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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 1.Overcomingbarrierstowalking 2.Activetransport 3.Thebuiltenvironment PartIII:Walkingandtheenvironment:awinwin PartIV:Casestudies 1.Introduction 2.Casestudies:walkingprogrammes 3.Casestudies:thebuiltenvironment AppendixI:Selectedliteratureonthehealthbenefitsofwalking Table1a:Benefitsofwalkingfortype2diabetes Table1b:Cardiovascularbenefitsofwalking Table1c:Otherchronicdiseasebenefitsofwalking Table2:Mentalhealthbenefitsofwalking AppendixII:Thewalkingenvironment Table3:Walkingandpedometers Table4:Activetransport Table5a:Selectedwalkingcampaignsfromaroundtheworld Table5b:Onlinewalkingtools AppendixIII:Levelsofevidenceandevidencegaps Endnotes 3 3 4 4 4 5 7 9 11 11 14 16 18 20 20 20 28 31 31 32 33 33 35 35 36 37 38 41 42

C3CollaboratingforHealth Director:ChristineHancock FirstFloor,28MargaretStreet,LondonW1W8RZ,UnitedKingdom Tel+44(0)2076374330;Fax+44(0)2076374336


C3CollaboratingforHealthisaregisteredcharity(no.1135930) andacompanylimitedbyguarantee(no.6941278),registeredinEnglandandWales

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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.

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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
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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
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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.

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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.

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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
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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.

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

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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

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Figure4:Somebarrierstoandenablersofwalking
Barriers Physicalbarriers

Lackofwalkingpaths/pavements Poorqualitywalkingsurfaces Highspeedtraffic Airpollution/trafficfumes Lackofattractiveplacestowalk(e.g.greenspace) Toomanysteps Fewplacestosit Weather Unfit/healthproblems Tootired Lackoftime Lackoffamilysupport Unsafe:fearofinjury,crime(especiallyafterdark)andgettinglost Boring Someculturesmayseeexerciseasinappropriateforwomen/girls

Personal/perceptual barriers

Enablers Physicalenablers 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

Personal/perceptual enablers


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

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. Particularlywherecitiesarerapidlyexpanding(the populationoftheworldscitiesiscurrentlygrowing byamillionpeopleaweek,largelyindeveloping countries),prioritisinggreenspacecanhave environmentalandhealthbenefitscreatingthe lungsofthecity,aswellasprovidingareasfor peopletowalkandexercise,withattendantphysical andmentalhealthbenefits. Thespecificenvironmentalbenefitsofwalkingdo notappeartohavebeenstudiedinpeerreviewed publicationsasubjectforinterestingfuture research. Carsandcarbondioxideemissions Anaveragecaremitsaround287gofcarbondioxide permile.Thisisgreaterforshortjourneys,ascarsuse morefuelwhentheengineiscold:ajourneyof1mile emitsaround574gofcarbondioxide,81andperhaps more,whenfactorssuchaspassengers,luggage,poor maintenance,underinflatedtyresoruseofair conditioningarefactoredin,allofwhichdecreasefuel efficiency.

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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.

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

Table1a:Benefitsofwalkingfortype2diabetes
Specificbenefit Walkingcanlowerbloodglucoselevels afterthewalk(demonstratedreduction 2.2mmol/l).Noeffectafteraperiodof rest Walkingreducedmortalityamongabroad spectrumofadultswithtype1andtype2 diabetes.Onedeathperyearmaybe preventedforevery61peoplewhowalkat leasttwohoursperweek Paper
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 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 Peel,E.,Type2diabetesanddogwalking:patients'longitudinal perspectivesaboutimplementingandsustainingphysical activity,BrJGenPract(2010)60(577):5707: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913737/

Encouragingdogwalkingoranother interestthatmotivatesacommitmentto physicalactivitycanresultinhealth benefits,especiallyforpeoplewholack motivationforotherformsofphysical activity,whowantslowlyincreasetheir physicalactivitylevelsslowly,andwho wanttomaintainphysicalactivitylevels Groupbriskwalkingwasequallyeffective asindividualisedfitnessprogrammesfor bloodsugarcontrolandreductionof cardiovascularriskprofile Adultswithdiabeteswhowalkatleast onemileperdayarelessthanhalfaslikely assedentaryadultswithdiabetestodie fromallcausescombined

Praet,S.F.E.,Briskwalkingcomparedwithanindividualized medicalfitnessprogrammeforpatientswithtype2diabetes:a randomizedcontrolledtrial,Diabetologia(2008)51(5):73646: http://www.springerlink.com/content/41wj6t344777421h/ 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 DosedependentreductionsinCVDriskwith higherwalkingduration,distance,energy expenditureandpace.Associationsappeared tobestrongerforischaemicstrokethanother CVDoutcomessuchascoronaryheartdisease orhaemorrhagicstroke Lighttomoderatephysicalactivity,aslowas onehourofwalkingperweeklowers coronaryheartdiseaseriskforwomen (includingthosewhowereoverweight, smokedorhadhighcholesterol)(menwere notincludedinthisstudy) Walkingisbeneficialforloweringblood pressure.Moreresearchisneededto determinethespecificwalkingintensitythat resultsinthegreatestfallinbloodpressure Walkingincreasedmaximumaerobiccapacity, anddecreasedbodyweight,BMI,bodyfat percentageandrestingdiastolicblood pressureinpreviouslysedentaryadults Walking30minutes/day,5days/week=19% reductionincoronaryheartdiseaserisk ReductioninsystolicanddiastolicBP IncreasedHDL(goodcholesterol) Averageweightlossof1.4kgandwaist circumferencereductionof2.2cm Increasedaerobicandtrunkmuscle endurance Exemplifiedwalkingasahighadherenceform ofphysicalactivity
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Paper
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 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 Note:thisstudywasconductedonacohortofwomenonly

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

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 Authorsconductedareviewof mentalhealthbenefitsofphysical activity(theauthorsfoundonly limitedevidencefromwalkingspecific studies) Leisurephysicalactivity(whichcan includewalking)canreducethe physicalsymptomsandanxiety associatedwithminorstress Shortwalks,whereactivemiddle agedandolderadultssettheirown pace,increaseselfreportedenergy levels Paper
Atkinson,M.andL.Weigand,AReviewofLiterature:TheMentalHealth BenefitsofWalkingandBicycling(2008): http://www.ibpi.usp.pdx.edu/media/Mental%20Health%20Benefits%20 White%20Paper.pdf

Carmack,C.L.,E.Boudreaux,etal.,Aerobicfitnessandleisurephysical activityasmoderatorsofthestressillnessrelation,AnnalsofBehavioral Medicine(1999)21(3):2517: http://www.springerlink.com/content/488406687w963150/ 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) Briskwalkingwasabletoelevate affectiveresponse,resultingin increasedpsychologicalwellbeingfor individualswithtype2diabetes Walkingcanimprovementalfunction ofadultsaged6075whencompared tostretchingandtoning Walkinginrural(vsurban)settings hasagreatercognitiverestorative affectforadultsofpoormental health,comparedtoadultsofgood mentalhealth Walkingorcyclingtoschoolis associatedwithbettercognitive performance Highlevelsofregular,longterm physicalactivitywereassociatedwith bettercognitiveperformanceandless cognitivedeclineamongolderwomen (menwerenotincludedinthisstudy)

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 Kopp,M.,etal.,Acuteeffectsofbriskwalkingonaffectandpsychological wellbeinginindividualswithtype2diabetes,DiabetesResearchand ClinicalPractice(2012)95(1):259: http://www.diabetesresearchclinicalpractice.com/article/S0168 8227(11)005195/abstract Kramer,A.F.,S.Hahn,etal.,Ageing,fitnessandneurocognitivefunction, Nature(1999)400:41819:http://www.biu.ac.il/tvunit/papers/Kramer Vakil_1999_(39).pdf Roe,J.andP.Aspinall,Therestorativebenefitsofwalkinginurbanand ruralsettingsinadultswithgoodandpoormentalhealth,Healthand Place(2011)17(1):10313: http://www.sciencedirect.com/science/article/pii/S1353829210001322

MartnezGmez,D.,etal.,Activecommutingtoschoolandcognitive performanceinadolescents:theAVENAStudy,ArchPediatrAdolesc Med.(2011)165(4):3005:http://archpedi.ama assn.org/cgi/content/short/archpediatrics.2010.244 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 Reviewfoundthatoverallpedometeruse increasesphysicalactivity26.9%over baseline,decreasesBMIanddecreases bloodpressure.Thesechangeswere associatedwithhavingasetstepgoal Useofpedometershasamoderate positiveeffectontheincreaseofphysical activity Averageincreaseof2,000stepsperday Greatesteffectamongwomenwiththe goalof10,000stepsperday Moderatewalking=atleast100 steps/minute Peopleshouldwalkaminimumof3,000 stepsin30minuteson5dayseachweek Threesetsof1,000stepsin10minutes eachdaycanalsobeusedtomeetthe abovegoal Byendof12weekperiod,pedometer groupofoverweightandobesewomen hadincreasedtheirnumberofstepsper dayby36%comparedtotheintervention group Pedometergroupalsodemonstrateda significantdecreaseinsystolicblood pressure Longerpedometerbasedinterventions resultsinthegreatestweightloss.On averageparticipantslost0.05kg/week Pilotprojectoflendingpedometersoutat fivepublicCanadianlibrariesresultedin increasedwalking,increasemotivationto walkandgoalsetting.Preliminary evidencethatlendingpedometersthrough librariesisaneffectivelowcostapproach toincreasingcommunitywalkingrates
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 Ryder,H.,K.Faloon,L.LevesqueandD.McDonald,Partnering withlibrariestopromotewalkingamongcommunitydwelling adults:aKingstonGetsActivepilotpedometerlendingproject, HealthPromotionPractice(2009)10:588: http://hpp.sagepub.com/content/10/4/588.short

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

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

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

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Table4:Activetransport
Specificbenefit Activetransportisinverselyrelatedto obesityrates.Europeanswalkonaverage threetimesasmuchdistanceinayearas Americans. Paper
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 Chillon,P.,K.Evenson,A.VaughnandD.S.Ward,Asystematic reviewofinterventionsforpromotingactivetransporttoschool, InternationalJournalofBehavioralNutritionandPhysicalActivity (2010)8(10):http://www.ijbnpa.org/content/8/1/10

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

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

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

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

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

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Table5a:Selectedwalkingcampaignsfromaroundtheworld
Initiative Country Typeofcampaign Website

i)Countryspecificinitiatives CanadaWalks! Canada Walkablecommunities www.canadawalks.ca/ /activetransport Groups

CanadianVolkssport Canada Federation EveryBodyWalk! USA

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

Resourcesandstories www.everybodywalk.org/ Challenge

HealthyFamiliesBC, Canada WalkingChallenge LivingStreets PathsforAll UK Scotland

http://healthyfamiliesbcwalkingchallenge.ca

Activetransport Access/active transport Activetransport

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

ProjectSMILES

Spain,UK (Irelandand Sweden) UK USA USA

http://www.smilesproject.eu/

Ramblers SeeMommyRun WalkforLunch

Access/groups Socialnetwork Groups Schools

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

http://www.seemommyrun.com/about http://walkforlunch.com/ www.walk.com.au

WalkSafelytoSchool Australia Day WalkingforHealth WalkingSite UK USAand Canada USA UK

Groups Resources

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

WalkingSpree Where2Walk

Workplace Routes

www.walkingspree.com where2walk.co.uk

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ii)Internationalinitiatives Global GlobalCorporate Challenge andtheGlobal ChildrensChallenge GlobalChildrens Challenge IMLWalking Association PedestrianQuality Needs(study) Global Workplace/challenge www.gettheworldmoving.org

Schools/challenge

www.gccjunior.org/

Global

Events

http://www.imlwalking.org

20countries across Europeand theMiddle East Global USA,New Zealandetc. Australia, UK,etc.

Access/activetravel

www.walkeurope.org

Walk21 WalkingSchoolBus

Conferences Schools

http://www.walk21.com

www.walkingschoolbus.org/index.html

Walkingwith Attitude

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). WalkScoregivesawalkabilityscoreforanarea, highlightinglanduse(e.g.localshopsandrestaurants), greenspace,schoolsandcommutingtime(seealsop.16). http://www.walkscore.com/

Walkscore

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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

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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

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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 Otherobservationalstudies(prospectivecohortstudies,casecontrolstudies,case series) Inadequateornodatainpopulationofinterest Anecdotalevidenceorclinicalexperience
Source:132

Level4

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

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Endnotes
Acknowledgements:KatyCooperandChristineHancock(C3CollaboratingforHealth)wouldliketothankRachel SteedandDeniseStevensatMATRIXPublicHealthSolutionsInc.fortheirassistanceinwritingandcompilingthis report.C3alsothanksBupaforfundinganearlierversionofthisreview. InternationalObesityTaskForceandEuropeanAssociationfortheStudyofObesity.ObesityinEurope:TheCasefor Action:http://www.iotf.org/media/euobesity.pdf. 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. 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. 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. 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. Hu,P.andT.Reuscher,SummaryofTravelTrends(2004)(USDepartmentofTransportation): http://nhts.ornl.gov/2001/pub/stt.pdf. NationalCenterforSafeRoutestoSchool,HowChildrengettoSchool:SchoolTravelPatternsfrom1969to2009 (2011):http://www.saferoutesinfo.org/sites/default/files/resources/NHTS_school_travel_report_2011_0.pdf,p.2. Killoran,A.etal.,TransportInterventionspromotingSafeCyclingandWalking:EvidenceBriefing(2006): https://nice.org.uk/nicemedia/pdf/Transport_Evidence_Briefing_0507.pdf,Table1,p.10. C3CollaboratingforHealth,TheBenefitsofPhysicalActivityforHealthandWellbeing(2011): http://www.c3health.org/wpcontent/uploads/2009/09/C3reviewofphysicalactivityandhealthv120110603.pdf Lee,IM.etal.,Effectofphysicalinactivityonmajornoncommunicablediseasesworldwide:ananalysisofburden ofdiseaseandlifeexpectancy,TheLancet(2012)380(9838):21929: http://www.thelancet.com/journals/lancet/article/PIIS01406736%2812%29610319/abstract NHSInformationCentre,HealthSurveyforEngland2008:PhysicalActivityandFitness(2009): http://www.ic.nhs.uk/webfiles/publications/HSE/HSE08/Volume_1_Physical_activity_and_fitness_revised.pdf,p.21.
12 13 14 11 10 9 8 7 6 5 4 3 2 1 *

BritishMedicalAssociation,HealthyTransport,HealthyLives(2012):http://bma.org.uk/transport,Figure14,p.30. Seehttp://www.livestrong.com/article/241650calculatewalkingcaloriesbydistance/

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

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See,forexample,WorldHealthOrganization,GlobalRecommendationsonPhysicalActivityforHealth(WHO,2011): http://whqlibdoc.who.int/publications/2010/9789241599979_eng.pdf Wen,C.P.etal.,Minimumamountofphysicalactivityforreducedmortalityandextendedlifeexpectancy:a prospectivecohortstudy,TheLancet(2011)378:9798:124453: http://www.thelancet.com/journals/lancet/article/PIIS01406736%2811%29607496/abstract Lee,I.M.,Physicalactivityandcancerpreventiondatafromepidemiologicalstudies,MedSciSportsExerc2003, 35:18237:http://www.ncbi.nlm.nih.gov/pubmed/14600545


19 20 18 17

16

Warburtonetal.:Systematicreview,opcit.

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 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 MacmillanCancerSupport,Theimportanceofphysicalactivityforpeoplelivingwithandbeyondcancer:aconcise evidencereview(2012): http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Physicalactivityevidencereview.pdf MacmillanCancerSupport,Physicalactivity:theunreportedwonderdrug, http://www.macmillan.org.uk/Documents/AboutUs/Newsroom/Physicalactivityreport.pdf,p.7.
24 25 26 23 22 21

Macmillan,Aconciseevidencereview,table5,p.10. PartnershipannouncedinMay2012:http://responsibilitydeal.dh.gov.uk/2012/05/23/macmillanandtheramblers/

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 28

SeeAppendix1,Table5inC3,TheBenefitsofPhysicalActivityforHealth.

Atkinson,M.andL.Weigand,Areviewofliterature:thementalhealthbenefitsofwalkingandbicycling(2008): http://www.ibpi.usp.pdx.edu/media/Mental%20Health%20Benefits%20White%20Paper.pdf 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/ 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. MIND,Ecotherapy:TheGreenAgendaforMentalHealth(2007): http://www.mind.org.uk/campaigns_and_issues/report_and_resources/835_ecotherapy
32 33 31 30 29

C3,TheBenefitsofPhysicalActivityforHealth.

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

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 36 37

TudorLockeetal.,Howmanysteps/dayareenough?Foradults. Ibid.

TudorLocke,C.,W.D.JohnsonandP.T.Katzmarzyk,AccelerometerdeterminedstepsperdayinUSadults,MedSci SportsExerc(2009)41:138491:http://www.ncbi.nlm.nih.gov/pubmed/19516163 Chan,C.B.,D.A.J.RyanandC.TudorLocke,Healthbenefitsofapedometerbasedphysicalactivityinterventionin sedentaryworkers,PreventativeMedicine(2004)39:121592:http://www.ncbi.nlm.nih.gov/pubmed/15539058


39 40 41 38

TudorLocke,Howmanysteps/dayareenough?Forolderadults. Ibid.

TudorLocke,Howmanysteps/dayareenough?Forchildrenandadolescents. http://www.ijbnpa.org/content/8/1/78 BassettD.R.,P.L.SchneiderandG.E.Huntington,PhysicalactivityinanOldOrderAmishcommunity,MedSci SportsExerc(2004)36:7985:http://www.ncbi.nlm.nih.gov/pubmed/14707772. TudorLocke,C.andD.R.Bassett,Howmanysteps/dayareenough?Preliminarypedometerindicesforpublic health,SportsMed(2004)34:18:http://www.ncbi.nlm.nih.gov/pubmed/14715035.


44 45 46 47 43 42

CavillandFoster,HealthBenefitsofWalking. Wenetal.,Minimumamountofphysicalactivityforreducedmortalityandextendedlifeexpectancy. Ibid.

Strazdins,L.andB.Loughrey,Toobusy:whytimeisahealthandenvironmentalproblem,NSWPublicHealth Bulletin(2007)18(1112):21921:http://www.publish.csiro.au/?act=view_file&file_id=NB07029.pdf Mackett,R.L.etal.,Overcomingthebarrierstowalkingforpeoplewhoaresociallyexcluded,CentreforTransport Studies,UniversityCollegeLondon:http://discovery.ucl.ac.uk/18721/1/18721.pdf


49 48

TransportforLondon,AttitudestoWalking2011(2011):http://www.tfl.gov.uk/assets/downloads/customer research/attitudestowalking2011report.pdf,table5.2. 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. Bjrs,G.,etal.,Walkingcampaign:amodelfordevelopingparticipationinphysicalactivity?Experiencesfrom threecampaignperiodsoftheStockholmDiabetesPreventionProgram(SDPP),PatientEducationandCounseling (2001)42:914:http://www.ncbi.nlm.nih.gov/pubmed/11080601 TransportforLondon,AttitudestoWalking2008ResearchReport(2008): http://www.tfl.gov.uk/assets/downloads/attitudestowalking2008researchreport.pdf,p.29.
53 54 52 51 50

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

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 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.
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56 57

Ibid.

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 59 60 61

Bassett,etal.,Walking,cycling,andobesityrates. Ibid. Ibid.

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. AscitedinMurtagh,E.M.,M.H.MurphyandJ.BooneHeinonen,Walkingthefirststepstocardiovasculardisease prevention,CurrOpinCardio.(2010)25(5):4906:http://www.ncbi.nlm.nih.gov/pubmed/20625280 GordonLarsen,P.,etal.,Activecommutingandcardiovasculardiseaserisk:theCARDIAstudy.ArchInternMed. (2009)169:121623:http://www.ncbi.nlm.nih.gov/pubmed/19597071


64 65 66 67 68 63 62

Ibid. Ibid. Ibid. Ibid.

Adams,J.,PrevalenceandsociodemographiccorrelatesofactivetransportintheUK:analysisoftheUKTimeUse Survey2005,PreventiveMedicine(2010)50(4):199203:http://www.ncbi.nlm.nih.gov/pubmed/20093137
69 70

Ibid.

Hemmingsson,E.,etal.,Increasedphysicalactivityinabdominallyobesewomenthroughsupportforchanged commutinghabits:arandomizedclinicaltrial,InternationalJournalofObesity(2009)33:64552: http://www.nature.com/ijo/journal/v33/n6/full/ijo200977a.html. 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 73 71

Saelensetal.,Environmentalcorrelatesofwalkingandcycling.

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


74 75

Franketal.,Obesityrelationshipswithcommunitydesign.

Leyden,K.M.,Socialcapitalandthebuiltenvironment:theimportanceofwalkableneighbourhoods,AmJPublic Health(2003)93:154651:http://www.ncbi.nlm.nih.gov/pubmed/12948978 Jacobsen,P.L.,F.RacioppiandH.Rutter,Whoownstheroads?Howmotorizedtrafficdiscourageswalkingand bicycling,InjPrev(2009)15:36973:http://injuryprevention.bmj.com/content/15/6/369.full.html#relatedurls Frank,L.D.,etal.,Manypathwaysfromlandusetohealth:Associationsbetweenneighborhoodwalkabilityand activetransportation,bodymassindex,andairquality,JournaloftheAmericanPlanningAssociation(2007)72(1): 7587:http://www.tandfonline.com/doi/abs/10.1080/01944360608976725 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 78 77 76

http://www.heatwalkingcycling.org/
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45

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


81 82 83

80

Seehttp://walkit.com/goinggreen/ http://www.eea.europa.eu/maps/ozone/whatcanIdo/avoidozonepollution

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 85 86

TransportforLondon,AttitudestoWalking2011,table5.2. SeeCleanAirInitiativeforAsianCities(CAIAsia)Center,WalkabilityinIndianCities(2011),p.7

A.Singh,TransportSectorGreenhouseGasEmissions2007(2010): http://moef.nic.in/downloads/others/Anil%20Singh.pdf
87 88

CAIAsia,WalkabilityinIndianCities,p.8

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


89 90 91

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

FoundationforChronicDiseasePreventionintheWorkplace(FDCP)(2012),FDCPClinicalResearch20052011. PowerpointPresentation.Personalcommunication,DrDavidBatman.
92 93 94 95 96

Ibid. http://www.gccjunior.org/ FDCP,FDCPClinicalResearch20052011,andhttp://www.gettheworldmoving.com/ http://www.walktoschool.org.uk/ourprojects/earlyyearsandprimary/walkonceaweek/

WavehillConsulting,EvaluationoftheWoWSchemeforLivingStreets(2009): http://www.walktoschool.org.uk/files/9612/8443/6107/Wavehill%20%20WoW%20Report%20%20FINAL%20.pdf
97 98 99

Ibid. http://www.heartfoundation.org.au/SiteCollectionDocuments/Ms%20Michelle%20Wilson.pdf http://www.aarp.org/health/healthyliving/info092011/mallwalkersslideshow.html

CulosReed,S.N.etal.,Mallwalkingasaphysicalactivityoption:resultsofapilotproject,CanadianJournalon Aging(2008)27:817:http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6626384 Forfurtherinformation,seehttp://nordicwalking.co.uk/?page=about_nordic_walking&c=24.Amongother projects,StMarysUniversityiscurrentlyrunningastudytocomparethehealthbenefitsofwalkingandNordic Walking,butthishasnotyetbeencompleted.


102 103 101

100

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

Mikalacki,M.,N.CokoriloandR.Katiae,EffectofNordicwalkingonfunctionalabilityandbloodpressureinelderly women,CollAnthropol.(2011)35(3):88994:http://nordicwalking.co.uk/?page=about_nordic_walking&c=24 Reuter,S.etal.,Effectsofaflexibilityandrelaxationprogramme,walking,andNordicWalkingonParkinson's Disease,JournalofAgingResearch(2011):http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3095265/ 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= Knowles,A.M.etal.,ApilotstudyexaminingthehealthbenefitsofNordicWalkinginsedentaryadults,Journalof SportandHealthResearch(2012)4(1):4556Lhttp://nrl.northumbria.ac.uk/5354/
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106 105 104

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


108

107

Aucklandtransport,Walkingschoolbus:http://www.aucklandtransport.govt.nz/movingaround/schooltravel plans/WalkingSchoolBus/Pages/default.aspx
109 110

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

Mendoza,J.A.etal.,Thewalkingschoolbusandchildren'sphysicalactivity:apilotclusterrandomizedcontrolled trial,Pediatrics(2011)128(3):e537e544:http://pediatrics.aappublications.org/content/128/3/e537.abstract. 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. CaliforniaDepartmentofEducation,AStudyoftheRelationshipbetweenPhysicalFitnessandAcademic AchievementinCaliforniausing2004TestResults(2005): http://www.cde.ca.gov/ta/tg/pf/documents/2004pftresults.doc:Therewasastrongpositiverelationshipbetween physicalfitnessandacademicachievement.Therelationshipbetweenfitnessandachievementwasstrongerfor femalesthanformalesandstrongerforhigherSESstudentsthanforlowerSESstudents.Note,however,thatthe resultsdonotindicatecausality. Forexample,MartnezGmez,D.etal.,Activecommutingtoschoolandcognitiveperformanceinadolescents: theAVENAStudy,ArchPediatrAdolescMed.(2011)165(4):3005:http://archpedi.ama assn.org/cgi/content/short/archpediatrics.2010.244 Moodie,M.etal.,CosteffectivenessofactivetransportforprimaryschoolchildrenWalkingSchoolBus program,IntJBehavNutrPhysAct(2009)6:63:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758827/.
115 116 117 114 113 112 111

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

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


119 120 121 122 123 124 125 118

Sarmientoetal.,TheCiclovaRecreativa. Citedinibid.,p.S176. Citedinibid.,p.S177. Citedinibid.,p.S177. Ibid. AtlantaBeltlineInc.andTheAtlantaBeltlinePartnership,AtlantaBeltline:http://beltline.org/

Ross,C.L.etal.,HealthimpactassessmentoftheAtlantaBeltline,AmericanJournalofPreventativeMedicine (2012)42(3):20313:http://www.ajpmonline.org/article/S07493797%2811%29009093/fulltext Ross,C.L.,AtlantaBeltlineHealthImpactAssessment(2007): http://www.healthimpactproject.org/resources/document/AtlantaBeltline.pdf Ross,C.L.,etal.,HealthimpactassessmentoftheAtlantaBeltline,AmJPrevMed(2012)42(3):20213: http://www.healthimpactproject.org/resources/document/Ross2012_AtlantaBeltline.pdf


128 129 127 126

CAIAsia,WalkabilityinIndianCities,p.41.

See,forexample,WallStreetJournal,19January2010: http://online.wsj.com/article/SB10001424052748703837004575013193075912272.html
47 www.c3health.org

130 131 132

See,forexample,http://www.metropolismag.com/html/content_0802/ped/ TheabstractforthisarticlealsolistsH.Staatsasanauthor,althoughthepdfonlylistsM.JohannsonandT.Hartig.

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

48

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