan
driveninthecar.

Carsandcarbondioxideemissions
Anaveragecaremitsaround287gofcarbondioxide
permile.Thisisgreaterforshortjourneys,ascarsuse
morefuelwhentheengineiscold:ajourneyof1mile
emitsaround574gofcarbondioxide,81andperhaps
more,whenfactorssuchaspassengers,luggage,poor
maintenance,underinflatedtyresoruseofair
conditioningarefactoredin,allofwhichdecreasefuel
efficiency.

Particularlywherecitiesarerapidlyexpanding(the
populationoftheworldscitiesiscurrentlygrowing
byamillionpeopleaweek,largelyindeveloping
countries),prioritisinggreenspacecanhave
environmentalandhealthbenefitscreatingthe
lungsofthecity,aswellasprovidingareasfor
peopletowalkandexercise,withattendantphysical
andmentalhealthbenefits.
Thespecificenvironmentalbenefitsofwalkingdo
notappeartohavebeenstudiedinpeerreviewed
publicationsasubjectforinterestingfuture
research.

Frieburg

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Illustratingtheissue:urbanIndia
InIndia,citieswereinitiallybuiltforwalkingandcyclingasthemainmodesoftransport,buttheurban
environmentdrivenbytherapidlyincreasingsizeofthecitiesnowprioritisesmotorisedformsof
transport,ratherthanpedestrianfacilities.Currently,manypeoplelivinginurbanareascannotaffordto
buytheirownmotorvehicle,butthisisrapidlychanging.VehicleregistrationsinIndiaincreasedfrom1.8
millionin1971to62.7millionin2003andalmost100millionby200785:thismaycontinuetogrowatarate
ofasmuchas812percentperyear,withconsequentrisesinpollution,congestion,andtrafficaccidents.
ThetransportsectoristhefourthlargestsectorforCO2emissions,86andemissionsfromroadtransportare
expectedtoincreasetwotothreefoldbetween2008and2025.87
ArecentLancetarticlefoundthatincreasingactivetravelanddecreasingcarusewouldhavegreaterhealth
benefitsinDelhithaninLondon,withthebenefitcomingprimarilyfromreductionsinheartdisease.Taking
thisapproachwouldalsohaveagreatereffectonhealththanwouldsimplyincreasingthenumberof
loweremissioncars.ItconcludedthatAlthoughuncertaintiesremain,climatechangemitigationin
transportshouldbenefitpublichealthsubstantially.88
Butpedestrianfacilitiesarenotapolicypriority:Indiancitiesareoftenseekingprojectsthatarehighly
capitalintensive,whichwalkingisnotsoorganisationssuchastheCleanAirInitiativeforAsianCities(CAI
Asia)Centeraretryingtolinkwalkingtopublictransport,inthehopethatinvestmentwillspilloverinto
walkability,whichisanimportantbasisforaliveablecity.

Jaipur

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PartIV:Casestudies
1.Introduction
Thesecasestudieshavebeenselectedtoillustratethevarioustypesofmacroandmicroscalewalking
activities,interventionsandprogrammescurrentlyunderway,andtosparkideasthatcanbefurther
exploredinlocalcommunities.Thissamplewaschosentoreflectgeographic,sociodemographicand
culturaldiversity,aswellasacombinationofdifferenttypesofwalkingactivities(e.g.leisuretimeactivities
andactivetransport).Thefinalcasestudieslookbeyondtheindividualtotheenvironmentalchangessuch
asadaptationoflocalbuiltenvironmentstoimprovepedestriansafety,whichwillimprovewalking
accessibility.
Onesizedoesnotfitallanyinitiativemustbeadaptedinordertosuitthecircumstancesinwhichitis
beingestablishedandthepopulationatwhichitisaimed.
Therecurrentlyexistmanywalkinginitiativesaroundtheworld,althoughthereisaneedforgreater
researchastotheshortandlongtermoutcomesoftheseprojects.Whilethehealthbenefitsofthe
initiativesinthecasestudieshavebeenincludedwhereknown(andthemajorityhaveevaluatedatleast
someofthementalorphysicalhealthbenefits),pleasenotethatmanyarenotsubjecttorigorousscientific
study.Lackofevaluationwhile,ofcourse,innowaydiminishingtheeffectsoftheinitiativeonthose
takingpartmaymakethevalueoftheprojectlessobvioustoothers,andmakeitlesslikelytobe
replicatedelsewhere.Tobeabestpracticecasestudy,anynewinitiativesshouldconsiderevaluating
participationratesandmental/physicalhealthimpacts.
Thecasestudiesthatpertaintothebuiltenvironmentdonotpossessevaluationspertainingtotheirhealth
benefits,butinsteadareexamplesoftherangeofoptionsavailabletogovernmentandpolicymakerswho
wishtoprioritisethelongtermhealthoftheircitizensandcommunitiesthroughpromotingwalkability.

2.Casestudies:walkingprogrammes
Casestudy1:TheGlobalCorporateChallenge
TheGlobalCorporateChallenge89isanannual,12weekwalkingchallengeforemployees,establishedin
Australiain2004andnowreaching55countries:130,000participantsfrom1,000organisationstookpartin
2011.Thisyear,startingon24May2012,over180,000participantsareexpectedtoparticipate.Thecostof
enteringtheGCCis49perheadintheUnitedKingdom.
Workplacesenterteamsofsevenpeople,eachofwhomareissuedwithastarterpack(includingtwo
pedometers),withtheaimofwalkingatleast10,000stepseachdayandin2011,theaveragedailystep
countwas12,725(about5miles).90Thehopeisnotonlythatphysicalactivitylevelswillincreaseforthe
periodoftheGCC,butthat,becauseofthelengthoftimeforwhichtheGCCruns,willmeanthatwalking
becomesahabit,i.e.theparticipantswillcontinuetodogreateramountsofphysicalactivityfollowingthe
endoftheGCC.
Eachparticipantaddstheirdailystepcountintoawebsite,whichbothtracksthestepprogressofthe
individualandalsocalculatesthedistancetravelledbytheteamasawhole,plottingacoursearoundthe
worldshowingtheteamsprogressonamap.Thewebsitealsocontainsnutritionalandhealth
information,andinformationonthecarbonemissionsthathavebeenavoidedbywalkingratherthan
takingthecar.
In2011,followingtheGCC,astudyof752participantsfoundthatbeforetheGCConly18percentof
employeeswerewalking10,000stepsperday,whileafterGCC58percentofemployeeswerewalkingan
averageof10,000stepsperday.91A2008longitudinalstudyhasalsodemonstratedthattheprogramme
createssustainablebehaviourchange,aspositiveresultsweremaintainedeightmonthsafterprogramme
participation.92
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ThepositiveeffectsoftheGCC,coupledwithconcernsoverhighratesofchildhoodobesity,promptedthe
establishmentoftheGlobalChildrensChallengein2011.93Initsfirstyearalone,120,000children
participatedfromaroundtheworld.In2012,foreachparticipanttakingpartintheadultGCC,achildfrom
thecommunitywillbeenrolledatnocosttotheschool,family,orgovernment.

Healthbenefits
Overthelastfouryears,theGCChasengagedinresearchprojectsandscientificstudiesinpartnershipwith
LancasterUniversity,MonashUniversityandtheFoundationforChronicDiseasePreventioninthe
Workplace(FDCP)toanalysetheevidencebasesurroundingtheGCCseffectonemployeehealthand
wellbeing.
ThephysicalandmentalhealthbenefitsoftheGCChavebeenassessedasfollows94:

90percentsaidthattheGCCimprovedtheiroverallhealthandwellbeing;

24percentand29percentofemployeesina2011surveyloweredtheirsystolicanddiastolicblood
pressurerespectively;

51percentreportedreducedstressandimprovedqualityofsleepatnight;

71percentreportedanincreaseinenergylevels;

whereweightlosswasreported,itaveraged4.5kg(9.9lbs);

54percentofthosesurveyedwithhighbloodpressurewerecategorisedaslowriskbytheendofthe
GCC;

therewasan11percentincreaseindailyconsumptionoffruitsandvegetables

the2011surveyfounda5.2cmaveragewaistreductionamongthosewhohadexperiencedareduction
inwaistmeasurement;

thesamestudyalsosawanaveragebodyfatreductionof10percentamongthosewhoexperienceda
reductioninbodyfat.

ThebenefitsoftheGCCfortheworkplaceinclude:

75percentreportedimprovedofficemorale;

57percentreportedbetterteamwork;

52percentreportedincreasedproductivityintheirdaytodaytasks;

54percentclaimedtheyhadhigherjobsatisfaction;

40percentfewersickdaysweretakenbyGCCparticipantscomparedtononGCCparticipants;and

52percentfeltstrongerworkengagement.

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Casestudy2:UKWalkonceaWeek
WalkonceaWeek(WoW)isthelargestnationalwalktoschoolprogrammeintheUnitedKingdom.95Since
itwasstartedbyLivingStreetsCharityin2005,WoWhasencouragedmorethan300,000childrentowalk
toschoolregularlywith,forexample,ParkandStridecardropoffzonesamilefromschools,fromwhere
childrencanwalktherestoftheway.Theprogrammeisunderwayinnearly2,000schoolsinEngland,and
schoolsinScotlandandWalesarealsostartingtoparticipate.Childrenwhowalktoschoolatleastoncea
weekcanearnadifferentbadgeeverymonth,withthebadgesdesignedbychildreninoneofthelargest
UKannualartcompetitions.Teachersalsopromotethewalkingprogrammethroughtheuseofclassroom
wallcharts,teampassportsandcertificates.
In2009WavehillConsultingwascontractedbyLivingStreetstoundertakeanindependentevaluationof
theWoWprogramme,96incorporatingstakeholderinterviewsaswellasasurveyofprimaryschoolchildren
andtheirparents.
Theevaluationfindingsaresummarisedbelow:

schoolwalkingrateshaverisenashighas96percent;

reducedtrafficandparkingcongestion;

schoolidentitiesareredefinedasprowalkingforexample,schoolassembliesonwalkingsafetyand
benefits;

improvementinchildrensmoodsandattentionspans;

schoolstakingparthave9percenthigherwalkingratesthanthenationalaverage;

23percentofchildrensurveyedwalkwithoneoftheirparentstoschool(demonstratingthatWoW
spreadsthebenefitsofwalkingwithinfamilies);and

thebenefitsofWoWfarexceedthecosts,witharatioof0.32(costs900,000,comparedwithbenefits
of2.8million).97Thiscalculationisderivedfromacomplexmodelthatincludesthecostofacarorbus
journeyifthechildrenhadnotwalked,thepercentageofchildrenwhoparticipateinWoWfromeach
school,thecarbontradingvalueofCO2savedbywalking,theassumptionthatmostchildrenwhowalk
toschoolwillalsowalkhome,andthecostsoftheWoWbadges,postcardsandmaterials.

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Casestudy3:AustraliaHeartFoundationWalking
HeartFoundationWalking(HFW)isAustraliaslargestnetworkoffreecommunitywalkinggroups,andis
aimedatimplementingsafe,accessible,andsustainablefreewalkinggroupsacrossthecountrythrough
communitypartnerships.98Itwaslaunchedin2007,andwasbasedontheHeartFoundationsJustWalkIt
programmethathadrunsince1995.Over37,000Australians,fromallstates,haveparticipatedintheHeart
Foundationswalkinggroups.HFWaimstomakingwalkingeasyandenjoyable,especiallyforpeoplewho
werepreviouslyinactive.
HFWgroupsareledbylocalvolunteerwalkorganisersandareparticipatedinbyawiderangeofpeople
parentswithstrollers,peoplewithspecialneedsandseniorsandtakeplaceinvenuesincludinglocal
communities,shoppingcentresandworkplaces.
Asof15March2011morethan14,000Australiansfrom249localgovernmentregionswereparticipatingin
anHFWgroup.Participantinformationanddemographicsisrecordedinacentraliseddatabase.In
addition,eachmonthparticipantsrecordtheirnumberofwalksandtotalminutesofphysicalactivity,with
walkersrewardedwhentheyreachmilestones,suchastheir25thwalk.Onlineregistrationandtoolssuch
asGooglemapsareusedtodelineatewalkingroutes.
HFWhasbeensuccessfulatattractingdiversepopulationgroups,includingthoseleastlikelytobe
physicallyactivesuchas:

seniors(43percentofthosetakingpartareoverage65);

peoplewhoareoverweight(36percent)orobese(23percent);

peopleonlowerincomes(36percenthavehouseholdincomebelowA$25,000);

peoplewholivealone(25percent);

peoplewithEnglishasasecondlanguage(5percent);and

Aboriginals(3percent).

HFWhasdemonstratedhighgroupandindividualretentionratesofabove80percentaftertwoyears,and
above70percentafterthreeyears.

Healthbenefits
Evaluationdatahasdemonstratedthat85percentofwalkersperceiveHFWasimportantfortheirsocial
andmentalwellbeingand94percentofwalkersperceiveHFWasimportantfortheirphysicalwellbeing.
AdditionalevaluationisneededtostudyacohortofHFWmembersandcomparetheirbaselinebiometric
indicatorswithoneyearfollowupstoidentifythespecifichealthbenefitsoftheHFWprogramme.

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Casestudy4:HillcrestHeights,MD,USAIversonMallWalkers
Since1989,agroupofseniorcitizens450stronghasbeenmeetingthreetimesperweektowalklaps
insideIversonshoppingmallinHillcrestHeights,Maryland.99Thegroupalsoparticipatesinseveralannual
WashingtonDCareacharitywalkseachyear,aswellasaerobicsandlinedancingwithinthemall.Although
thehealthbenefitsofthisspecificprojecthavenotbeenevaluated,walkinghasmanybenefitstosenior
citizens,suchas:

Italleviatesmanyoftheoutdoorwalkingbarriers/dangersforseniorssuchasbadweather,lackof
sidewalksandtrafficcrossings,lackofpublictoilets,andfearofcriminalactivity;

mallsareoftencentrallylocatedandeasilyaccessiblebypublictransport;and

brightlightingandevenfloorsurfacesreducesthepotentialforfalls.

ApilotstudybytheUniversityofCalgary100ofaneightweekmallwalkingprogrammefound:

highattendancerateforaselfmotivatedprogramme,withthemajority(64.1percent)attendingmore
thanthreetimesperweek;

averageageof66;

secondmostpopularreportedwalkingsiteforpeople45andolder;

36.4percentincreaseinleisuretimeactivitylevels;

18percentincreaseinmallwalkingstepsovertheeightweekperiod;

increasedhipflexibilityby11percent;and

asignificantdecreaseinparticipantBMIfromanaverageof29.1atthebeginningoftheprogrammeto
28.5attheendoftheeightweeks

Mallwalkingprovidesacommunitybasedalternativetooutdoorwalking,whichiseasilyaccessibletothe
generalpopulation.
Additionalresearchisalsoneededonthementalhealthbenefitsofthesocialrelationshipsestablished
duringmallwalking.

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Casestudy5:Oxfordshire,UKNordicWalking
OxfordshireCountyCouncil,inconjunctionwithGoActive,hasestablishedastrongnetworkofNordic
Walkersinthecounty.Theprogrammebeganwith17NordicWalkinginstructors(andhassincetraineda
further32volunteerleaders,toensurethesustainabilityoftheproject),andhasreachedover1,000
people.Theprogrammewasaimedattheover50sandwassosuccessfulthat,forthefirsttime,GoActive
hadawaitinglistforitsinitiative.Thereisnowademandamongyoungeradultsandfamiliestotakepart,
sotheinitiativeisbeingexpanded.
TherearealsomovestoworkwithGPsandpracticenursestoprescribeNordicWalking,aswalkingwitha
trainedpracticenursecanbemuchlessintimidatingthanforexample,suggestingthatpatientsattend
exerciseclassesatalocalleisurecentre,andtheaimistoincreasephysicalactivitylevels.

Healthbenefits
AlthoughtheOxfordshireinitiativeisnotbeingspecificallyevaluated(otherthanforparticipationlevels),
NordicWalkinghasanumberofdemonstratedhealthbenefits,whichinclude101:

mentalhealthbenefitsofhigherlevelsofconfidenceandenjoymentbothofphysicalactivityandof
beingoutdoors;

reducedlevelsofdepression102;

lowerbloodpressureandrestingpulserateforelderlywomen103;

improvedposture104;

improvesmobilityforpeoplesufferingfromchronicconditionssuchasParkinsonsdisease105;

reductionsinwaist,upperarmandhipcircumference106;

moreenergy;and

improvedsleeppatterns.107

Whenthecorrecttechniqueisused,NordicWalkingusesuptoabout20percentmoreenergy(kcal)than
regularwalking,andusesmanymoremuscles(upto90percentofthemajorskeletalmuscles),anditalso
relievespressureonthejointsofthelowerbody.

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Casestudy6:NewZealandWalkingschoolbus
Since1999,theregionofAuckland,inNewZealand,hasbeenspearheadingthewalkingschoolbus
initiative,inwhichgroupsofchildrenwalktoandfromschooltogether;childrenlovetakingpart
becausetheyfinditfun!108Justlikearealbus,itleavesatasettime(usuallyaround8:30),withthe
childrenjoiningatstopssituatedclosetotheirhomestheyaresupervisedbylocaladultvolunteers
(usuallyparents),whoactasthebusdriver.Theroutesareabout1.5km(ora30minutewalk)inlength.
Therearenowover300walkingschoolbusroutesintheAucklandregionover1,800volunteerssupport
it,anditisusedbyaround5,000schoolchildreneveryday.Thelocaltransportauthorityhasalsobecomea
partnerintheproject,producingaguideforpeopleestablishingawalkingschoolbus.109
Theprojecthasavarietyofbenefitsinadditiontothehealthbenefitsofgreaterphysicalactivity:children
learnaboutroadsafetyandincreasetheirindependence;parentshaveachancetomeetandspeak,
buildingastrongercommunity;andtrafficcongestionandairpollutionfromtheschoolrunaredecreased
inthelocalcommunity.

Healthbenefits
Thehealthbenefitsofwalkingschoolbusesarebeginningtobeevaluatedanddoseemtoindicateasmall
increaseintheamountofphysicalactivitytakenbychildren.110Inadditiontocontributingtothe
recommendedhouradayofphysicalactivityforchildren,smallstudieshaveindicatedthat,amongolder
children(particularlyboys),walkingtoschoolmayalsobeassociatedwithhigherlevelsofphysicalactivity
duringtherestoftheday(e.g.afterschool).111Inaddition,thereisevidencethatchildrenwhoare
physicallyfit112andcommutetoschool113havebettercognitiveperformancethanthosewhodonot.A
studyofthewalkingschoolbushasquestionedwhethertheyarecosteffectiveinreducingchildobesity114
thisdidnot,however,includethebenefitsofreducingpollution,andtheauthorsnotethatcost
effectivenesscouldbeimprovedbymorecomprehensiveimplementationwithinexistinginfrastructure
arrangements,andthatmoreresearchandevaluationshouldbeundertakenonsuchprogrammes,given
theimportanceofactivetransportinincreasingchildrensphysicalactivitylevels.

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Casestudy7:HongKongQualiWalk
InHongKong,acampaignentitledHealthyExerciseforAllincludesawalkinginitiative,QualiWalk115(other
strandsofthecampaignincludeExerciseintheworkplaceandDanceforhealth.Itisaimedatall
agegroups,andencouragesthebuildingofwalkingintoeverydaylife.ThecampaignisrunbytheLeisure
andCulturalServicesDepartment,withinputfromtheDepartmentofHealthandthePhysicalFitness
AssociationofHongKong.ItincludesQualiWalktrainingclasses,andarangeofonlinematerialsto
encouragewalking(inbothChineseandEnglish).Participantsareencouragedtohavetheirfitnesslevels
checkedbytheinstructorsintheclassandthereisalsoinformationandchartsavailablebothattheclass
andonlinetomakeiteasierforpeopletoworkouttheirownfitnesslevels,andtoworkoutwhentheir
heartrateiswithinthetargetheartratezoneformoderateexercise.
Thewebsitealsosuggestsanumberofsafewalkingtrails,andmakessuggestionsforincreasingregular
walking,suchasgettingoffpublictransportacoupleofstopsearlyandwalkingtherestoftheway,or
takingpartinwalkingactivitieswithfriends:simplesteps,butthingsthatcanmakeadifference.

Healthbenefits
AlthoughtheimpactofQualiwalkdoesnotappeartohavebeenevaluated,thosetakingpartare
encouragedtoconsidertheirhealthbothintermsofthementalandphysicalbenefitsofwalking(suchas
easingstress),andalsotoensurethattheydonotpushthemselvestoofartoofast.

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3.Casestudies:thebuiltenvironment
Casestudy8:LatinAmericaCiclovas
Theciclovaswhichtranslatesasbikepathsareinitiativestotransformbusystreets,ononedayofthe
week,bybanningallformsofmotorisedtransport,leavingthemopenforwalkers,runnersandcyclists.116
Notonlydoesthispromotealternativeformsoftransport,ittransformstheurbanenvironmentand
strengthenscitizenownershipandresponsibility.ThefirstciclovawasinBogoteachSunday,forseven
hours,over70milesofroadsareclosedtomotortraffic,andupto1.5millionpeopleusethestreets.In
addition,freeyogaandotherexerciseclasses(knownastheRecreovia)areheldinlocalparksover70per
centofciclovasincludephysicalactivityclasses.117ThecostsofciclovasarelowtheBogotaciclova,for
example,isestimatedtocostaboutUS$6perpersonperyear.118
ThesuccessesinBogothaveencouragedanetworklookingtoadoptsimilarmodelsinothercitiesthe
BikeTrailsNetworkoftheAmericasandciclovasarealsonowheldincitiesincountriesincludingPeru,
Mexico,NewZealandandtheUnitedStates.

Healthbenefits
Areviewof38ciclovasfoundthattheyhaverealpotentialforpositivepublichealthoutcomes,
summarisingtheevidencetodatewhichislimited,butencouraging.119Forexample,onestudyfoundan
estimated41percentofciclovaparticipantsinBogotatookpartformorethanthreehours(including
aboutathirdwalkingorrunning,andabouthalftheparticipantscycling).120Astudyofhealthrelated
qualityoflifemeasuresfoundthatadultsparticipatinginatleastonedayoftheciclovaeachmonthscored
higherthanthosewhodidnotparticipate(evenafteradjustingforsociodemographicandotherfactors),121
andonestudyshowedthatlevelsofparticulatematteralongasectionofBogotasciclovastreetwas13
timeshigheronaweekdaythanonSunday(thedayoftheciclova).122
Thehealthbenefitsoftheciclovashaverecentlybeenevaluatedwiththecostbenefitratioforhealth
benefitfromphysicalactivityestimatedat3.234.26forBogot,1.83forMedelln(alsoinColombia),1.02
1.23forGuadalajara(Mexico)and2.32forSanFrancisco.123

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Casestudy9:UnitedStatesTheAtlantaBeltline
TheAtlantaBeltlineisamultimilliondollarprojectcurrentlyunderwaytodevelopa22mileloopof
transit,trailsandpedestrianfriendlydevelopmentusingexistinghistoricalrailroadsthatencirclethecityof
Atlanta,Georgia.124TheBeltlineconnects45ofthecitysneighbourhoods,andover100,000peoplelive
withinhalfamileoftheBeltline,whichhasaradiusofbetweentwoandfourmilesfromthecitycentre.
Theprojectcreates2,100acresofnewparksand33milesofnewmultiusetrails.125Inadditiontheproject
willdevelopcommercialandresidentialareasandimproveroadinfrastructure(includingpavements)and
transitinfrastructure(includingalightrailline).Thisinitiativewilloccupy6,500acres,approximately7per
centofAtlantastotalarea,andwillaffectthedailylivesofthosewholive,work,playandgotoschoolnear
it.Theprojectisfundedbytaxallocationbondsthatwillberepaidfromtherisingpropertyvaluesinthe
districtresultingfromtheBeltlinedevelopment.
TheBeltlineprojectexemplifiestheinterrelationshipbetweenthebuiltenvironmentandhealth.AHealth
ImpactAssessment126wasconductedfrom2005to2007toassesstheBeltlinesimpactonphysicaland
environmentalhealthdeterminants.AHIAisaneffectivetoolforincorporatingevidencebasedhealth
recommendationsintoplanningofcityinfrastructureandtransportationnetworks,especiallywhenthe
goalistomaximisepedestrianaccess,safetyanduse.Itaddressesissuessuchassocialequity,physical
activity,safetyandtheenvironment.TheHIAwascitedintheawardingofadditionalfundsfor$7million
forbrownfieldcleanupandgreenspacedevelopment.127
TheHIAnoted,amongotherthings,that:

theBeltlinewillprovideparkaccess(definedaslivingwithin0.5milesofapark)to11,000people;

approximately88,000people(41percentofthepopulation)willhaveaccesstothetrailsystem;

theBeltlinecanbeusedtofacilitateactivetransportofstudentstoschoolsthroughtheSafeRoutesto
Schoolsprogramme.Currently,19schoolsarelocatedwithin0.5milesoftheBeltlinetransitandtrails,
andacombinationofinfrastructureimprovements,safetyeducationandenforcementwillcreatean
environmentthatfavourswalkingtoschool;

safeandconvenientwalking(suchassidewalks)willbefacilitatedbetweencommunitiesandpublic
transportstops;

facilitiessuchassportscourtsandwalkingcircuitsinparkswillbesetup,ensuringthattheymeetthe
particularneedsofchildren,seniorsandindividualswithdisabilities;and

educationalcampaignsonparksandtrailswillbeputinplacetopromotephysicalactivity.

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Casestudy10:IndiaandDenmarkUrbanwalkability
Walkabilityincitiesisanimportantdeterminantinbuildingphysicalactivityintoeverydaylife,allowing
peopletochoosetowalkratherthantotakemotorisedtransport.Differentchallengesthatarefacedin
developedanddevelopingcountrieswithvastlydifferentlevelsofpollution,trafficcongestion,
infrastructure(suchaspedestrianfootpathssuitableforall,includingtheelderlyanddisabled)androad
safety.
AshasalreadybeennotedinPartIII,above,walkabilityinIndian
citiesisoftenverylowevenwhereacitymayappearonpaper
tobewalkable(e.g.mixedlanduse)itmay,infact,have
dangerousstreetsthatprecludesafewalking,withpedestrians
directlycompetingwithmotorvehiclesforroadspace.Arecent
surveyinsixIndiancities,includingChennai,foundthat60per
centseepedestrianfacilitiesasbadorverybad,and62per
centwouldshifttheircurrentwalkingtripstomotorised
transportunlessthewalkingenvironmentimproves.
Improvementscanbemadebutcurrentlyitisoftenonlyin
thewealthiestareaswherethestreetsaresuitablefor
walking,128andonescheme,Mumbais23kmofskywalks,has
notbeenuniversallywelcomed,beingbothexpensive(a
projectedcostofUS$300million)andleadingtobusinessesat
groundlevellosingbusiness.129
However,thereareanumberofmorepracticalpolicystepsthat
Mumbai
arebeingencouragedbyorganisationssuchastheCleanAir
InitiativeforAsianCities(CAIAsia)Center,whichcouldbegintohelptointegratewalkingintocitydesign
theseincludeconductingpedestrianbenchmarksurveys,developingstreetdesignguidelines,promoting
appliedresearchonwalkability,andestablishingUrbanMetropolitanTransportAuthorities(althoughthese
tendtoberecommendatorybodies,ratherthanimplementingagencies).
Incontrast,thecapitalcityofDenmark,Copenhagen,hasspentthelast50yearstakingaseriesofgradual
steps,beginningwiththeclosureofthemainstreet,Strget,tomotorvehicles,toshiftthecityfromacar
orientedtoapedestrianorientedspace.130By1996,Copenhagenhadsixtimestheamountofcarfree
spacethanithadin1962whenpedestrianinitiativesbegan.
Thestepsinclude:

attemptingtoreduceparkingspacesby23percentannually;

thecreationofpedestrianonlystreets,allowingthe
transformationofcarparksonthesestreetsinto
publicspaces;

encouragingchildrentowalkorcycletoschool;

pathsforwalkingandcyclinghavebeencreatedand
extendednow,overathirdofpeoplecommuteto
workbybike;

inaddition,themajorityofthebuildingsarelowin
height,anddenselypacked.Thisallowsthewindto
passoverthem,andgivesthecitycentreamild,airy
climatemoreconducivetowalkingthantherest
ofCopenhagen.

Copenhagen

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AppendixI:Selectedliteratureonthehealthbenefitsof
walking
Tables1a1cprovideselectexamplesofkeyresearchstudiesand/orreportsthatsupporttheimpactofwalkingonthe
preventionandcontrolofmajorNCDs,notablytype2diabetesandcardiovasculardisease.Table2provides
informationonthementalhealthbenefitsofwalking.

Table1a:Benefitsofwalkingfortype2diabetes
Specificbenefit

Paper

Walkingcanlowerbloodglucoselevels
afterthewalk(demonstratedreduction
2.2mmol/l).Noeffectafteraperiodof
rest

Fritz,T.andU.Rosenqvist,Walkingforexercise?Immediate
effectonbloodglucoselevelsintype2diabetes,Scandinavian
JournalofPrimaryHealthCare(2001)19(1):313:
http://informahealthcare.com/doi/abs/10.1080/pri.19.1.31.33

Walkingreducedmortalityamongabroad
spectrumofadultswithtype1andtype2
diabetes.Onedeathperyearmaybe
preventedforevery61peoplewhowalkat
leasttwohoursperweek

Gregg,E.W.,R.B.Gerzoff,C.J.Caspersen,D.F.Williamson,V.
Narayan,RelationshipofwalkingtomortalityamongUSadults
withdiabetes,ArchInternMed.(2003)163:14407:
http://archinte.amaassn.org/cgi/content/abstract/163/12/1440

Hu,F.B.etal.,Walkingcomparedwithvigorousphysicalactivity
Moderatephysicalactivity,suchas
walking,canreduceriskofdevelopingtype andriskoftype2diabetesinwomen,JAMA(1999)282(15):
2diabetes(menwerenotincludedinthis 14339:http://jama.amaassn.org/content/282/15/1433.short
study)

Heartrateprescribedwalkingcanimprove
cardiorespiratoryfitness,butdidnothave
animpactonbloodsugarcontrolin
patientswithtype2diabetes

Morton,R.D.,D.J.West,J.W.Stephens,C.BainandR.M.Bracken,
Heartrateprescribedwalkingtrainingimproves
cardiorespiratoryfitnessbutnotglycemiccontrolinpeoplewith
type2diabetes,JournalofSportsSciences(2010)28(1):
http://www.tandfonline.com/doi/abs/10.1080/02640410903365
685

Encouragingdogwalkingoranother
interestthatmotivatesacommitmentto
physicalactivitycanresultinhealth
benefits,especiallyforpeoplewholack
motivationforotherformsofphysical
activity,whowantslowlyincreasetheir
physicalactivitylevelsslowly,andwho
wanttomaintainphysicalactivitylevels

Peel,E.,Type2diabetesanddogwalking:patients'longitudinal
perspectivesaboutimplementingandsustainingphysical
activity,BrJGenPract(2010)60(577):5707:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913737/

Groupbriskwalkingwasequallyeffective
asindividualisedfitnessprogrammesfor
bloodsugarcontrolandreductionof
cardiovascularriskprofile

Praet,S.F.E.,Briskwalkingcomparedwithanindividualized
medicalfitnessprogrammeforpatientswithtype2diabetes:a
randomizedcontrolledtrial,Diabetologia(2008)51(5):73646:
http://www.springerlink.com/content/41wj6t344777421h/

Adultswithdiabeteswhowalkatleast
onemileperdayarelessthanhalfaslikely
assedentaryadultswithdiabetestodie
fromallcausescombined

Smith,T.C.,D.L.Wingard,B.Smith,D.KritzSilverstein,E.Barrett
Connor,Walkingdecreasedriskofcardiovasculardisease
mortalityinolderadultswithdiabetes,JournalofClinical
Epidemiology(2007)60(3):30917:
http://www.jclinepi.com/article/S08954356(06)00256
3/abstract

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Structurededucationprogrammein
conjunctionwithpedometeruseresulted
inreductionsoftwohourpostwalkingand
fastingglucoseof1.31mmol/land.32
mmol/lrespectively.Noimprovementin
glucosecontrolfortheeducation
programmealone

Yates,T.,M.Davies,T.Gorely,F.BullandK.Khunti,
Effectivenessofapragmaticeducationprogramdesignedto
promotewalkingactivityinindividualswithimpairedglucose
tolerance:arandomizedcontrolledtrial,DiabetesCare(2009)
32(8):140410:
http://care.diabetesjournals.org/content/32/8/1404.short

Table1b:Cardiovascularbenefitsofwalking
Specificbenefit

Paper

DosedependentreductionsinCVDriskwith
higherwalkingduration,distance,energy
expenditureandpace.Associationsappeared
tobestrongerforischaemicstrokethanother
CVDoutcomessuchascoronaryheartdisease
orhaemorrhagicstroke

BooneHeinonen,J.,K.R.Evenson,D.R.TaberandP.Gordon
Larsen,Walkingforpreventionofcardiovasculardiseasein
menandwomen:asystematicreviewofobservational
studiesObesRev(2009)10:20417:
http://www.ncbi.nlm.nih.gov/pubmed/19207874

Lighttomoderatephysicalactivity,aslowas
onehourofwalkingperweeklowers
coronaryheartdiseaseriskforwomen
(includingthosewhowereoverweight,
smokedorhadhighcholesterol)(menwere
notincludedinthisstudy)

Lee,I.M.,K.M.Rexrode,N.R.Cook,J.E.MansonandJ.E.
Buring,Physicalactivityandcoronaryheartdiseasein
women:Isnopain,nogainpasse?JAMA(2001)285(11):
144754:http://www.ncbi.nlm.nih.gov/pubmed/11255420

Walkingisbeneficialforloweringblood
pressure.Moreresearchisneededto
determinethespecificwalkingintensitythat
resultsinthegreatestfallinbloodpressure

Lee,L.,M.C.Watson,C.A.Mulvaney,C.TsaiandS.Lo,The
effectofwalkinginterventiononbloodpressurecontrol:a
systematicreview,InternationalJournalofNursingStudies
(2010)47:154561.
http://www.ncbi.nlm.nih.gov/pubmed/20863494

Walkingincreasedmaximumaerobiccapacity,
anddecreasedbodyweight,BMI,bodyfat
percentageandrestingdiastolicblood
pressureinpreviouslysedentaryadults

Murphy,M.H.,A.M.Nevill,E.M.MurtaghandR.L.Holder,
Theeffectofwalkingonfitness,fatnessandrestingblood
pressure:ametaanalysisofrandomizedcontrolledtrials,
PrevMed(2007)44(5):37785:
http://www.ncbi.nlm.nih.gov/pubmed/17275896

Walking30minutes/day,5days/week=19%
reductionincoronaryheartdiseaserisk

Murtagh,E.M.,M.H.MurphyandJ.BooneHeinonen,
Walkingthefirststepstocardiovasculardisease
prevention,CurrOpinCardio.(2010)25(5):4906:
http://www.ncbi.nlm.nih.gov/pubmed/20625280

ReductioninsystolicanddiastolicBP
IncreasedHDL(goodcholesterol)
Averageweightlossof1.4kgandwaist
circumferencereductionof2.2cm
Increasedaerobicandtrunkmuscle
endurance

Note:thisstudywasconductedonacohortofwomenonly

Parkkari,J.,A.Natri,P.Kannus,A.Mnttri,R.Laukkanen,H.
Haapasalo,etal.,Acontrolledtrialofthehealthbenefitsof
regularwalkingonagolfcourse,AmericanJournalof
Medicine(2000)109:1028.
http://www.amjmed.com/article/S00029343(00)00455
1/abstract

Exemplifiedwalkingasahighadherenceform
ofphysicalactivity
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Potentialannualcostsavingsof$419.9million
ifalltheinactiveadultAustraliansengagedin
1hourofnormalwalkingadayfor57daysa
week

Zheng,H.,F.EhrlichandJ.Amin,Economicevaluationofthe
directhealthcarecostsavingsresultingfromtheuseof
walkinginterventionstopreventcoronaryheartdiseasein
Australia,IntJHealthCareFinanceEcon(2010)10:187201.
http://www.ncbi.nlm.nih.gov/pubmed/19882347

Table1c:Otherchronicdiseasebenefitsofwalking
Specificbenefit

Paper

Peoplewithchronicobstructivepulmonary GarciaAymerich,J.etal.,Riskfactorsofreadmissiontohospital
foraCOPDexacerbation:aprospectivestudy,Thorax(2003)
diseasewhoundertakemorewalking
58(2):1005:http://www.ncbi.nlm.nih.gov/pubmed/12554887
halvetheirriskofbeingadmittedasan
emergencyadmission
ReviewoffourRCTswalkingresultedin
19%improvementinaerobiccapacity,18%
improvementinfunctionalexercise
capacity,reductionsinarthritispain(24
32%)

Westby,M.D.,Ahealthprofessionalsguidetoexercise
prescriptionforpeoplewitharthritis:areviewofaerobicfitness
activities,ArthritisCare&Research(2001)45:50111:
http://onlinelibrary.wiley.com/doi/10.1002/1529
0131%28200112%2945:6%3C501::AIDART375%3E3.0.CO;2
Y/abstract

Lowtomoderateevidencethatwalkingis Hendrick,P.,A.M.TeWake,A.S.Tikkisetty,L.Wulff,C.YapandS.
aneffectivetreatmentforlowerbackpain. Milosavljevic,Theeffectivenessofwalkingasaninterventionfor
lowbackpain:asystematicreview,EurSpineJ(2010)19:1613
Needformoreresearch
20:http://www.ncbi.nlm.nih.gov/pubmed/20414688

Table2:Mentalhealthbenefitsofwalking
Specificbenefit

Paper

Authorsconductedareviewof
mentalhealthbenefitsofphysical
activity(theauthorsfoundonly
limitedevidencefromwalkingspecific
studies)

Atkinson,M.andL.Weigand,AReviewofLiterature:TheMentalHealth
BenefitsofWalkingandBicycling(2008):
http://www.ibpi.usp.pdx.edu/media/Mental%20Health%20Benefits%20
White%20Paper.pdf

Leisurephysicalactivity(whichcan
includewalking)canreducethe
physicalsymptomsandanxiety
associatedwithminorstress

Carmack,C.L.,E.Boudreaux,etal.,Aerobicfitnessandleisurephysical
activityasmoderatorsofthestressillnessrelation,AnnalsofBehavioral
Medicine(1999)21(3):2517:
http://www.springerlink.com/content/488406687w963150/

Shortwalks,whereactivemiddle
agedandolderadultssettheirown
pace,increaseselfreportedenergy
levels

Ekkekakis,P.,S.H.Backhouse,C.GrayandE.Lind,Walkingispopular
amongadultsbutisitpleasant?Aframeworkforclarifyingthelink
betweenwalkingandaffectasillustratedintwostudies,Psychologyof
SportExercise(2008)9(3):24664:
http://www.sciencedirect.com.proxy.lib.sfu.ca/science/article/pii/S14690
29207000337

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Erickson,K.,etal.,reportedattheAlzheimer'sAssociationInternational
Astudyof120previouslysedentary
Conference2012.Fullreferencetofollowonpublication.
olderadultsfoundthatafterayearof
moderateintensitywalkingtheir
hippocampushadgrownby2percent
(anareaofthebrainimportantfor
memory)

Improvedsleepforgroupwithnormal Fritz,T.,etal.,EffectsofNordicWalkingonhealthrelatedqualityoflife
inoverweightindividualswithtype2diabetesmellitus,impairedor
glucosetoleranceafterfourmonths
normalglucosetolerance,DiabetMed.(2011)28(11):136272
ofNordicWalking
http://www.ncbi.nlm.nih.gov/pubmed/21658122

Psychologicalbenefitsofabriskwalk
aredependentuponsocialcontext
andfeaturesoftheoutdoor
environment(greeneryandwater)

JohanssonM.,andT.Hartig,Psychologicalbenefitsofwalking:
moderationbycompanyandoutdoorenvironment,AppliedPsychology:
HealthandWellbeing(2011)3(3):26180:
http://onlinelibrary.wiley.com/doi/10.1111/j.1758
0854.2011.01051.x/abstract131

Briskwalkingwasabletoelevate
affectiveresponse,resultingin
increasedpsychologicalwellbeingfor
individualswithtype2diabetes

Kopp,M.,etal.,Acuteeffectsofbriskwalkingonaffectandpsychological
wellbeinginindividualswithtype2diabetes,DiabetesResearchand
ClinicalPractice(2012)95(1):259:
http://www.diabetesresearchclinicalpractice.com/article/S0168
8227(11)005195/abstract

Walkingcanimprovementalfunction
ofadultsaged6075whencompared
tostretchingandtoning

Kramer,A.F.,S.Hahn,etal.,Ageing,fitnessandneurocognitivefunction,
Nature(1999)400:41819:http://www.biu.ac.il/tvunit/papers/Kramer
Vakil_1999_(39).pdf

Walkinginrural(vsurban)settings
hasagreatercognitiverestorative
affectforadultsofpoormental
health,comparedtoadultsofgood
mentalhealth

Roe,J.andP.Aspinall,Therestorativebenefitsofwalkinginurbanand
ruralsettingsinadultswithgoodandpoormentalhealth,Healthand
Place(2011)17(1):10313:
http://www.sciencedirect.com/science/article/pii/S1353829210001322

Walkingorcyclingtoschoolis
associatedwithbettercognitive
performance

MartnezGmez,D.,etal.,Activecommutingtoschoolandcognitive
performanceinadolescents:theAVENAStudy,ArchPediatrAdolesc
Med.(2011)165(4):3005:http://archpedi.ama
assn.org/cgi/content/short/archpediatrics.2010.244

Highlevelsofregular,longterm
physicalactivitywereassociatedwith
bettercognitiveperformanceandless
cognitivedeclineamongolderwomen
(menwerenotincludedinthisstudy)

Weuve,J.,J.H.Kang,etal.Physicalactivity,includingwalking,and
cognitivefunctioninolderwomen,JournaloftheAmericanMedical
Association(2004)292(12):145461:
http://www.ncbi.nlm.nih.gov/pubmed/15383516

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AppendixII:Thewalkingenvironment
Table3providesevidenceonthebenefitsofusingpedometerstoencouragewalking.Table4givesinformationonthe
impactofactivetravelonhealth.Table5aisalistofsomewalkinginitiativesfromaroundtheworldandinarangeof
settings;table5bisashortsummaryofsomeonlinetoolstoencourageandfacilitatewalking.Table6listssome
studiesofthebuiltenvironmentanditsimpactonwalking.

Table3:Walkingandpedometers
Specificbenefits

Paper

Reviewfoundthatoverallpedometeruse
increasesphysicalactivity26.9%over
baseline,decreasesBMIanddecreases
bloodpressure.Thesechangeswere
associatedwithhavingasetstepgoal

Bravata,D.M.etal.(2007).Usingpedometerstoincrease
physicalactivityandimprovehealth:asystematicreview,JAMA
(2007)298:2296304:http://jama.ama
assn.org/content/298/19/2296.short

Useofpedometershasamoderate
positiveeffectontheincreaseofphysical
activity

Kang,M.,S.J.Marshall,T.V.BarreiraandJ.O.Lee,Effectof
pedometerbasedphysicalactivityinterventions:ameta
analysis,ResQExercSport(2009)80:64855:
http://mtweb.mtsu.edu/mkang/Effect%20of%20pedometer
based%20physical%20activity%20interventions%20A%20meta
analysis.pdf

Averageincreaseof2,000stepsperday
Greatesteffectamongwomenwiththe
goalof10,000stepsperday
Moderatewalking=atleast100
steps/minute
Peopleshouldwalkaminimumof3,000
stepsin30minuteson5dayseachweek
Threesetsof1,000stepsin10minutes
eachdaycanalsobeusedtomeetthe
abovegoal
Byendof12weekperiod,pedometer
groupofoverweightandobesewomen
hadincreasedtheirnumberofstepsper
dayby36%comparedtotheintervention
group

Marshall,S.,S.Levy,C.TudorLocke,C.,etal.,Translating
physicalactivityrecommendationsintoapedometerbasedstep
goal3,000stepsin30minutes,AmericanJournalofPreventive
Medicine(2009)36:41015:
http://www.ajpmonline.org/article/S07493797(09)00087
7/abstract

Pal,S.,C.Cheng,G.Egger,etal.,Usingpedometerstoincrease
physicalactivityinoverweightandobesewomen:apilotstudy,
BMCPublicHealth(2009)9:309:
http://www.ncbi.nlm.nih.gov/pubmed/19703317

Pedometergroupalsodemonstrateda
significantdecreaseinsystolicblood
pressure
Longerpedometerbasedinterventions
resultsinthegreatestweightloss.On
averageparticipantslost0.05kg/week

Richardson,C.R.,T.L.Newton,J.J.Abraham,A.Sen,M.Jimboand
A.M.Swartz,Ametaanalysisofpedometerbasedwalking
interventionsandweightloss,AnnFamMed(2008)6:6977:
http://www.annfammed.org/content/6/1/69.abstract

Pilotprojectoflendingpedometersoutat
fivepublicCanadianlibrariesresultedin
increasedwalking,increasemotivationto
walkandgoalsetting.Preliminary
evidencethatlendingpedometersthrough
librariesisaneffectivelowcostapproach
toincreasingcommunitywalkingrates

Ryder,H.,K.Faloon,L.LevesqueandD.McDonald,Partnering
withlibrariestopromotewalkingamongcommunitydwelling
adults:aKingstonGetsActivepilotpedometerlendingproject,
HealthPromotionPractice(2009)10:588:
http://hpp.sagepub.com/content/10/4/588.short

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Table4:Activetransport
Specificbenefit

Paper

Activetransportisinverselyrelatedto
obesityrates.Europeanswalkonaverage
threetimesasmuchdistanceinayearas
Americans.

Bassett,D.R.,J.Pucher,R.Buehler,D.L.ThompsonandS.E.
Crouter,Walking,cycling,andobesityratesinEurope,North
American,andAustralia,JournalofPhysicalActivityandHealth
(2008)5:795814.
http://policy.rutgers.edu/faculty/pucher/jpah08.pdf

Reviewidentifies14studiesfromtheUnited
States,AustraliaandtheUnitedKingdom
focusingonactivetransportofchildrento
school.Mostquasiexperimentaland
demonstratedasmalleffectonactive
transportation.Morerigorousstudiesare
needed.

Chillon,P.,K.Evenson,A.VaughnandD.S.Ward,Asystematic
reviewofinterventionsforpromotingactivetransporttoschool,
InternationalJournalofBehavioralNutritionandPhysicalActivity
(2010)8(10):http://www.ijbnpa.org/content/8/1/10

Frank,L.D.,M.A.AndresenandT.L.Schmid,Obesityrelationships
Landusemix,timespentincars,andtime
withcommunitydesign,physicalactivity,andtimespentincars,
spentwalkinghaveastrongassociationwith
AmJPrevMed(2004)27:8796:
obesity
http://www.ncbi.nlm.nih.gov/pubmed/15261894

Hamer,M.andY.Chida,Activecommutingandcardiovascularrisk:
Activecommuting(includingwalkingand
ametaanalyticreview,PreventiveMedicine(2008)46(1):913:
cycling)wasassociatedwithan11%
reductionincardiovascularriskfactors,with http://www.ncbi.nlm.nih.gov/pubmed/17475317
astrongercorrelationamongwomen

Evidencedemonstratingthatlongterm
walkinglevels(notcyclinglevels)remained
stableafteraninitialincrease,suggesting
thatwalkingfortransportationmaybean
effectivelongtermstrategyforincreased
physicalinabdominallyobesewomen

Hemmingsson,E.,J.Uddn,M.Neovius,etal.,Increasedphysical
activityinabdominallyobesewomenthroughsupportforchanged
commutinghabits:arandomizedclinicaltrial,InternationalJournal
ofObesity(2009)33:64552:
http://www.ncbi.nlm.nih.gov/pubmed/19417772

Studyof5%ofthepopulationofMontreal
foundthat837,000motorisedkilometres(for
tripslessthan1.6km)couldbeconverted
intoalmost1,156millionstepseveryday.

Morency,C.,M.DemersandL.Lapierre,Howmanystepsdoyou
haveinreserve?Thoughtsandmeasuresaboutahealthierwayto
travel,TranspResRec.(2007)2002:16:
http://www.mendeley.com/research/stepsreservethoughts
measuresabouthealthierwaytravel/

Contributestobodyofevidence
demonstratingthehealthbenefitsofactive
travel,asitresultsinahigherpercentageof
adultswhoachieverecommendedlevelsof
physicalactivity,lowerpercentageofadults
withobesity,andalowerpercentageof
adultswithdiabetes

Pucher,J.,T.Buehler,D.R.BassettandA.L.Dannenberg,Walking
andcyclingtohealth:acomparativeanalysisofcity,state,and
internationaldata,AmericanJournalofPublicHealth(2010)
100(10):198692:
http://www.ncbi.nlm.nih.gov/pubmed/20724675

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Table5a:Selectedwalkingcampaignsfromaroundtheworld
Initiative

Country

Typeofcampaign

Website

i)Countryspecificinitiatives
CanadaWalks!

Canada

Walkablecommunities www.canadawalks.ca/
/activetransport

CanadianVolkssport Canada
Federation

Groups

EveryBodyWalk!

Resourcesandstories www.everybodywalk.org/

USA

http://walks.ca/CVF/Home.html

HealthyFamiliesBC, Canada
WalkingChallenge

Challenge

http://healthyfamiliesbcwalkingchallenge.ca

LivingStreets

UK

Activetransport

http://www.livingstreets.org.uk/

PathsforAll

Scotland

Access/active
transport

http://www.pathsforall.org.uk/

ProjectSMILES

Spain,UK
(Irelandand
Sweden)

Activetransport

http://www.smilesproject.eu/

Ramblers

UK

Access/groups

http://www.ramblers.org.uk/

SeeMommyRun

USA

Socialnetwork

http://www.seemommyrun.com/about

WalkforLunch

USA

Groups

http://walkforlunch.com/

WalkSafelytoSchool Australia
Day

Schools

www.walk.com.au

WalkingforHealth

UK

Groups

http://www.walkingforhealth.org.uk/

WalkingSite

USAand
Canada

Resources

www.thewalkingsite.com

WalkingSpree

USA

Workplace

www.walkingspree.com

Where2Walk

UK

Routes

where2walk.co.uk

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ii)Internationalinitiatives
Global
GlobalCorporate
Challenge
andtheGlobal
ChildrensChallenge

Workplace/challenge www.gettheworldmoving.org

GlobalChildrens
Challenge

Global

Schools/challenge

www.gccjunior.org/

IMLWalking
Association

Global

Events

http://www.imlwalking.org

PedestrianQuality
Needs(study)

20countries
across
Europeand
theMiddle
East

Access/activetravel

www.walkeurope.org

Walk21

Global

Conferences

http://www.walk21.com

WalkingSchoolBus

USA,New
Zealandetc.

Schools

www.walkingschoolbus.org/index.html

Walkingwith
Attitude

Australia,
UK,etc.

Workplace/challenge http://www.walkingwithattitude.com/index

Table5b:Onlinewalkingtools
Tool

Description

Website

MapMyWalk Websitethatallowsmapping(andsharing)ofwalking
http://www.mapmywalk.com/
routes,usingGooglemaps.Ittracksdistanceandelevation.
WalkIt

Thisurbanwalkingrouteplannerplotsthebestroutesfor www.walkit.com
walkinginover40UKcities,givingachoiceofthefastestor
theleastpollutedroute,calculatingthetimeitwilltaketo
walk(atslow,mediumorfastpace),thecaloriesburned,
stepstaken,andtheCO2emissionsoffsetbywalkingrather
thandriving(seealsop.11).

Walkscore

WalkScoregivesawalkabilityscoreforanarea,
highlightinglanduse(e.g.localshopsandrestaurants),
greenspace,schoolsandcommutingtime(seealsop.16).

38

http://www.walkscore.com/

www.c3health.org

Table6:Walkingandthebuiltenvironment
Ball,K.,A.Timperio,J.Salmon,etal.,Personal,socialandenvironmentaldeterminantsofeducationalinequalitiesin
walking:amultilevelstudy,JEpidemiolCommunityHealth(2007)61:10814:
http://www.ncbi.nlm.nih.gov/pubmed/17234868
Cho,G.,D.A.RodriguezandA.J.Khattak,Theroleofthebuiltenvironmentinexplainingrelationshipsbetween
perceivedandactualpedestrianandbicyclistsafety,AccidAnalPrev(2009)41(4):692702:
http://www.ncbi.nlm.nih.gov/pubmed/19540957
Christian,H.E.etal.,Howimportantisthelandusemixmeasureinunderstandingwalkingbehaviour?Resultsfrom
theRESIDEstudy,InternationalJournalofBehavioralNutritionandPhysicalActivity(2011)8(55):
http://www.ijbnpa.org/content/8/1/55
Coogan,P.F.,L.F.White,T.J.Adler,etal.,ProspectivestudyofurbanformandphysicalactivityintheBlackWomen's
HealthStudy,AmJEpidemiol(2009)170:110517:http://www.ncbi.nlm.nih.gov/pubmed/19808635
Deehr,R.andA.Shumann,ActiveSeattle:Achievingwalkabilityindiverseneighborhoods,AmericanJournalof
PreventiveMedicine(2009)37:S40311.http://www.ncbi.nlm.nih.gov/pubmed/19944941
Ewing,R.,T.Schmid,R.Killingsworth,etal.,Relationshipbetweenurbansprawlandphysicalactivity,obesity,and
morbidity,AmJHealthPromot(2003)18:4757:http://www.ncbi.nlm.nih.gov/pubmed/13677962
Frank,L.D.,T.L.Schmid,J.F.Sallis,etal.(2005).Linkingobjectivelymeasuredphysicalactivitywithobjectively
measuredurbanform:findingsfromSMARTRAQ,AmJPrevMed(2005)28:11725:
http://www.ncbi.nlm.nih.gov/pubmed/15694519
GilesCorti,B.,M.H.Broomhall,M.Knuiman,etal.,Increasingwalking:howimportantisdistanceto,attractiveness,
andsizeofpublicopenspace?,AmJPrevMed(2005)28:16976:http://www.ncbi.nlm.nih.gov/pubmed/15694525
Hoehner,C.M.,L.K.BrennanRamirez,M.B.Elliott,S.L.HandyandR.C.Brownson,Perceivedandobjective
environmentalmeasuresandphysicalactivityamongurbanadults,AmJPrevMed(2005)28:10516:
http://www.ncbi.nlm.nih.gov/pubmed/15694518
Jacobsen,P.L.,F.RacioppiandH.Rutter,Whoownstheroads?Howmotorizedtrafficdiscourageswalkingand
bicycling,InjPrev(2009)15:36973:http://injuryprevention.bmj.com/content/15/6/369.full.html#relatedurls
Kaczynski,A.T.andK.A.Henderson,Environmentalcorrelatesofphysicalactivity:areviewofevidenceaboutparks
andrecreation,LeisureSciences(2007)29:31554:
http://www.ingentaconnect.com/content/routledg/ulsc/2007/00000029/00000004/art00001
Krieger,J.,J.Rabkin,D.SharifyandL.Song,Highpointwalkingforhealth:creatingbuiltandsocialenvironmentsthat
supportwalkinginapublichousingcommunity,AmJPublicHealth(2009)99(3):S5939:
http://www.ncbi.nlm.nih.gov/pubmed/19890163
Lachapelle,U.andL.Frank,Transitandhealth:modeoftransport,employersponsoredpublictransitpassprograms
andphysicalactivity,JournalofPublicHealthPolicy(2009)S73S94:
http://www.ncbi.nlm.nih.gov/pubmed/19190584

39

www.c3health.org

Leyden,K.M.,Socialcapitalandthebuiltenvironment:theimportanceofwalkableneighbourhoods,AmJPublic
Health(2003)93:154651:http://www.ncbi.nlm.nih.gov/pubmed/12948978
McGinn,A.P.,K.R.Evenson,A.H.Herring,S.L.HustonandD.A.Rodruguez,Exploringassociationsbetweenphysical
activityandperceivedandobjectivemeasuresofthebuiltenvironment,JUrbanHealth(2007)84(2):16284:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231636/
Michael,Y.L.,L.A.Perdue,E.S.Orwoll,etal.,Physicalactivityresourcesandchangesinwalkinginacohortofolder
men,AmJPublicHealth(2010)100:65460:http://www.ncbi.nlm.nih.gov/pubmed/20167887
Nagel,C.L.,N.E.Carlson,M.BosworthandY.L.Michael,Therelationbetweenneighborhoodbuiltenvironmentand
walkingactivityamongolderadults,AmJEpidemiol(2008)168:4618:
http://www.ncbi.nlm.nih.gov/pubmed/18567638
Papas,M.A.,A.J.Alberg,R.Ewing,etal.,Thebuiltenvironmentandobesity,EpidemiolRev(2007)29:12943.
http://www.ncbi.nlm.nih.gov/pubmed/17533172
Renalds,A.,T.H.SmithandP.J.Hale,Asystematicreviewofbuiltenvironmentandhealth,FamCommunityHealth
(2010)33(1):6878:http://www.ncbi.nlm.nih.gov/pubmed/20010006

40

www.c3health.org

AppendixIII:Levelsofevidenceandevidencegaps
Despitetheextensivebodyofresearchlinkingphysicalactivityandhealthbenefits,thereisrelativelylittle
scientificevidenceonspecifictypesofactivities(seeBox1),includingwalking.TherearefarfewerLevel1
andLevel2studies(whicharecostlyandtimeconsuming),comparedtoLevel3studies.However,thisdoes
notcastdoubtontheveracityoftheoverwhelmingevidenceonthebenefitsofphysicalactivity,whichis
whymajornationalandinternationalauthoritiesresponsibleforhealthandwellbeinghaveunanimously
endorsedthebenefitsofphysicalactivityinreducingriskfactorsassociatedwithNCDs.

Box1:Levelsofscientificevidence
Level1
Level2

Randomisedcontroltrialswithoutimportantlimitations
Randomisedcontroltrialswithimportantlimitations
Observationalstudies(nonrandomisedclinicaltrialsorcohortstudies)with
overwhelmingevidence

Level3

Level4

Otherobservationalstudies(prospectivecohortstudies,casecontrolstudies,case
series)
Inadequateornodatainpopulationofinterest
Anecdotalevidenceorclinicalexperience

Source:132

Thereareanumberofinterestinggapsintheresearch,forexamplehowthesuggested10,000stepsaday
linksintothegeneralrecommendationof30minutesadayofmoderatephysicalactivity.
Therearealsopotentialareasforresearchsuchastheenvironmentalbenefitsofwalking,andthe
economicbenefitsthatcouldbeobtainedbyprioritisingwalkingasaformofphysicalactivityandactive
transport.

41

www.c3health.org

Endnotes
*

Acknowledgements:KatyCooperandChristineHancock(C3CollaboratingforHealth)wouldliketothankRachel
SteedandDeniseStevensatMATRIXPublicHealthSolutionsInc.fortheirassistanceinwritingandcompilingthis
report.C3alsothanksBupaforfundinganearlierversionofthisreview.

InternationalObesityTaskForceandEuropeanAssociationfortheStudyofObesity.ObesityinEurope:TheCasefor
Action:http://www.iotf.org/media/euobesity.pdf.
2

Siegel,P.Z.,R.M.BrackbillandG.W.Heath,Theepidemiologyofwalkingforexercise:implicationsforpromoting
activityamongsedentarygroups,AmJPublicHealth(1995)85:70610:
http://www.ncbi.nlm.nih.gov/pubmed/12972873;Eyler,A.A.,etal.,Theepidemiologyofwalkingforphysicalactivity
intheUnitedStates,MedSciSportsExerc(2003)35:152936:http://www.ncbi.nlm.nih.gov/pubmed/12972873.
3

Westby,M.D.,Ahealthprofessionalsguidetoexerciseprescriptionforpeoplewitharthritis:areviewofaerobic
fitnessactivities,ArthritisCare&Research(2001)45:50111:http://onlinelibrary.wiley.com/doi/10.1002/1529
0131%28200112%2945:6%3C501::AIDART375%3E3.0.CO;2Y/abstract.
4

Lamb,S.E.etal.,Canlayledwalkingprogrammesincreasephysicalactivityinmiddleagedadults?Arandomised
controlledtrial,JournalofEpidemiologyandCommunityHealth(2002)56:24625:
http://jech.bmj.com/content/56/4/246.abstract;Parkkari,J.etal.,Acontrolledtrialofthehealthbenefitsofregular
walkingonagolfcourse,AmericanJournalofMedicine(2000)109:1028:
http://www.ncbi.nlm.nih.gov/pubmed/10967150;Zunft,H.F.etal.,Perceivedbenefitsandbarrierstophysical
activityinanationallyrepresentativesampleintheEuropeanUnion,PublicHealthNutrition(1999)2:15360:
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=554588.
5

Simpson,M.E.etal.,WalkingtrendsamongUSadults:theBehavioralRiskFactorSurveillanceSystem,19872000,
AmericanJournalofPreventiveMedicine(2003)25:95100:http://www.ajpmonline.org/article/S0749
3797%2803%29001120/abstract;RamblersCharity,RamblersattheHeartofWalking:
http://www.ramblers.org.uk/Walking/policy/caseforwalking/participation.htm.
6

Hu,P.andT.Reuscher,SummaryofTravelTrends(2004)(USDepartmentofTransportation):
http://nhts.ornl.gov/2001/pub/stt.pdf.
7

NationalCenterforSafeRoutestoSchool,HowChildrengettoSchool:SchoolTravelPatternsfrom1969to2009
(2011):http://www.saferoutesinfo.org/sites/default/files/resources/NHTS_school_travel_report_2011_0.pdf,p.2.
8

Killoran,A.etal.,TransportInterventionspromotingSafeCyclingandWalking:EvidenceBriefing(2006):
https://nice.org.uk/nicemedia/pdf/Transport_Evidence_Briefing_0507.pdf,Table1,p.10.
9

C3CollaboratingforHealth,TheBenefitsofPhysicalActivityforHealthandWellbeing(2011):
http://www.c3health.org/wpcontent/uploads/2009/09/C3reviewofphysicalactivityandhealthv120110603.pdf
10

Lee,IM.etal.,Effectofphysicalinactivityonmajornoncommunicablediseasesworldwide:ananalysisofburden
ofdiseaseandlifeexpectancy,TheLancet(2012)380(9838):21929:
http://www.thelancet.com/journals/lancet/article/PIIS01406736%2812%29610319/abstract
11

NHSInformationCentre,HealthSurveyforEngland2008:PhysicalActivityandFitness(2009):
http://www.ic.nhs.uk/webfiles/publications/HSE/HSE08/Volume_1_Physical_activity_and_fitness_revised.pdf,p.21.
12

BritishMedicalAssociation,HealthyTransport,HealthyLives(2012):http://bma.org.uk/transport,Figure14,p.30.

13

Seehttp://www.livestrong.com/article/241650calculatewalkingcaloriesbydistance/

14

Lee,I.M.andP.J.Skerrett,Physicalactivityandallcausemortality:whatisthedoseresponserelation?Medicine
andScienceinSportsandExercise(2001)33:S459S471:http://www.ncbi.nlm.nih.gov/pubmed/11427772;discussion
S493S494;Woodcock,J.etal.,Nonvigorousphysicalactivityandallcausemortality:systematicreviewandmeta
analysisofcohortstudies,IntJEpidemiology(2011)40(1):12138:
http://ije.oxfordjournals.org/content/40/1/121.abstract.
15

Woodcocketal.,Nonvigorousphysicalactivityandallcausemortality.

42

www.c3health.org

16

See,forexample,WorldHealthOrganization,GlobalRecommendationsonPhysicalActivityforHealth(WHO,2011):
http://whqlibdoc.who.int/publications/2010/9789241599979_eng.pdf
17

Wen,C.P.etal.,Minimumamountofphysicalactivityforreducedmortalityandextendedlifeexpectancy:a
prospectivecohortstudy,TheLancet(2011)378:9798:124453:
http://www.thelancet.com/journals/lancet/article/PIIS01406736%2811%29607496/abstract
18

Lee,I.M.,Physicalactivityandcancerpreventiondatafromepidemiologicalstudies,MedSciSportsExerc2003,
35:18237:http://www.ncbi.nlm.nih.gov/pubmed/14600545
19

Warburtonetal.:Systematicreview,opcit.

20

Speck,R.M.etal.,Anupdateofcontrolledphysicalactivitytrialsincancersurvivors:asystematicreviewandmeta
analysis,JournalofCancerSurvivorship(2010)4:87100:
http://www.springerlink.com/content/p1500840qt11h157/;Fong,D.Y.etal.,Physicalactivityforcancersurvivors:
metaanalysisofrandomisedcontrolledtrials,BMJ(2012)344:e70:http://www.bmj.com/content/344/bmj.e70
21

MacmillanCancerSupport,MoveMore:
http://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Physicalactivity/Movemoreorderform.as
px?utm_source=Activity&utm_medium=Clickin&utm_content=home&utm_campaign=awarenessmonths
22

MacmillanCancerSupport,Theimportanceofphysicalactivityforpeoplelivingwithandbeyondcancer:aconcise
evidencereview(2012):
http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Physicalactivityevidencereview.pdf
23

MacmillanCancerSupport,Physicalactivity:theunreportedwonderdrug,
http://www.macmillan.org.uk/Documents/AboutUs/Newsroom/Physicalactivityreport.pdf,p.7.
24

Macmillan,Aconciseevidencereview,table5,p.10.

25

PartnershipannouncedinMay2012:http://responsibilitydeal.dh.gov.uk/2012/05/23/macmillanandtheramblers/

26

GarciaAymerich,J.etal.,RiskfactorsofreadmissiontohospitalforaCOPDexacerbation:aprospectivestudy,
Thorax(2003)58(2):1005:http://www.ncbi.nlm.nih.gov/pubmed/12554887,citedinCavill,N.andC.Foster,Health
BenefitsofWalking:TheEvidenceBase(2008):http://nationalcampaignforwalking.net/evidence/
27

SeeAppendix1,Table5inC3,TheBenefitsofPhysicalActivityforHealth.

28

Atkinson,M.andL.Weigand,Areviewofliterature:thementalhealthbenefitsofwalkingandbicycling(2008):
http://www.ibpi.usp.pdx.edu/media/Mental%20Health%20Benefits%20White%20Paper.pdf
29

MartnezGmez,D.etal.,Activecommutingtoschoolandcognitiveperformanceinadolescents:theAVENA
Study,ArchPediatrAdolescMed.(2011)165(4):3005:http://archpedi.ama
assn.org/cgi/content/short/archpediatrics.2010.244andWeuve,J.etal.Physicalactivity,includingwalking,and
cognitivefunctioninolderwomen,JournaloftheAmericanMedicalAssociation(2004)292(12):145461:
http://www.ncbi.nlm.nih.gov/pubmed/15383516/
30

GilesCorti,B.etal.,Increasingwalking:howimportantisdistanceto,attractiveness,andsizeofpublicopen
space?AmJPrevMed.(2005)28:16976:http://www.ncbi.nlm.nih.gov/pubmed/15694525;Kaczynski,A.T.andK.A.
Henderson,Environmentalcorrelatesofphysicalactivity:areviewofevidenceaboutparksandrecreation,Leisure
Sciences(2007)29:31554:
http://www.ingentaconnect.com/content/routledg/ulsc/2007/00000029/00000004/art00001;Johansson,M.andT.
Hartig,Psychologicalbenefitsofwalking:moderationbycompanyandoutdoorenvironment,AppliedPsychology:
HealthandWellbeing(2011)3(3):26180:http://onlinelibrary.wiley.com/doi/10.1111/j.1758
0854.2011.01051.x/abstract.
31

MIND,Ecotherapy:TheGreenAgendaforMentalHealth(2007):
http://www.mind.org.uk/campaigns_and_issues/report_and_resources/835_ecotherapy
32

C3,TheBenefitsofPhysicalActivityforHealth.

33

See,forexample,Marshall,S.etal.,Translatingphysicalactivityrecommendationsintoapedometerbasedstep
goal3,000stepsin30minutes,AmericanJournalofPreventiveMedicine(2009)36:41015:
http://www.ajpmonline.org/article/S07493797(09)000877/abstract
34

TudorLocke,C.etal.,Howmanysteps/dayareenough?Forchildrenandadolescents,InternationalJournalof
BehavioralNutritionandPhysicalActivity(2011)8(78):http://www.ijbnpa.org/content/8/1/78;TudorLocke,C.etal.,
43

www.c3health.org

Howmanysteps/dayareenough?Forolderadultsandspecialpopulations,InternationalJournalofBehavioral
NutritionandPhysicalActivity(2011)8(80):http://www.ijbnpa.org/content/8/1/80;TudorLocke,C.etal.,Howmany
steps/dayareenough?Foradults,InternationalJournalofBehavioralNutritionandPhysicalActivity(2011)8(79):
http://www.ijbnpa.org/content/8/1/79.
35

TudorLockeetal.,Howmanysteps/dayareenough?Foradults.

36

Ibid.

37

TudorLocke,C.,W.D.JohnsonandP.T.Katzmarzyk,AccelerometerdeterminedstepsperdayinUSadults,MedSci
SportsExerc(2009)41:138491:http://www.ncbi.nlm.nih.gov/pubmed/19516163
38

Chan,C.B.,D.A.J.RyanandC.TudorLocke,Healthbenefitsofapedometerbasedphysicalactivityinterventionin
sedentaryworkers,PreventativeMedicine(2004)39:121592:http://www.ncbi.nlm.nih.gov/pubmed/15539058
39

TudorLocke,Howmanysteps/dayareenough?Forolderadults.

40

Ibid.

41

TudorLocke,Howmanysteps/dayareenough?Forchildrenandadolescents.
http://www.ijbnpa.org/content/8/1/78
42

BassettD.R.,P.L.SchneiderandG.E.Huntington,PhysicalactivityinanOldOrderAmishcommunity,MedSci
SportsExerc(2004)36:7985:http://www.ncbi.nlm.nih.gov/pubmed/14707772.
43

TudorLocke,C.andD.R.Bassett,Howmanysteps/dayareenough?Preliminarypedometerindicesforpublic
health,SportsMed(2004)34:18:http://www.ncbi.nlm.nih.gov/pubmed/14715035.
44

CavillandFoster,HealthBenefitsofWalking.

45

Wenetal.,Minimumamountofphysicalactivityforreducedmortalityandextendedlifeexpectancy.

46

Ibid.

47

Strazdins,L.andB.Loughrey,Toobusy:whytimeisahealthandenvironmentalproblem,NSWPublicHealth
Bulletin(2007)18(1112):21921:http://www.publish.csiro.au/?act=view_file&file_id=NB07029.pdf
48

Mackett,R.L.etal.,Overcomingthebarrierstowalkingforpeoplewhoaresociallyexcluded,CentreforTransport
Studies,UniversityCollegeLondon:http://discovery.ucl.ac.uk/18721/1/18721.pdf
49

TransportforLondon,AttitudestoWalking2011(2011):http://www.tfl.gov.uk/assets/downloads/customer
research/attitudestowalking2011report.pdf,table5.2.
50

Williams,D.M.etal.,Interventionstoincreasewalkingbehavior,MedSciSportsExerc.(2008)40(7Suppl):S567
S573:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2694671/?tool=pubmed;Ogilvie,D.etal.,Interventionsto
promotewalking:systematicreview,BMJ(2007)334:12047:
http://www.bmj.com/content/334/7605/1204.abstract.
51

Bjrs,G.,etal.,Walkingcampaign:amodelfordevelopingparticipationinphysicalactivity?Experiencesfrom
threecampaignperiodsoftheStockholmDiabetesPreventionProgram(SDPP),PatientEducationandCounseling
(2001)42:914:http://www.ncbi.nlm.nih.gov/pubmed/11080601
52

TransportforLondon,AttitudestoWalking2008ResearchReport(2008):
http://www.tfl.gov.uk/assets/downloads/attitudestowalking2008researchreport.pdf,p.29.
53

Forthevideo,see:http://www.youtube.com/watch?v=PEdHhZcmEoM

54

Sourcesinclude:Thomas,N.etal.,Barrierstophysicalactivityinpatientswithdiabetes,PostgradMedJ(2004)80:
28791:http://pmj.bmj.com/content/80/943/287.full.pdf+html;AlKaabi,J.etal.,Physicalactivityandreported
barrierstoactivityamongtype2diabeticpatientsintheUnitedArabEmirates,TheReviewofDiabeticStudies(209)6:
2718:http://ukpmc.ac.uk/articles/PMC2836198//reload=0;jsessionid=nPGmtL5IyseirNdcaryk.2;Bicycleand
PedestrianInformationCenterwebsiteathttp://www.walkinginfo.org/why/barriers_physical.cfmand
http://www.walkinginfo.org/why/barriers_personal.cfm;Mackettetal.,Overcomingthebarriers,Table1;Kopp,M.
etal.,Acuteeffectsofbriskwalkingonaffectandpsychologicalwellbeinginindividualswithtype2diabetes,
DiabetesResearchandClinicalPractice(2012)95(1):259:
http://www.diabetesresearchclinicalpractice.com/article/S01688227(11)005195/abstract
55

Bell,A.C.,K.GeandB.M.Popkin,Theroadtoobesityorthepathtoprevention:motorizedtransportationand
obesityinChina,ObesRes.(2002)10:27783:http://www.nature.com/oby/journal/v10/n4/full/oby200238a.html.
44

www.c3health.org

56

Ibid.

57

Schafer,A.,Regularitiesintraveldemand:aninternationalperspective,JTranspStat(2000)December:131:
http://ntl.bts.gov/lib/10000/10900/10907/1schafer.pdf,ascitedinBassett,D.R.etal.,Walking,cycling,andobesity
ratesinEurope,NorthAmerica,andAustralia,JournalofPhysicalActivityandHealth(2008)5:795814:
policy.rutgers.edu/faculty/pucher/jpah08.pdf.
58

Bassett,etal.,Walking,cycling,andobesityrates.

59

Ibid.

60

Ibid.

61

Frank,L.D.,M.A.AndresenandT.L.Schmid,Obesityrelationshipswithcommunitydesign,physicalactivity,and
timespentincars,AmJPrevMed(2004)27:8796:http://www.ajpmonline.org/article/S0749
3797%2804%2900087X/abstract.
62

AscitedinMurtagh,E.M.,M.H.MurphyandJ.BooneHeinonen,Walkingthefirststepstocardiovasculardisease
prevention,CurrOpinCardio.(2010)25(5):4906:http://www.ncbi.nlm.nih.gov/pubmed/20625280
63

GordonLarsen,P.,etal.,Activecommutingandcardiovasculardiseaserisk:theCARDIAstudy.ArchInternMed.
(2009)169:121623:http://www.ncbi.nlm.nih.gov/pubmed/19597071
64

Ibid.

65

Ibid.

66

Ibid.

67

Ibid.

68

Adams,J.,PrevalenceandsociodemographiccorrelatesofactivetransportintheUK:analysisoftheUKTimeUse
Survey2005,PreventiveMedicine(2010)50(4):199203:http://www.ncbi.nlm.nih.gov/pubmed/20093137
69

Ibid.

70

Hemmingsson,E.,etal.,Increasedphysicalactivityinabdominallyobesewomenthroughsupportforchanged
commutinghabits:arandomizedclinicaltrial,InternationalJournalofObesity(2009)33:64552:
http://www.nature.com/ijo/journal/v33/n6/full/ijo200977a.html.
71

Saelens,B.E.andS.L.Handy,Builtenvironmentcorrelatesofwalking:areview,MedSciSportsExerc.(2008)40:
S55066.http://www.ncbi.nlm.nih.gov/pubmed/18562973;Saelens,B.E,J.F.SallisandL.D.Frank,Environmental
correlatesofwalkingandcycling:findingsfromthetransportation,urbandesign,andplanningliteratures,AnnBehav
Med.(2003)25:8091:http://www.ncbi.nlm.nih.gov/pubmed/12704009
72

Saelensetal.,Environmentalcorrelatesofwalkingandcycling.

73

Wong,F.,etal.,CommunityHealthEnvironmentScanSurvey(CHESS):anoveltoolthatcapturestheimpactofthe
builtenvironmentonlifestylefactors,GlobalHealthAction(2011):
http://www.globalhealthaction.net/index.php/gha/article/view/5276
74

Franketal.,Obesityrelationshipswithcommunitydesign.

75

Leyden,K.M.,Socialcapitalandthebuiltenvironment:theimportanceofwalkableneighbourhoods,AmJPublic
Health(2003)93:154651:http://www.ncbi.nlm.nih.gov/pubmed/12948978
76

Jacobsen,P.L.,F.RacioppiandH.Rutter,Whoownstheroads?Howmotorizedtrafficdiscourageswalkingand
bicycling,InjPrev(2009)15:36973:http://injuryprevention.bmj.com/content/15/6/369.full.html#relatedurls
77

Frank,L.D.,etal.,Manypathwaysfromlandusetohealth:Associationsbetweenneighborhoodwalkabilityand
activetransportation,bodymassindex,andairquality,JournaloftheAmericanPlanningAssociation(2007)72(1):
7587:http://www.tandfonline.com/doi/abs/10.1080/01944360608976725
78

Leinberger,C.B.andM.Alfonzo(fortheBrookingsInstitute),Walkthisway:theeconomicpromiseofwalkable
placesinmetropolitanWashingtonDC(2012):
http://www.brookings.edu/~/media/Research/Files/Papers/2012/5/25%20walkable%20places%20leinberger/25%20
walkable%20places%20leinberger.pdf
79

http://www.heatwalkingcycling.org/

45

www.c3health.org

80

See,inparticular,HEATMethodologyandUserGuide:EconomicAssessmentofTransportInfrastructureandPolicies
(2011):http://www.euro.who.int/__data/assets/pdf_file/0003/155631/E96097.pdf:seepp.2631onwalking
specifically.
81

Seehttp://walkit.com/goinggreen/

82

http://www.eea.europa.eu/maps/ozone/whatcanIdo/avoidozonepollution

83

See,forexample,NationalInstituteofEnvironmentalHealthScienceswebsite,Airpollutionandcardiovascular
disease:http://www.niehs.nih.gov/health/impacts/cardiovascular/andAirpollutionandrespiratorydisease:
http://www.niehs.nih.gov/health/impacts/respiratory/index.cfm
84

TransportforLondon,AttitudestoWalking2011,table5.2.

85

SeeCleanAirInitiativeforAsianCities(CAIAsia)Center,WalkabilityinIndianCities(2011),p.7

86

A.Singh,TransportSectorGreenhouseGasEmissions2007(2010):
http://moef.nic.in/downloads/others/Anil%20Singh.pdf
87

CAIAsia,WalkabilityinIndianCities,p.8

88

Woodcock,J.etal.,Publichealthbenefitsofstrategiestoreducegreenhousegasemissions:urbanlandtransport,
TheLancet(2009)374(9705):193043:http://www.thelancet.com/journals/lancet/article/PIIS0140
6736%2809%29617141/abstract
89

http://www.gettheworldmoving.com/

90

http://www.gettheworldmoving.com/aboutus/halloffame

91

FoundationforChronicDiseasePreventionintheWorkplace(FDCP)(2012),FDCPClinicalResearch20052011.
PowerpointPresentation.Personalcommunication,DrDavidBatman.
92

Ibid.

93

http://www.gccjunior.org/

94

FDCP,FDCPClinicalResearch20052011,andhttp://www.gettheworldmoving.com/

95

http://www.walktoschool.org.uk/ourprojects/earlyyearsandprimary/walkonceaweek/

96

WavehillConsulting,EvaluationoftheWoWSchemeforLivingStreets(2009):
http://www.walktoschool.org.uk/files/9612/8443/6107/Wavehill%20%20WoW%20Report%20%20FINAL%20.pdf
97

Ibid.

98

http://www.heartfoundation.org.au/SiteCollectionDocuments/Ms%20Michelle%20Wilson.pdf

99

http://www.aarp.org/health/healthyliving/info092011/mallwalkersslideshow.html

100

CulosReed,S.N.etal.,Mallwalkingasaphysicalactivityoption:resultsofapilotproject,CanadianJournalon
Aging(2008)27:817:http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6626384
101

Forfurtherinformation,seehttp://nordicwalking.co.uk/?page=about_nordic_walking&c=24.Amongother
projects,StMarysUniversityiscurrentlyrunningastudytocomparethehealthbenefitsofwalkingandNordic
Walking,butthishasnotyetbeencompleted.
102

Ascitedonhttp://www.nordixx.com/health/npwanddepression/

103

Mikalacki,M.,N.CokoriloandR.Katiae,EffectofNordicwalkingonfunctionalabilityandbloodpressureinelderly
women,CollAnthropol.(2011)35(3):88994:http://nordicwalking.co.uk/?page=about_nordic_walking&c=24
104

Reuter,S.etal.,Effectsofaflexibilityandrelaxationprogramme,walking,andNordicWalkingonParkinson's
Disease,JournalofAgingResearch(2011):http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3095265/
105

VanEijkeren,F.J.M.etal.,NordicwalkingimprovesmobilityinParkinson'sdisease,Mov.Disord.(2008)23:2239
43:
http://onlinelibrary.wiley.com/doi/10.1002/mds.22293/abstract?userIsAuthenticated=false&deniedAccessCustomise
dMessage=
106

Knowles,A.M.etal.,ApilotstudyexaminingthehealthbenefitsofNordicWalkinginsedentaryadults,Journalof
SportandHealthResearch(2012)4(1):4556Lhttp://nrl.northumbria.ac.uk/5354/
46

www.c3health.org

107

Fritz,T.etal.,EffectsofNordicwalkingonhealthrelatedqualityoflifeinoverweightindividualswithtype2
diabetesmellitus,impairedornormalglucosetoleranceDiabetMed(2011)11:136272:
http://www.ncbi.nlm.nih.gov/pubmed/21658122
108

Aucklandtransport,Walkingschoolbus:http://www.aucklandtransport.govt.nz/movingaround/schooltravel
plans/WalkingSchoolBus/Pages/default.aspx
109

http://www.nzta.govt.nz/resources/walkingschoolbuscoordinatorsguide/

110

Mendoza,J.A.etal.,Thewalkingschoolbusandchildren'sphysicalactivity:apilotclusterrandomizedcontrolled
trial,Pediatrics(2011)128(3):e537e544:http://pediatrics.aappublications.org/content/128/3/e537.abstract.
111

Alexander,L.M.etal.,Thebroaderimpactofwalkingtoschoolamongadolescents:sevendayaccelerometry
basedstudy,BMJ(2005)3331:1061:http://www.bmj.com/content/331/7524/1061.fullandCooper,A.R.,
Commutingtoschool:arechildrenwhowalkmorephysicallyactive?AmJPrevMed.(2003)25(4):2736:
http://www.ncbi.nlm.nih.gov/pubmed/14580626.
112

CaliforniaDepartmentofEducation,AStudyoftheRelationshipbetweenPhysicalFitnessandAcademic
AchievementinCaliforniausing2004TestResults(2005):
http://www.cde.ca.gov/ta/tg/pf/documents/2004pftresults.doc:Therewasastrongpositiverelationshipbetween
physicalfitnessandacademicachievement.Therelationshipbetweenfitnessandachievementwasstrongerfor
femalesthanformalesandstrongerforhigherSESstudentsthanforlowerSESstudents.Note,however,thatthe
resultsdonotindicatecausality.
113

Forexample,MartnezGmez,D.etal.,Activecommutingtoschoolandcognitiveperformanceinadolescents:
theAVENAStudy,ArchPediatrAdolescMed.(2011)165(4):3005:http://archpedi.ama
assn.org/cgi/content/short/archpediatrics.2010.244
114

Moodie,M.etal.,CosteffectivenessofactivetransportforprimaryschoolchildrenWalkingSchoolBus
program,IntJBehavNutrPhysAct(2009)6:63:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758827/.
115

Seehttp://www.lcsd.gov.hk/healthy/en/qualiwalk.php

116

http://www.cicloviasrecreativas.org/en/

117

Sarmiento,O.etal.,TheCiclovaRecreativa:amassrecreationalprogramwithpublichealthpotential,Journalof
PhysicalActivityandHealth(2010)7(Suppl2):S16380:
http://cicloviarecreativa.uniandes.edu.co/english/advocacy/anexos/The_CicloviaRecreativa_A_Mass
Recreational_Program.pdf
118

Montes,F.etal.Dohealthbenefitsoutweighthecostsofmassrecreationalprograms?Aneconomicanalysisof
fourciclovaprograms,JournalofUrbanHealth(2011)89(1):15370:
http://springerlink3.metapress.com/content/8225m7wu391321r4/
119

Sarmientoetal.,TheCiclovaRecreativa.

120

Citedinibid.,p.S176.

121

Citedinibid.,p.S177.

122

Citedinibid.,p.S177.

123

Ibid.

124

AtlantaBeltlineInc.andTheAtlantaBeltlinePartnership,AtlantaBeltline:http://beltline.org/

125

Ross,C.L.etal.,HealthimpactassessmentoftheAtlantaBeltline,AmericanJournalofPreventativeMedicine
(2012)42(3):20313:http://www.ajpmonline.org/article/S07493797%2811%29009093/fulltext
126

Ross,C.L.,AtlantaBeltlineHealthImpactAssessment(2007):
http://www.healthimpactproject.org/resources/document/AtlantaBeltline.pdf
127

Ross,C.L.,etal.,HealthimpactassessmentoftheAtlantaBeltline,AmJPrevMed(2012)42(3):20213:
http://www.healthimpactproject.org/resources/document/Ross2012_AtlantaBeltline.pdf
128

CAIAsia,WalkabilityinIndianCities,p.41.

129

See,forexample,WallStreetJournal,19January2010:
http://online.wsj.com/article/SB10001424052748703837004575013193075912272.html
47

www.c3health.org

130

See,forexample,http://www.metropolismag.com/html/content_0802/ped/

131

TheabstractforthisarticlealsolistsH.Staatsasanauthor,althoughthepdfonlylistsM.JohannsonandT.Hartig.

132

Warburton,D.E.R.etal.,AsystematicreviewoftheevidenceofCanadasPhysicalActivityGuidelinesforAdults,
IntJBehavNutrPhysAct2010,7:39:http://www.ijbnpa.org/content/pdf/14795868739.pdf

48

www.c3health.org