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Journal of Physical Activity and Health, (Ahead of Print)
https://doi.org/10.1123/jpah.2021-0245
© 2021 Human Kinetics, Inc. ORIGINAL RESEARCH
First Published Online: Oct. 23, 2021

Associations Between Active Commuting and Cardiovascular

Disease in the United States
James E. Peterman, David R. Bassett Jr, W. Holmes Finch, Matthew P. Harber, Mitchell H. Whaley,
Bradley S. Fleenor, and Leonard A. Kaminsky

Background: Active commuting is inversely related with cardiovascular disease (CVD) risk factors yet associations with CVD
prevalence in the US population are unknown. Methods: Aggregate data from national surveys conducted in 2017 provided
state-level percentages of adults who have/had coronary heart disease, myocardial infarction, and stroke, and who actively
commuted to work. Associations between active commuting and CVD prevalence rates were assessed using Pearson correlations
and generalized additive models controlling for covariates. Results: Significant correlations were observed between active
commuting and all CVD rates (r range = −.31 to −.47; P < .05). The generalized additive model analyses for active commuting
(walking, cycling, or public transport) in all adults found no relationships with CVD rates; however, a significant curvilinear
association was observed for stroke within men. The generalized additive model curves when examining commuting via walking
or cycling in all adults demonstrated nuanced, generally negative linear or curvilinear associations between coronary heart
disease, myocardial infarction, and stroke. Conclusion: Significant negative correlations were observed between active
commuting and prevalence rates of coronary heart disease, myocardial infarction, and stroke. Controlling for covariates
influenced these associations and highlights the need for future research to explore the potential of active commuting modes to
reduce CVD in the United States.

Keywords: active transportation, walking, cycling, travel

According to the American Heart Association, in 2016,
24.3 million adults in the United States had cardiovascular disease
(CVD), excluding hypertension.1 Since 1921, CVD has been the
leading cause of death in the United States with 859,125 deaths
attributed to CVD in 2017, an average of one CVD death every
38 seconds.1–3 Along with mortality, there are other consequences
associated with the substantial number of individuals with CVD.
For 2014–2015, the direct costs associated with CVD in the United
States were estimated at over $213 billion with costs expected to
increase to over $749 billion by 2035.1 In addition to direct health
care costs, CVD is also associated with significant indirect costs
due to decreased productivity as well as reduced quality of life.1
Performing regular physical activity is important for decreas-
ing CVD risk.1,4 However, since at least the 1950s, there has been a
gradual decline in daily levels of physical activity.5,6 In 2017, 54%
of Americans self-reported that they met the recommendations for
aerobic physical activity7; however, previous objective measures of
physical activity suggest the actual percentage is probably sub-
stantially lower.8,9 The declines in physical activity to 2017 levels
have occurred due to decreases within different physical activity
domains.5,6 One domain where this is particularly notable is
transportation, evidenced by the increased prevalence of trips taken
by private automobile.6 The daily miles traveled by automobile has
increased since 19506 and in 2017 an average of 56 minutes per day
was spent sitting in a private motor vehicle.10 This time spent
Peterman and Kaminsky are with the Fisher Institute of Health and Well-Being, Ball
State University, Muncie, IN, USA. Bassett is with the Department of Kinesiology,
Recreation, and Sport Studies, The University of Tennessee, Knoxville, Knoxville,
TN, USA. Finch is with the Department of Educational Psychology, Ball State
University, Muncie, IN, USA. Harber, Whaley, and Fleenor are with the Clinical
Exercise Physiology Laboratory, Ball State University, Muncie, IN, USA. Peterman
(jepeterman@bsu.edu) is corresponding author.
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sedentary in motor vehicles is concerning as it is associated with
greater risk for obesity and other CVD risk factors.11,12
Active commuting, which involves walking, cycling, or taking
public transport, provides an opportunity to promote physical
activity, can help individuals meet physical activity recommenda-
tions,13–16 and is the focus of a recent American Heart Association
Policy Statement.17 Accompanying the increases in physical activ-
ity, active commuting is also associated with improvements to
CVD risk factors. Epidemiological research has found higher levels
of active commuting are associated with a decreased risk for
hypertension,18–21 dyslipidemia,19,20 and chronic diseases, such
as obesity and diabetes.15,18–20,22–24 Intervention research has
also found improvements to CVD risk factors with the uptake
of active commuting. For example, active commuting interventions
have found improvements in blood glucose levels during an oral
glucose tolerance test13 and improvements to cardiorespiratory
fitness.13,25,26 In addition to CVD risk factors, research on popula-
tions outside of the United States has found inverse associations
between active commuting and CVD,27,28 including coronary heart
disease (CHD),29,30 myocardial infarction (MI),31–33 stroke,30,34
and heart failure.35 Of note, much of the previous research on
CVD has focused on Asian30 or European28,29,31,33–35 populations
with little research conducted on US populations.
Associations between active commuting and CVD in the
United States may differ compared with other developed countries
due to differences in infrastructure and active commuting patterns.
For example, US cities have lower residential density and mixed
land use as well as less developed walking and cycling infrastruc-
ture compared with European cities.36,37 These differences from
European cities contribute to the substantially lower percentage of
trips taken by active transportation in the United States.16,22,37
Furthermore, the socioeconomic and demographic characteristics
of individuals who use active transportation differ between the
1
2 Peterman et al
United States and Europe.16 Accordingly, further research is
needed examining potential associations between active commut-
ing and CVD in the United States.
Research on populations from the United States has found an
inverse relationship between active commuting and CVD risk
factors.18–20 While this would suggest a potential inverse associa-
tion between active commuting and CVD prevalence rates in the
United States, research is needed to confirm this assumption. Thus,
the purpose of this study was to compare levels of active commuting
to the prevalence of CHD, MI, and stroke. Using state-level
aggregate data, we hypothesized that higher levels of active com-
muting would be associated with a lower prevalence of CVD rates.
Methods
The present study used state-level aggregate data from 2 different
national surveys with active commuting defined as traveling to the
workplace via walking, cycling, or public transport. State-level
percentiles indicating the prevalence of each measure were used to
examine the association between active commuting and CVD
prevalence rates. The study was considered to be exempt research
by the Ball State University Institutional Research Board due to the
use of aggregate data from surveys that are anonymized and
publicly available.
Data Source—Active Commuting
State-level percentages of active commuting were obtained from
the 2017 American Community Survey (ACS). Previously called
the “long-form census,” the ACS is conducted by the US Census
Bureau and collects information on social, economic, housing, and
demographic characteristics of the United States.38 Using the
Census Bureau Master Address File, randomized housing unit
addresses from each of the counties and county equivalents within
the United States were selected to participate in the ACS.39
Participants respond to the survey primarily online or by returning
paper versions through the mail. For 2017, the ACS was mailed to a
sample of roughly 3.5 million households and there was a com-
bined response rate of 94% for the 50 states.
The ACS collected data on commuting transportation mode
by asking each individual within the household, “How did this
person usually get to work last week?” If more than one mode of
transportation was used by an individual, they were instructed to
select the mode used for most of the distance. State-level data for
the survey were downloaded from the 2017 ACS 1-year estimates
Commuting Characteristics by Sex Subject Table. The state-level
percentages for individuals who walked, cycled, or took public
transport to work were then combined to determine the percentage
of active commuters in each state.
Data Source—CVD Prevalence Rates and Model
Covariates
State-level percentages of CVD and model covariates were ob-
tained from the Centers for Disease Control and Prevention 2017
Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS
collects health-related data from US adults via landline and cellu-
lar telephone interviews. Disproportionate stratified sampling is
used for creating the landline sample while the cellular telephone
sample is randomly generated from a frame of confirmed cellular
area code and prefix combinations.40 For the 2017 BRFSS, the
mean response rate was 45%.41
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The BRFSS collected data on CVD prevalence rate separately
with participants asked if “a doctor, nurse, or other health profes-
sional EVER told you that you had: a heart attack also called
myocardial infarction, angina or coronary heart disease, or stroke.”
The BRFSS data set also includes a calculated variable which
indicated if participants had experienced either an MI or CHD.
Thus, the CVD rates examined in the present study included CHD,
MI, combined CHD/MI, and stroke.
Covariates for the statistical models were also obtained from
the BRFSS to be included in the analyses. The covariates included
smoking status (current smoker vs former smoker/never smoked),
low annual income (≤$35,000 vs >$35,000), poor diet status (de-
fined based on vegetable consumption: over the past 30 d consum-
ing <1 vegetable per day vs consuming ≥1 vegetable per day),
exercise status (no vs yes for participating in physical activities or
exercises outside of the regular job in the past month), and access
to health care coverage (no vs yes for having any kind of health
care coverage). These covariates were measured as the percentage
of the state population having the covariate (eg, percentage of
smokers). State-level ethnicity percentages were also obtained to
be included as covariates (non-Hispanic white, non-Hispanic
black, Hispanic, or other). The online BRFSS Web Enabled
Analysis Tool was used to create custom cross-tabulation tables
and download the state-level percentages of the CVD prevalence
rates and model covariates.
Statistical Analysis
Analyses were performed in R (version 3.6.3; R Core Team,
Vienna, Austria). The linear associations between active commut-
ing and CVD were initially assessed using Pearson product–
moment correlations. Next, the associations between active com-
muting and CVD were explored using both linear and nonlinear
models, when controlling for covariates. The covariates included in
the models were smoking, income, diet, exercise status, access to
health care coverage, and ethnicity. The state-level percentages of
the 3 most common ethnicities in the United States (non-Hispanic
white, non-Hispanic black, and Hispanic) were each included in
the models. Multicollinearity among active commuting and the
covariates was assessed by computing a variance inflation factor.
Multicollinearity was determined not to be a major concern when
the variance inflation factor values were <5.42 Both linear and
curvilinear associations between active commuting and CVD were
then explored using generalized additive models (GAM).43 To
estimate relationships between variables, GAMs employ splines
that identify the degree of nonlinearity that optimizes model fit to
the data. The GAMs were created using the “gam” function in the
“mgcv” R library (version 1.8-21). The maximum number of knots
for the models was set to 5, and the generalized cross-validation
score served to identify the optimal model. The GAMs provided
information regarding the associations between the CVD preva-
lence rates and active commuting as well as each of the covariates.
Pearson correlations and GAMs were initially performed using all
modes of active commuting combined and then using the combined
rates of only walking and cycling to work. Statistical significance
was set at P < .05, 2-tailed.
Results
The averages and ranges of the state-level percentages of CVD,
active commuting, and covariates are provided in Table 1. The
percentages of CVD, active commuting, and covariates for each
 Active Commuting and Cardiovascular Disease 3

Table 1 Averages (and Ranges [Minimum to Maximum]) for the State-Level

Percentages of the Total Adult Population for Cardiovascular Disease, Active
Commuting, and the Generalized Additive Model Covariates
All Men Women
Cardiovascular disease
CHD 4.1 (2.5–7.4) 5.0 (3.3–8.3) 3.3 (1.7–6.6)
MI 4.4 (2.8–7.5) 5.7 (3.4–9) 3.2 (1.6–6.1)
Combined CHD/MI 6.6 (4.4–11.6) 8.1 (5.7–13) 5.2 (2.9–10.2)
Stroke 3.2 (2.1–5.1) 3.2 (1.7–5.1) 3.3 (2–5.8)
Active commuting
Walking, cycling, or public transport 6.4 (1.7–35) 6.6 (1.5–33.4) 6.2 (1.3–36.6)
Walking or cycling 3.4 (1.3–8.2) 3.7 (1.2–8.9) 3.0 (1.1–7.2)
Model covariates
Smoker 17.3 (8.9–26) 19.2 (11–26.9) 15.6 (6.8–26.9)
Low income 37.0 (23.9–52.2) 33.0 (21.8–47.5) 40.9 (26–59.9)
Diet (<1 vegetable per day) 18.1 (12.4–23.9) 20.5 (15.1–26.8) 15.8 (8.9–23.5)
Nonexerciser 26.6 (19.2–34.4) 25.3 (18.2–31.1) 27.7 (20.2–37.6)
No health care access 11.0 (5.3–24.3) 12.7 (7.0–26.8) 9.4 (3.8–21.8)
White, non-Hispanic 71.3 (25.5–94.3) 71.2 (27.5–93.6) 71.4 (23.5–95)
Black, non-Hispanic 10.6 (1–35.4) 10.3 (1.3–33.6) 12.2 (1.3–37.1)
Hispanic 10.4 (0.9–46.3) 10.7 (1–46.6) 10.2 (0.9–46.1)
Abbreviations: CHD, coronary heart disease; MI, myocardial infarction. Note: Data for cardiovascular disease and model
covariates from the 2017 Behavioral Risk Factor Surveillance System and data for active commuting from the 2017 American
Community Survey.

individual state are provided in Supplementary Table S1 (available Table 2 Pearson Correlations Between Active
online). Significant negative correlations were observed between Commuting (Walking, Cycling, or Public Transport)
active commuting and CVD across all adults (r range = −.33 to and CVD Prevalence
−.43; P < .05) (Table 2; Figure 1). Within the sex-specific analy-
ses, significant negative correlations were also observed between All Men Women
active commuting and the prevalence of each CVD rate in men CHD −.33* −.34* −.31*
(r range = −.34 to −.47; P < .05) as well as women (r range = −.31 MI −.40* −.40* −.37*
to −.37; P < .05) (Table 2).
Combined CHD/MI −.37* −.37* −.34*
For the GAM analysis, when examining all adults, no signifi-
cant associations between active commuting and CHD, MI, or Stroke −.43* −.47* −.36*
stroke prevalence rates were observed (Supplementary Table S2 Abbreviations: CVD, cardiovascular disease; CHD, coronary heart disease; MI,
[available online]). Within the sex-specific analyses, the GAM myocardial infarction.
results also found no significant associations, with the exception of *Significant correlation (P < .05).
a significant curvilinear association between active commuting
and stroke prevalence in men (Supplementary Table S2 [available walking and cycling to work and MI, CHD or MI, and stroke
online]). For stroke prevalence in men, the nonlinear curve in prevalence rates (Supplementary Figure S2 [available online] and
Figure 2 demonstrates that with an increasing percentage of active Supplementary Table S3 [available online]). For women, the GAM
commuters, there is an initial decrease in the prevalence of stroke results found no significant associations (Supplementary Table S3
followed by an increase and then a subsequent decrease once the [available online]).
percentage of active commuters exceeds ∼12%.
When examining commuting by walking or cycling, there
were significant negative correlations observed between rates of Discussion
walking and cycling to work and CVD across all adults (r range =
−.42 to −.55; P < .01) (Supplementary Figure S1 [available The present study used state-level aggregate data to examine the
online]). The GAM results when including all adults demonstrated association between active commuting and CVD in the United
significant linear or curvilinear associations between walking and States, where active commuting demographics and infrastructure
cycling to work and CHD, MI, and stroke prevalence rates (Figure 3 differ from other countries.16,36,37 As hypothesized, states with
and Supplementary Table S3 [available online]). The nonlinear higher levels of active commuting had lower levels of CHD, MI,
curves in Figure 3 demonstrate that for all adults when controlling and stroke. These findings were initially observed in the Pearson
for covariates, the prevalence of CHD and stroke remains relatively correlations. However, there are a number of covariates that can
constant until decreasing when the percentage of commuters influence these correlations and may explain some of the outliers
walking or cycling exceeds ∼6%. Within men, the GAM results observed in Figure 1. For example, the states of Utah and West
indicated significant linear or curvilinear associations between Virginia had a similar percentage of active commuters, yet West
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4 Peterman et al

Figure 1 — Scatter plots for the correlations between active commuting (walking, cycling, and public transport) and the different CVD prevalence rates
for combined men and women. Significant correlations (P < .05) were observed for (A) CHD, (B) MI, (C) either CHD or MI, and (D) stroke. AL indicates
Alabama; AK, Alaska; AZ, Arizona; AR, Arkansas; CA, California; CO, Colorado; CHD, coronary heart disease; CVD, cardiovascular disease; CT,
Connecticut; DE, Delaware; FL, Florida; GA, Georgia; HI, Hawaii; ID, Idaho; IL, Illinois; IN, Indiana; IA, Iowa; KA, Kansas; KY, Kentucky; LA,
Louisiana; ME, Maine; MD, Maryland; MA, Massachusetts; MI, myocardial infarction; MI, Michigan; MN, Minnesota; MO, Missouri; MS, Mississippi;
MT, Montana; NC, North Carolina; ND, North Dakota; NE, Nebraska; NH, New Hampshire; NJ, New Jersey; NM, New Mexico; NV, Nevada; NY, New
York; OH, Ohio; OK, Oklahoma; OR, Oregon; PA, Pennsylvania; RI, Rhode Island; SC, South Carolina; SD, South Dakota; TN, Tennessee; TX, Texas;
UT, Utah; VA, Virginia; VT, Vermont; WA, Washington; WI, Wisconsin; WV, West Virginia; WY, Wyoming.

Virginia had a greater prevalence of CHD and MI, which may be

Figure 2 — The GAM curve between active commuting (walking,
cycling, or public transport) and the prevalence rate for stroke in men.
The y-axis represents the value that the GAM predicts for the dependent
variable (the stroke rate), put on a standard normal distribution scale. GAM
indicates generalized additive model.
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due to differences in CVD risk factors (eg, 26% reported smoking
in West Virginia compared with 9% in Utah). To control for these
covariates, GAMs were performed. The GAM analysis for all
adults found no relationships with CVD rates, although a signifi-
cant curvilinear association was observed for stroke rates within
men. Additional analysis examined rates of walking and cycling to
work and the GAMs in these analyses demonstrated nuanced,
generally negative linear or curvilinear associations between CHD,
MI, and stroke. Accordingly, the present study highlights associa-
tions between active commuting and CVD in the United States,
suggesting the need for future research to explore the potential
impact of active commuting to reduce CVD risk.
Previous research on populations within the United States
has shown active commuting is associated with decreased CVD
risk factors, including decreased obesity,18–20 hypertension,18,19
and dyslipidemia.19,20 The present study extends these findings
and shows a significant association between active commuting and
stroke in men, even after controlling for potential covariates.
 Active Commuting and Cardiovascular Disease 5

Figure 3 — The GAM curves between rates of walking and cycling to work and the combined prevalence rates in men and women for (A) CHD,
(B) MI, (C) either CHD or MI, and (D) stroke. The y-axis represents the value that the GAM predicts for the dependent variable (the CVD rates), put on a
standard normal distribution scale. CHD indicates coronary heart disease; CVD, cardiovascular disease; GAM, generalized additive model; MI,
myocardial infarction.

However, in contrast to our hypothesis, other associations between
active commuting and CVD when controlling for covariates were
not significant. These differences between past and present
research may be due to previous research focusing primarily on
walking or cycling to work while the present study also included
the use of public transport when defining active commuting.
Although public transport involves walking or cycling to a transit
stop and can help individuals meet physical activity recommenda-
tions,44 there may be other factors that impact the usage of public
transport that are also related to CVD risk, which were not
accurately controlled for in the GAM analysis. As such, future
research is needed to better understand the impact of public
transport on CVD risk.
When only walking and cycling to work were included in the
analyses, the present study did find that these modes of commuting
were inversely associated with CHD, MI, and stroke as significant
linear and nonlinear associations remained after the inclusion of
covariates in the models. The significant GAM curves (Figure 3)
indicated that increasing levels of commuting by walking or
cycling are initially associated with a steady or slightly decreasing
prevalence of CVD until the percentage exceeded ∼6%, after which
the higher percentages of adults walking or cycling was associated
with a decreased prevalence of CVD. Due to the use of aggregate,
cross-sectional data in the present study, it is not possible to
determine the mechanism behind these associations. However,
intervention research has shown walking or cycling commuting
interventions result in improvements to CVD risk factors13,25,26 and
the established benefits of physical activity for reducing CVD risk4
are a probable explanation for these findings.
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Of note, in the analysis of walking and cycling to work, sex
differences were observed. The GAMs that controlled for covari-
ates found significant associations in men but not in women. This
suggests within the women-specific analyses, the predictive con-
tribution from the other covariates outweighed that from walking or
cycling to work. In some research on populations outside of the
United States, sex differences in the association between active
commuting and CVD prevalence have also been reported.29,35
However, in this previous research, significant associations were
observed in women rather than men.29,35 As the present study
examined cross-sectional associations, the reasons for the observed
sex differences were not investigated and future research is war-
ranted to clarify and explore potential mechanisms behind these
observed sex differences in the association between active com-
muting and CVD prevalence.
The results of the present study add to the growing body of
epidemiological as well as intervention research highlighting the
potential health benefits associated with active commuting.
Accordingly, while physical activity guidelines have traditionally
focused on the promotion of leisure-time physical activity,4 pro-
motion of walking or cycling to work is another viable approach to
help individuals meet recommendations.17 For example, the aver-
age 1-way US commute time by car in 2017 was 25 minutes.10
If one assumes walking or cycling of similar duration for a 5-day
work schedule, the result would be 250 minutes per week, exceed-
ing the recommended goal of 150 minutes per week of aerobic
physical activity.45 Certainly, it is reasonable to suspect that time
spent walking or cycling would be greater than driving over the
same distance, which would only further increase physical activity
6 Peterman et al
levels and potentially lead to greater health improvements. Fur-
thermore, active commuting incorporates physical activity into the
day without the need of designating time specifically for exercise, a
barrier individuals commonly cite for why they are unable to meet
physical activity guidelines.46 Within the United States, however,
there are a variety of barriers to active commuting and many of
these are centered around infrastructure/safety.37 Programs and
infrastructure improvements are therefore needed to increase the
uptake of active commuting.
The strengths of the present study include the use of 2 different
national surveys that represent the US population and their average
commuting habits. However, there were limitations. The study
used aggregated, cross-sectional data for the analysis, which
limited the ability to control for confounding variables or determine
the individual-level causation behind the observed associations.
Furthermore, all surveys used in the present study relied on self-
report, which is susceptible to social desirability biases47 and may
have contributed to error. The use of self-report data also limited
the investigation to cases of nonfatal CVD. In addition, commuting
mode was defined as the mode most commonly used for the
greatest distance traveled in the previous week. Assessing active
commuting in such a way excludes occasional or multimodal active
commuting; thus, it is associated with a lower reported prevalence
of active commuting48 and may have impacted the strength of the
associations. There were also limitations associated with GAM
covariates. The contribution of diet as a risk factor was based on a
simple component of diet (vegetable consumption), primarily due
to the confined questions of the BRFSS. Finally, the present study
did not compare associations across ethnicities, although it did
include the 3 most common US ethnicities as covariates.
In conclusion, significant negative correlations were observed
between active commuting (involving walking, cycling, or public
transport) and prevalence rates of CHD, MI, and stroke. However,
when controlling for covariates, only a significant curvilinear
association between active commuting and stroke was observed
in men. In analyses that included only walking or cycling to work,
significant linear and curvilinear associations were observed
between these modes of commuting and prevalence of CHD,
MI, and stroke. These findings highlight the need for future
research to explore how different active commuting modes may
impact CVD risk in the United States. Further research is also
needed to examine how programs and infrastructure improvements
in the United States could promote active commuting since incor-
porating physical activity into the commute to the workplace
provides an opportunity to reverse the declines in daily physical
activity levels and could reduce the prevalence and costs associated
with CVD.
Acknowledgments
The authors received no funding from an outside source and have no
conflicts of interest to declare.
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