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bupa 2012

T h e h e a lT h b e n e f i T s o f wa l k i n g for people and The environmenT

geT walking
Care homes Cash plans dental insurance health analytics health assessments health at work services health centres health coaching health information health insurance home healthcare hospitals international health insurance personal medical alarms retirement villages Travel insurance

keep walking

www.bupa.com

ConTenTs

fo r e wo r d
3 4 6 12 18 19 bupas purpose is to help people live longer, healthier, happier lives. every day, thousands of our staff around the world work hard to turn these words into action for our 11 million customers. we support families through illness, guide them to the mosteffective treatments, and care for them as they face the challenges of old age and the diseases that come with it. but our purpose drives us to do more. with an ageing global population and a dramatic increase in the incidence of chronic disease, promoting healthy lifestyles is essential if people are really going to enjoy longer, healthier, happier lives. environmental degradation and the threats from climate change are also widely recognised as some of the greatest threats to global health in the 21st century. healthy people need a healthy planet.

foreword summary physical and mental health benefits of walking why people are walking less Conclusions and recommendations appendix

our aim is To enCourage aT leasT 100,000 people To walk more ofTen and furTher, and To build more walking inTo Their everyday life
we have launched bupa well world as part of our commitment to help people to avoid illness and stay well. bupa well world is a promise to empower 60 million people around the world to make positive changes to their lifestyles to improve both their health and the health of the planet; and to reduce bupas carbon footprint by 20%. it requires bupa to move beyond our immediate customers to create partnerships with governments and other organisations around the world, to work with and support the development of more sustainable communities. in 2011, more than 60,000 people were motivated to get moving in bupas global Challenge. employees and people from local communities took part in 450 events in 15 countries from dancing in bupas new Zealand care homes to cycling in bolivia. in 2012 we are focusing on walking the simplest and most inclusive form of physical activity. our aim is to encourage at least 100,000 people to walk more often and further, and to build more walking into their everyday life. This report, produced with the help of our friends at C3 Collaborating For Health, shows that there are clear health benefits for individuals, communities, businesses, and the planet, if we all walk more and use cars less. Just 15 minutes more a day of brisk walking can have significant health benefits, even adding up to three years to our life expectancy. we also highlight a number of actions that could help promote more walking so that people can enjoy the health benefits that it brings. all of us at bupa will be doing whatever we can to support these programmes and schemes being introduced in the communities that we serve around the world.

Stuart Fletcher Chief executive bupa group

2 3

summary
The world is facing a chronic disease epidemic. The rising rates of non-communicable diseases (nCds), such as heart attacks, stroke and diabetes, are caused in part by the rising trend in obesity rates and declining rates of physical activity. 1 The number of people walking is in decline. walking rates have declined steadily over several decades.2 The proportion of children walking or cycling to school fell from 48% to 13% between 1969 and 2009 in the us, and from 62% to 50% between 1989 and 2004 among primary-school children in the uk. 3 This decline is continuing around the world. for example, rising car ownership in india is discouraging walking and, in China, the reduction in walking has seen an increase in obesity levels among drivers. One in 10 people say they regularly drive short journeys that they could walk.4 a survey of 13 countries by bupa showed that significant numbers of people admit that they still use their cars for journeys which are short enough to walk. Walking just an extra 15 minutes a day can extend your life by up to three years. The health benefits begin to be seen at relatively low levels. a recent study of 400,000 people found that every additional 15 minutes of daily exercise such as brisk walking reduced premature death rates by a further 4%.5 walking can also cut the risks of strokes, heart disease and diabetes. Walking is one of the least expensive and most accessible forms of physical activity.6 it is rarely associated with physical injury and people of all ages can easily take part, including those who have never participated in formal physical exercise.7 Studies have shown that walking has higher levels of stickability than other forms of physical activity. it is convenient and overcomes many of the commonly perceived barriers to physical activity: lack of time, lack of fitness or lack of skill.8 There is also evidence that using pedometers and counting steps helps to maintain greater levels of walking, even among older people and individuals suffering from chronic conditions and disabilities.9 Individuals, businesses, local governments, and health professionals can all act to promote more walking as part of encouraging healthier lifestyles. bupa believes the following five initiatives could help to promote more walking and we will be doing our best to support their introduction in the communities we serve.

R e c o m m e n d at i o n s
1. Primary care doctors should prescribe supported group walking schemes to encourage people to be more active. organised group walking activities provide support for patients, are less intimidating than formal exercise classes in gyms or leisure centres and so enjoy higher retention rates. 2. Businesses of all sizes should introduce workplace schemes that encourage employees to walk more. Corporate schemes are a winwin, with health benefits for the individual (90% of participants in one scheme said their overall wellbeing improved) while organisations report that levels of staff engagement, job satisfaction, and productivity also increase. 3. Parents and teachers should work together to create walking buses to encourage children to walk to school and be more active, lower traffic congestion and reduce pollution around schools. schools using walking buses show an increase in the amount of physical activity taken by children, higher levels of physical activity after school, and better cognitive performance in class. 4. Governments and planners should ensure new developments are designed for people first, to encourage more walking and less car use, and adapt existing areas to increase walkability. studies have shown that the higher the speed and volume of traffic in an area, the lower the levels of walking. a 5% increase in walkability is associated with a 5.5% reduction in vehicleemitted air pollution one of the major health threats for children and older people. 5. Health professionals should provide pedometers to key at risk groups. research has shown that people using pedometers to set daily step goals increase their physical activity by almost 27% and gain health benefits as a result.

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4 5

international obesity Task force and european association for the study of obesity. Obesity in Europe: The Case for Action: http://www.iotf.org/media/euobesity.pdf. hu, p. and T. reuscher, Summary of Travel Trends (2004, washington, dC: u.s. department of Transportation): http://nhts.ornl.gov/2001/pub/stt.pdf. national Center for safe routes to school, How Children get to School: School Travel Patterns from 1969 to 2009 (2011): http://www.saferoutesinfo.org/sites/default/files/resources/ nhTs_school_travel_report_2011_0.pdf, p. 2. killoran, a., et al., Transport Interventions promoting Safe Cycling and Walking: Evidence Briefing (2006): https://nice.org.uk/nicemedia/ pdf/Transport_evidence_briefing_05-07.pdf, Table 1, p. 10. bupa health pulse 2012. wen, C.p. et al., minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study, The Lancet (2011) 378: 9798: 1244 53: http://www.thelancet.com/journals/lancet/article/piis0140-6736%2811%2960749-6/abstract siegel, p.Z., r.m. brackbill and g.w. heath, The epidemiology of walking for exercise: implications for promoting activity among sedentary groups, Am J Public Health (1995) 85: 70610: http://www.ncbi.nlm.nih.gov/pubmed/12972873; eyler, a.a., et al., The epidemiology of walking for physical activity in the united states, Med Sci Sports Exerc (2003) 35: 152936: http://www.ncbi.nlm.nih.gov/pubmed/12972873.

westby, m.d., a health professionals guide to exercise prescription for people with arthritis: a review of aerobic fitness activities, Arthritis Care & Research (2001) 45: 50111: http://onlinelibrary.wiley.com/doi/10.1002/1529-0131%28200112%2945:6%3C501::aid-arT375%3e3.0.Co;2-y/abstract. lamb, s.e., h.p. bartlett, a. ashley and w. bird, Can lay-led walking programmes increase physical activity in middle aged adults? a randomised controlled trial, Journal of Epidemiology and Community Health (2002) 56: 24625: http://jech.bmj.com/content/56/4/246.abstract: J. parkkari, et al., a controlled trial of the health benefits of regular walking on a golf course, American Journal of Medicine (2000) 109: 1028: http://www.ncbi.nlm.nih.gov/pubmed/10967150; Zunft, h.f., et al., perceived benefits and barriers to physical activity in a nationally representative sample in the european union, Public Health Nutrition (1999) 2: 15360: http://journals.cambridge.org/action/displayabstract?fro mpage=online&aid=554588. bravata, d.m. et al. (2007). using pedometers to increase physical activity and improve health: a systematic review, JAMA (2007) 298: 2296304: http://jama.ama-assn.org/ content/298/19/2296.short

15 minuTes a day of brisk walking Can have signifiCanT healTh benefiTs

1 . p h y s i C a l a n d m e n Ta l h e a lT h b e n e f i T s o f wa l k i n g

H e a lt H y wa l k i n g c o m m u n i t y wa l k i n g i n a u s t R a l i a
heart foundation walking (hfw) is australias largest network of free community walking groups, aimed making walking easy and enjoyable, especially for previously inactive people. since 2007, over 37,000 australians have participated in hfw walking groups, led by local volunteer organisers in a range of venues. participants record their number and timing of walks, and are rewarded when they reach milestones, such as their 25th walk. online registration and tools such as google maps are used to delineate walking routes. hfw successfully attracted diverse groups with over 43% of participants aged over 65; 35% are overweight or obese (23%); and 36% on lower incomes. hfw has demonstrated high retention rates of above 80% after two years, and above 70% after three years. evaluation studies show that: 94% of walkers say hfw is important for their physical wellbeing; and 85% perceive it as important for their social and mental wellbeing.

H e a lt H y wa l k i n g n o R d i c wa l k i n g i n ox f o R d s H i R e
oxfordshire County Council, in conjunction with goactive, has established a strong network of nordic walkers. nordic walking uses poles so that the upper body muscles are used as well as the legs which means that while the walker works harder than usual the poles provide support to make it feel easier. The programme was aimed at the over-50s and has now reached over 1,000 people. however, demand from younger adults and families means it is being expanded. There are also moves to work with gps and practice nurses to prescribe nordic walking, as walking with a trained practice nurse can be much less intimidating than for example, suggesting that patients attend exercise classes at a local leisure centre. nordic walking has a number of demonstrated health benefits, which include: reducing levels of depression; lowering blood pressure and resting pulse rate for elderly women; improving mobility for people suffering from chronic conditions such as parkinsons disease; reducing waist, upper arm and hip circumference; and improving sleep patterns. nordic walking expends up to about 20% more energy than regular walking, uses up to 90% of the major skeletal muscles, and relieves pressure on lower body joints.

1 . 1 h o w wa l k i n g C a n h e l p i m p r o v e p h y s i C a l h e a lT h
in the european union around 60% of adults and over 20% of school-age children are overweight or obese around 260 million adults and over 12 million children. globally it is estimated that up to 200 million school-aged children are either overweight, up to 50 million of whom are classified as obese.10 at the same time the world is facing an epidemic of rising rates of non-communicable diseases (nCds), such as heart attacks, stroke and diabetes, caused in part by rising rates of obesity and declining rates of physical activity. increasing numbers of studies support the physical benefits of walking and how it can help in reducing the risk of nCds.11 walking is low-impact, appropriate for all age groups, accessible to almost everyone, and is free. it can also help people to avoid weight gain over the long term.12 even slow walking burns around 114 calories per mile for someone weighing 14 stone (200lb or 91kg).13 recent studies have shown an association between walking and a reduction in premature deaths, ranging from 19%30% depending on the amount of walking.14 a recent study of 400,000 people found that just 15 minutes a day of brisk walking can have significant health benefits, adding up to three years to life expectancy and every additional 15 minutes of daily exercise reduced all-cause death rates by a further 4%.15

Type 2 diabetes Type 2 diabetes is the chronic condition on which the effects of walking have been most researched. it has been shown to: reduce the risk of developing type 2 diabetes; increase fitness in adults with type 2 diabetes; effectively control blood-sugar levels; and reduce deaths from all causes in adults with type 1 or type 2 diabetes: one death per year could be prevented for every 61 people with diabetes who walk at least two hours per week. studies have also shown that walking briskly in groups is as effective as individual fitness programmes for blood-sugar control. sedentary adults with diabetes, are twice as likely to die prematurely as adults with diabetes who walk at least one mile per day.16 Cardiovascular health The impact of walking on reducing the risk of cardiovascular disease (heart disease and stroke) including lowered blood pressure, improved blood cholesterol levels and reduced body mass index has been examined in several studies.17 The studies have demonstrated that walking can: reduce the risk of cardiovascular disease (especially for ischaemic stroke) by 11%;18 decrease body weight, bmi, body fat percentage and waist circumference; lower blood pressure, and increase aerobic capacity by up to 19% (the capacity of an individuals body to transport and use oxygen during exercise); lower levels of the fat that can cause hardening and narrowing of the arteries (triglycerides);19 increase good (hdl) cholesterol;20 and increase muscle endurance.

as little as one hour of walking per week can lower coronary heart disease risk for people (including those who are overweight, smokers, or have high cholesterol). research has also shown potential cost savings from the benefits of walking. if all the inactive adult australians engaged in just one hour of normal walking a day, for five to seven days a week, it could save the countrys economy around aus $419.9 million a year.21 researchers have found that regular walking can reduce pain for people with arthritis by 2432%; and be a moderate, but effective treatment, for lower back pain. importantly, people with chronic obstructive pulmonary disease (Copd) who undertake more walking halve their risk of being admitted as an emergency admission.22

regular walking Can reduCe pain for people wiTh arThriTis by 2432%

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international obesity Taskforce, www.iaso.org/iotf/ The Benefits of Physical Activity on Health and Well-being. A rough estimate: to calculate the number of calories burned walking at mile at casual walking speed (2mph), multiply your weight in pounds by 0.49, and for brisk walking (3.5mph) multiply it by 0.57. http://www.livestrong.com/article/241650-calculate-walking-calories-by-distance/ lee, i.m. and p.J. skerrett, physical activity and all cause mortality: what is the dose-response relation? Medicine and Science in Sports and Exercise (2001) 33: s459-s471: http://www.ncbi.nlm.nih.gov/pubmed/11427772; discussion s493s494; woodcock, J., o.h. franco, n. orsini and i. roberts, non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies, Int J Epidemiology (2011) 40(1): 12138: http://ije.oxfordjournals.org/content/40/1/121.abstract. wen, C.p. et al., minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study, The Lancet (2011) 378: 9798: 1244-53: http://www.thelancet.com/journals/lancet/article/piis0140-6736%2811%2960749-6/abstract yates, T., m. davies, T. gorely, f. bull and k. khunti, effectiveness of a pragmatic education program designed to promote walking activity in individuals with impaired glucose tolerance: a randomized controlled trial, Diabetes Care (2009) 32(8): 140410: http://care.diabetesjournals.org/content/32/8/1404.short

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body mass index is defined as a persons weight in kilograms divided by the square of his/her height in metres: kg/m2 cited in murtagh, e.m., m.h. murphy and J. boone-heinonen, walking the first steps to cardiovascular disease prevention, Curr Opin Cardio. (2010) 25(5): 4906: http://www.ncbi.nlm.nih. gov/pubmed/20625280 gordon-larsen, p., et al.,active commuting and cardiovascular disease risk: the Cardia study. arch intern med. (2009) 169: 121623: http://www.ncbi.nlm.nih.gov/pubmed/19597071 high-density lipoprotein (hdl) Zheng, h., f. ehrlich and J. amin, economic evaluation of the direct health care cost savings resulting from the use of walking interventions to prevent coronary heart disease in australia, Int J Health Care Finance Econ (2010) 10: 187201. http://www.ncbi.nlm.nih.gov/pubmed/19882347 garcia-aymerich, J. et al., risk factors of readmission to hospital for a Copd exacerbation: a prospective study, Thorax (2003) 58(2): 1005: http://www.ncbi.nlm.nih.gov/pubmed/12554887, cited in Cavill, n. and C. foster, Health Benefits of Walking: The Evidence Base (2008): http://nationalcampaignforwalking.net/evidence/

walking has also been shown To relieve sympToms of depression and anxieTy

1 . 2 . h o w wa l k i n g C a n i m p r o v e m e n Ta l h e a lT h
walking has also been shown to relieve symptoms of depression and anxiety. This can improve an individuals quality of life and reduce the medical costs associated with treating these disorders.23 The greatest psychological benefits have been found where people are at the same time able to enjoy specific aspects of the outdoor environment such as green spaces and water features. adults in poor mental health gain greater benefits in rural settings compared to those in good mental health.24 This link between mental health and exercising in green space is also shown in figure 1. studies examining the relationship between walking and mental health, have shown that walking can: reduce physical symptoms of anxiety associated with minor stress; increase self-reported energy levels when older adults set their own walking pace; improve sleep quality; increase psychological well-being for individuals with type 2 diabetes; improve mental functioning of adults aged 6075 when compared to stretching and toning; improve cognitive performance and reduce cognitive decline among older people; and be associated with better cognitive performance for children at school.

F I G u R E 1 : p h y s i C a l a n d m e n Ta l h e a lT h b e n e f i T s o f wa l k i n g i n g r e e n s pa C e

why have green space?

impact on mental health impact on physical health

encourages physical activity

allows us to engage with nature and each other

reduces obesity, blood pressure, cholesterol, etc.

reduces nCd risk factors

improved mental health

less stress, increased cognitive function, etc.

PHYSICAL HEALTH AND ENVIRONMENT

better physical health

better mental health

PHYSICAL HEALTH AND ENVIRONMENT

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atkinson, m. and l. weigand, a review of literature: the mental health benefits of walking and bicycling (2008): http://www.ibpi.usp.pdx.edu/media/mental%20health%20benefits%20 white%20paper.pdf. martnez-gmez, d., et al., active commuting to school and cognitive performance in adolescents: the avena study, arch pediatr adolesc med.( 2011) 165(4): 3005: http://archpedi.ama-assn.org/cgi/content/short/archpediatrics.2010.244 and weuve, J., J.h. kang, et al. physical activity, including walking, and cognitive function in older women, Journal of the american medical association (2004) 292(12): 145461: http://www.ncbi.nlm.nih.gov/pubmed/15383516/ giles-Corti, b., et al. (2005). increasing walking: how important is distance to, attractiveness, and size of public open space? Am J Prev Med. (2005) 28: 16976: http://www.ncbi.nlm.nih.gov/ pubmed/15694525; kaczynski, a.T. and k.a. henderson, environmental correlates of physical activity: a review of evidence about parks and recreation, Leisure Sciences (2007) 29: 31554: http://www.ingentaconnect.com/content/routledg/ulsc/2007/00000029/00000004/art00001; Johansson, m. and T. hartig, psychological benefits of walking: moderation by company and outdoor environment, Applied Psychology: Health and Well-being (2011) 3(3): 26180: http://onlinelibrary.wiley.com/doi/10.1111/j.1758-0854.2011.01051.x/abstract.

JusT 15 minuTes of brisk walking Can add up To Three years To life expeCTanCy

1 . 3 h ow m a n y sT e p s is enough?
physical activity guidelines are usually stated in terms of intensity, duration and frequency. a common guideline is that moderate-intensity physical activity should be performed for a minimum of 30 minutes on five days per week (not necessarily in a single bout of 30 minutes). an easy rule of thumb for gauging levels of physical activity is the talk test: if youre doing moderate-intensity activity you can talk but not sing. if youre doing vigorous-intensity activity, you will not be able to say more than a few words without pausing for breath. 25 with the increasing popularity of pedometers as a means of measuring physical activity in terms of steps per day, it is important to understand how these guidelines translate into number of steps. adults usually walk between 4,000 and 18,000 steps per day, although american adults currently average just 6,500 steps per day.26 Children aged between the ages of six and 12 typically average between 10,000 and 16,000 steps per day, while adolescents only average 8,0009,000 steps per day.27 moderate-intensity walking is at least 100 steps per minute, equivalent to approximately 3,000 steps per half hour.28 The health benefits of physical activity begin to be seen at levels well below that of 30 minutes a day or 10,000 steps a day. a recent study of 400,000 people found that just 15 minutes a day of brisk walking can have significant health benefits, adding up to three years to life expectancy and every additional 15 minutes of daily exercise reduced all-cause death rates by a further 4%.29 advice on how much walking to undertake depends on the age of the individual. a person walking at 3mph (5kph) uses around 30% of their maximum energy consumption when they are 25, but this increases by 10% a decade, so that someone aged 75 walking at 3mph uses up 60% of their maximum energy.30 researchers have also used pedometers to categorise the number of steps by activity level see Table 1 (right).31

TA B L E 1 : n u m b e r o f s T e p s by aC T i v i T y l e v e l Number of steps per day fewer than 2,500 2,5004,999 5,0007,499 7,5009,999 10,00012,499 more than 12,500 Activity level sedentary limited activity low active somewhat active active highly active

u s i n g p e d o m e t e R s : t H e g lo b a l co R p o R at e c H a l l e n g e

1.4 using pedomeTers Can e n C o u r a g e wa l k i n g

a number of studies have shown that using pedometers and counting steps can help to encourage greater walking. The majority of pedometer-based projects result in an increase of 2,0002,500 steps per day; while among older adults and individuals suffering from chronic conditions and disabilities they have shown an average increase of 775 and 2,215 steps per day respectively. a pilot project of lending pedometers out at five Canadian public libraries resulted in more people walking, increased motivation to walk and encouraged goal-setting. lending pedometers through libraries could be an effective, low-cost approach to increasing walking rates. a number of other studies have also shown how using pedometers can encourage more walking, bringing the health benefits associated with it: a study of office workers who average approximately 7,000 steps per day, saw an increase of more than 3,000 steps per day after less than one month of using pedometers to measure their activity levels.32 over a 12-week period, a group of overweight and obese women using pedometers increased their number of steps per day by 36% and showed a significant decrease in blood pressure.

The global Corporate Challenge (www. gettheworldmoving.com ) is an annual, 12-week walking challenge for employees. launched in australia in 2004, it now reaches 55 countries with 180,000 people expected to participate in 2012. workplace team members aim to walk at least 10,000 steps a day in 2011, the average daily step count was 12,725 (about 5 miles/8 kilometres). before the global Corporate Challenge (gCC), only 18% of employees walked 10,000 steps per day, while afterwards 58% did and these results were maintained eight months after programme participation.* analysis carried out by lancaster university in the uk, australias monash university, and the foundation for Chronic disease prevention in the workplace (fdCp) found that: 90% of employees said it improved their overall health and wellbeing; 29% of employees lowered their blood pressure levels; 51% of employees reported reduced stress levels and improved quality of sleep at night, while 71% reported an increase in energy levels; and where weight loss was reported, it averaged 4.5 kg (9.9 lbs). The benefits of the gCC for the workplace include: 75% reported improved office morale; 57% reported better teamwork; 52% reported increased productivity in their day-to-day tasks; 54% claimed they had higher job satisfaction; and 40% fewer sick days were taken by gCC participants.
* williams, d.m. et al., interventions to increase walking behavior, Med Sci Sports Exerc. (2008) 40(7 suppl): s567s573: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmC2694671/?tool=pubmed; ogilvie, d., C.e. foster, h. rothnie, et al., interventions to promote walking: systematic review, bmJ (2007) 334: 12047: http://www.bmj. com/content/334/7605/1204.abstract.

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http://www.cdc.gov/physicalactivity/everyone/measuring/index.html Tudor-locke, C., w.d. Johnson and p.T. katzmarzyk, accelerometer-determined steps per day in us adults, Med Sci Sports Exerc (2009) 41: 138491: http://www.ncbi.nlm.nih.gov/ pubmed/19516163 Tudor-locke, how many steps/day are enough? for children and adolescents. http://www.ijbnpa.org/content/8/1/78 marshall, s., s. levy, C. Tudor-locke, C., et al., Translating physical activity recommendations into a pedometer-based step goal 3,000 steps in 30 minutes, American Journal of Preventive Medicine (2009) 36: 41015: http://www.ajpmonline.org/article/s0749-3797(09)00087-7/abstract wen, C.p. et al., minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study, The Lancet (2011) 378: 9798: 1244 53: http://www.thelancet.com/journals/lancet/article/piis0140-6736%2811%2960749-6/abstract Cavill and foster, Health Benefits of Walking. Tudor-locke, C. and d.r. bassett, how many steps/day are enough? preliminary pedometer indices for public health, Sports Med (2004) 34: 18: http://www.ncbi.nlm.nih.gov/ pubmed/14715035. Chan, C.b., d.a.J. ryan and C. Tudor-locke, health benefits of a pedometer-based physical activity intervention in sedentary workers, Preventative Medicine (2004) 39: 121592: http://www.ncbi.nlm.nih.gov/pubmed/15539058

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2 . w h y p e o p l e a r e wa l k i n g l e s s

TA B L E 2 : b a r r i e r s T o wa l k i n g a n d s o l u T i o n s Physical barriers lack of walking paths/pavements poor quality walking surfaces high-speed traffic lack of attractive places to walk (e.g. green space) Too many steps few places to sit weather solutions improve the number and quality of walking paths requires funding for municipal improvements, and may be helped by pressure from local groups engineering improvements roads that are wide, with safe places to cross, traffic calming measures, and ramps rather than steps improvements to facilities, such as seating in parks if the weather is a barrier, buy appropriate clothing and watch the weather forecast, and walk during the middle of the day when it is cold, and in the early mornings/late evenings in hot climates

although it is the easiest and most accessible form of physical activity, people still identify real or perceived barriers to walking. These can include a perceived lack of time (although in fact people may not realise how little time it takes to walk short distances), lack of safe and attractive places to walk, and adverse weather (either too hot or too cold).33 The physical barriers may significantly increase for people who are socially excluded, such as the elderly, people with disabilities, or parents with small children due to, for example, steps, narrow pavements and lack of places to sit down.34 Table 2 (see next page) sets out the range of physical and perceptual barriers to walking and possible solutions.

2 .1 o v e r C o m i n g T h e b a r r i e r s T o wa l k i n g
a range of initiatives have proved successful in motivating individuals to increase their walking duration, frequency and intensity, helping to overcome the barriers to walking. These initiatives include improving the built environment, as well as specific, targeted interventions to promote more walking often include pedometer use. recent reviews have found that, to be effective, interventions to promote walking should be individually tailored as massmedia campaigns may increase knowledge and awareness, but are unlikely to result in behaviour change. prescriptions to walk 5-to-7 days per week at a moderate pace can be effective, especially if they are group oriented. The social aspect can increase adherence to a walking programme.35 successful walking campaigns are often run by volunteers. for example, the stockholm diabetes prevention programme advertised in local media to recruit volunteers to be leaders of walking groups that lasted up to 11-weeks. many leaders volunteered for multiple campaigns. This method of newspaper recruitment resulted in attracting diverse participants over the 11 weeks, one-third of whom had no previous exercise experience, indicating that volunteer networking can be an effective way of reaching previously underserved populations.36 Table a in the appendix provides links to a variety of global walking programmes and campaigns.

Personal/perceptual barriers unfit/health problems Too tired lack of time lack of family support unsafe: fear of injury, crime (especially after dark) and getting lost boring some cultures may see exercise as inappropriate for women/girls solutions start small even walking for a few minutes is better than nothing, and it is a great way to build up fitness levels walk locally: you will get to know your neighbourhood gradually. use your smartphone map to help to overcome the fear of getting lost Taking more exercise, such as walking, may help improve sleep patterns and give you more, rather than less, energy walking may be quicker than you think for short trips (try a tool such as www.walkit.com to work out how long it will take) or add short walks to your schedule, such as parking further away from the building, or getting off the bus a stop early walking with other people makes the activity social, and helps overcome feeling unsafe or afraid of crime or just bored social media can help to identify people locally who may be interested in setting up walking groups dog-walking can also be a strong motivator

a n e x a m p l e : wa l k i t.c o m
The urban walking route planner walkit.com (available online and as a smartphone app) facilitates walking in over 40 uk cities by plotting the best route (whether the fastest or the least polluted), calculating the time it will take to walk (at slow, medium or fast pace), calories burned, steps taken, and the carbon dioxide emissions offset by walking rather than driving.

sources37

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strazdins, l. and b. loughrey, Too busy: why time is a health and environmental problem, nsw public health bulletin (2007) 18(1112): 21921: http://www.publish.csiro.au/?act=view_ file&file_id=nb07029.pdf mackett, r.l. et al., overcoming the barriers to walking for people who are socially excluded, Centre for Transport studies, university College london: http://discovery.ucl. ac.uk/18721/1/18721.pdf williams, d.m. et al., interventions to increase walking behavior, Med Sci Sports Exerc. (2008) 40(7 suppl): s567s573: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmC2694671/?tool=pubmed; ogilvie, d., C.e. foster, h. rothnie, et al., interventions to promote walking: systematic review, bmJ (2007) 334: 12047: http://www.bmj.com/ content/334/7605/1204.abstract. bjrs, g., l.k. hrberg, J. sydhoff and C.g. ostenson, walking campaign: a model for developing participation in physical activity? experiences from three campaign periods of the stockholm diabetes prevention program (sdpp), Patient Education and Counseling (2001) 42: 914: http://www.ncbi.nlm.nih.gov/pubmed/11080601

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sources include: Thomas, n. et al., barriers to physical activity in patients with diabetes, Postgrad Med J (2004) 80: 28791: http://pmj.bmj.com/content/80/943/287.full.pdf+html; al-kaabi, J., et al., physical activity and reported barriers to activity among type 2 diabetic patients in the united arab emirates, The Review of Diabetic Studies (209) 6: 2718: http://ukpmc.ac.uk/ articles/pmC2836198//reload=0;jsessionid=npgmtl5iyseirndcaryk.2; bicycle and pedestrian information Center website at http://www.walkinginfo.org/why/barriers_physical.cfm and http:// www.walkinginfo.org/why/barriers_personal.cfm; mackett et al., overcoming the barriers, Table 1; kopp, m., et al., acute effects of brisk walking on affect and psychological well-being in individuals with type 2 diabetes, Diabetes Research and Clinical Practice (2012) 95(1): 259: http://www.diabetesresearchclinicalpractice.com/article/s0168-8227(11)00519-5/abstract

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s a f e wa l k i n g t H e i v e R s o n m a l l wa l k e R s
a 450-strong group of senior citizens meets three times per week to walk laps inside a shopping centre iverson mall in hillcrest heights, maryland, usa. mall walking has many benefits to older citizens, such as: alleviating many of the outdoor walking barriers/ dangers such as bad weather, lack of pavements and traffic crossings, lack of public toilets, and fear of crime; being centrally located and easily accessible by public transport; and having bright lighting and even floor surfaces reduces the potential for falls. a pilot study by the university of Calgary of an eight-week mall-walking programme found: over 64% walked more than three times per week; it was the second most popular walking site for people 45 and older; it created a 36.4% increase in leisure-time activity levels; an 18% increase in steps walked over the eight-week period; hip flexibility increased by 11%; and a significant decrease in participants average bmi from 29.1 to 28.5 after eight weeks

s a f e wa l k i n g Q u a l i wa l k i n H o n g ko n g
in hong kong, a campaign entitled healthy exercise for all includes a walking initiative, Qualiwalk. it is aimed at all age groups, and encourages the building of walking into everyday life. The campaign includes Qualiwalk training classes, and a range of online materials to encourage walking (in both Chinese and english). participants are encouraged to have their fitness levels checked by instructors. further information and charts are available at the class and online for people to work out their own fitness levels, and to enable them to work out within the target heartrate zone for moderate exercise. The website also suggests a number of safe walking trails, and ways of increasing regular walking, such as getting off public transport a couple of stops early and walking the rest of the way, or taking part in walking activities with friends.

2.2 less driving, m o r e wa l k i n g

The greater use of cars has resulted in a decrease of walking and corresponded with rising obesity levels around the world. a study in China emphasised this link. in the 1980s, very few people in China owned a motor vehicle. between 1989 and 1997, 14% of Chinese households acquired a motor vehicle. researchers found that, after adjusting for diet, Chinese men who acquired a motor vehicle were twice as likely to become obese, and experienced an average greater weight gain than their non-vehicle-owning peers.38 encouraging people to walk or cycle in place of taking the car or other forms of motor transport, can benefit both the health of individuals and the environment. walking is especially beneficial as there is also clear evidence that long-term walking levels remain stable after the initial increase, suggesting that more people especially obese women will continue walking in the long term than cycling. researchers in atlanta, united states, found that each extra kilometre walked per day was associated with a 4.8% reduction in an individuals probability of becoming obese, whereas each hour spent driving was associated with a 6% increase in an individuals probability of becoming obese.39 reducing motor vehicle use decreases air pollution levels, which can have significant benefits for health. pollution can be particularly harmful to the health of children and older adults, and a strong relationship has been shown between levels of airborne particles, sulphur dioxide and other fossil-fuel emissions, and risk of early death from heart disease and respiratory illnesses such as allergies, asthma and lung cancer. Cars are often used for very short journeys that could be walked. in the united states, cars are used for 55% of trips of one-third of a mile (half a kilometre) in length and 85% of trips that are two-thirds of a mile (1km) in length.40 a journey of one mile (1.6km) emits around 574g of carbon dioxide twice as much as the average emission of 287g of carbon dioxide per mile on longer journeys.

TA B L E 3 : b u pa h e a lT h p u l s e 2 0 1 2 number of people who agreed with the statement: i regularly make short journeys by car that i could walk. COuNTRY australia brazil China egypt great britain hong kong india mexico new Zealand saudi arabia spain Thailand united states bupa health pulse 2012 average MEN 16% 13% 11% 10% 20% 9% 13% 7% 22% 20% 11% 12% 9% 14% WOMEN 20% 12% 11% 8% 16% 10% 15% 9% 21% 8% 10% 11% 10% 13% ALL 18% 13% 11% 9% 18% 9% 14% 8% 22% 15% 11% 11% 9% 13%

research carried out for bupa in 13 countries shows that significant numbers of people admit that they still use their cars for journeys which are short enough to walk (Table 3, above).41 one-in-10 people in spain, the united states, eygpt and China said they used vehicles for trips that could be walked, this figure rises to around one-in-five in great britain, australia, new Zealand, and saudi arabia. a uk study of public transport users found that two-thirds were active enough through their daily routines to meet physical activity recommendations with the majority spending between 20 and 60 minutes per day walking or cycling.42

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bell, a.C., k. ge and b.m. popkin, The road to obesity or the path to prevention: motorized transportation and obesity in China, Obes Res. (2002) 10: 27783: http://www.nature.com/oby/ journal/v10/n4/full/oby200238a.html. frank, l.d., m.a. andresen and T.l. schmid, obesity relationships with community design, physical activity, and time spent in cars, Am J Prev Med (2004) 27: 8796: http://www.ajpmonline. org/article/s0749-3797%2804%2900087-x/abstract. schafer, a., regularities in travel demand: an international perspective, J Transp Stat (2000) december:131: http://ntl.bts.gov/lib/10000/10900/10907/1schafer.pdf, as cited in bassett, d.r., J. pucher, r. buehler, d.l. Thompson and s.e. Crouter, walking, cycling, and obesity rates in europe, north america, and australia, Journal of Physical Activity and Health (2008) 5: 795814: policy.rutgers.edu/faculty/pucher/jpah08.pdf. bupa healthpulse 2012, research carried out by ipsos mori. adams, J., prevalence and socio-demographic correlates of active transport in the uk: analysis of the uk Time use survey 2005, Preventive Medicine (2010) 50(4): 199203: http://www.ncbi.nlm.nih.gov/pubmed/20093137

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62% of people in six indian CiTies say They will move To moTor TransporT unless The walking environmenT improves

2 . 3 s C h o o l s l e a d i n g T h e way
although walking rates in industrialised countries are on the wane, school-based activity programmes such as walk once a week (wow) are gaining popularity. wow is the largest national walk-to-school programme in the united kingdom. since being started by living streets Charity in 2005, it has encouraged more than 300,000 children to walk to school regularly. nearly 2,000 schools in england are already taking part while schools in scotland and wales are also starting to participate. an independent evaluation of the wow programme has found: school walking rates have risen as high as 96%; there is reduced traffic and parking congestion; school activities are redefined as pro-walking for example, assemblies on walking safety and the benefits of walking; an improvement in childrens moods and attention spans; schools taking part have 9% higher walking rates than the national average; and 23% of children surveyed walk with a parent to school (demonstrating that wow spreads the benefits of walking within families). The benefits of wow have been estimated at 2million exceeding the costs of 900,000. The benefits were calculated by including the cost of a car or bus journey if the children had not walked, the percentage of children who participate in wow from each school, the carbon trading value of Co2 saved by walking, and the assumption that most children who walk to school will also walk home. another innovation of the scheme is called park and stride. The scheme uses one-mile car drop-off zones, where children can walk the rest of the way to school, and can also help families in more rural areas participate.

a c t i v e t R a n s p o R t : wa l k i n g scHool bus in new Zealand

since 1999, auckland, new Zealand, has been spearheading walking school buses, in which groups of children walk to and from school together. Just like a real bus, it leaves at a set time (usually around 8:30am), with children joining at stops near their homes. They are supervised by adult volunteers (usually parents) who act as the bus driver. The routes are about 3miles (5km) or 30-minutes long. There are now over 300 walking school bus routes in the region, used by around 5,000 schoolchildren and supported by over 1,800 volunteers. The local transport authority has also become a partner in the project, producing a guide for people establishing a walking school bus. in addition to contributing to the recommended hour a day of physical activity for children, studies have indicated that, among older children (particularly boys), walking to school may also be associated with higher levels of physical activity during the rest of the day (e.g. after school). in addition, there is evidence that children who are physically fit and walk to school have better cognitive performance than those who do not. as well as the health benefits, children learn about road safety and increase their independence; parents have a chance to meet and build a stronger community; while traffic congestion and air pollution from the school run are decreased locally.

2 . 4 b e C o m i n g h e a lT h i e r b y d e s i g n T h e b u i lT environmenT
The population of the worlds cities is currently growing by a million people a week, largely in developing countries, which is putting pressure on open spaces.43 prioritising green space can have environmental and health benefits by providing areas for people to walk and exercise. people who live in areas with high walkability and good access to neighbourhood amenities such as shops and parks are more likely to be active. individuals whose neighbourhoods have high levels of walkability participate in around 30 minutes of more walking or cycling each week. 44 The factors that have a favourable impact on pedestrian activity include: good street lighting and pavements; availability of public transport; street connectivity; pedestrian crossings and traffic calming in residential areas; and reductions in motor vehicle speed.45 studies have also shown that the higher the speed and volume of traffic, the lower the levels of walking.46 promoting neighbourhood walkability can benefit not only the health of pedestrians, but also the broader natural environment. a study in king County, washington, usa, found a 5% increase in walkability was associated with a 5.5% reduction in vehicle emission of air pollutants.47 in india, cities initially built for walking and cycling have become overrun by cars, at the expense of pedestrians. vehicle registrations in india increased from 1.8 million in 1971 to almost 100 million by 2007 and this is predicted to continue to grow by 8%12% per year, with consequential rises in pollution, congestion, and traffic accidents.48 a survey in six indian cities, including Chennai, found that 60% of people see pedestrian facilities as bad or very bad, and 62% will move from walking to motor transport unless the walking environment improves.

sHaping tHe enviRonment t H e at l a n ta b e lt l i n e

The atlanta beltline is a multi-million dollar project to develop a 22-mile loop of trails and pedestrian-friendly development using existing historical railroads that encircle the city of atlanta, georgia, usa. The beltline connects 45 of the citys neighbourhoods, and over 100,000 people live within half a mile of the beltline. The project creates 2,100 acres of new parks and 33 miles of new multi-use trails. it will also develop commercial and residential areas and improve road infrastructure, including pavements. a health impact assessment conducted from 2005 to 2007 to assess the beltlines impact on physical and environmental-health, noted that: approximately 88,000 people (41% of the local population) will have access to the trails; the beltline can help students walk or cycle to schools. Currently, 19 schools are located within half a mile of the beltline transit and trails, and a combination of infrastructure improvements, safety education and enforcement will create an environment that favours walking; and it will ensure safe walking on pavements between communities and public transport.

a number of practical policy steps are being encouraged by organisations such as the Clean air initiative for asian Cities (Cai-asia) Center, which could begin to help to integrate walking into city design these include conducting pedestrian benchmark surveys, developing street-design guidelines, promoting applied research on walkability, and establishing urban metropolitan Transport authorities.

43 44 45 46 47 48

The world comes to town report, www.peopleandplanet.net referencing un-habiTaTs state of the worlds Cities report 2008/9: harmonious Cities. saelens et al., environmental correlates of walking and cycling. saelens, b.e. and s.l. handy, built environment correlates of walking: a review, Med Sci Sports Exerc. (2008) 40: s55066. http://www.ncbi.nlm.nih.gov/pubmed/18562973; saelens, b.e, J.f. sallis and l.d. frank, environmental correlates of walking and cycling: Jacobsen, p.l., f. racioppi and h. rutter, who owns the roads? how motorized traffic discourages walking and bicycling, Inj Prev (2009) 15: 36973: http://injuryprevention.bmj.com/ content/15/6/369.full.html#related-urls frank, l.d., et al., many pathways from land use to health: associations between neighborhood walkability and active transportation, body mass index, and air quality, Journal of the American Planning Association (2007) 72(1): 7587: http://www.tandfonline.com/doi/abs/10.1080/01944360608976725 see Clean air initiative for asian Cities (Cai-asia) Center, Walkability in Indian Cities (2011), p. 7

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a p p e n d i x : m o r e i n f o r m aT i o n

TA B L E A : s e l e C T e d wa l k i n g C a m pa i g n s f r o m a r o u n d T h e w o r l d Initiative be active wa Country australia australia australia australia Canada Canada Canada Canada spain, uk, ireland and sweden uk uk uk uk uk uk uk (scotland) usa usa usa usa and Canada usa and Canada usa, new Zealand etc. global global global 20 countries across europe and middle east Website www.beactive.wa.gov.au www.getactivegoldcoast.com.au www.walk.com.au http://www.walkingwithattitude.com/challenges www.canadawalks.ca/ http://healthyfamiliesbcwalkingchallenge.ca/ http://walks.ca/Cvf/home.html http://www.walkmetrovan.ca http://www.smilesproject.eu/ http://www.ramblers.org.uk/ www.sustrans.org.uk www.walkthewalk.org www.wfh.naturalengland.org.uk/ www.livingstreets.org.uk where2walk.co.uk http://www.pathsforall.org.uk/ www.everybodywalk.org/ http://www.seemommyrun.com/about http://walkforlunch.com/ www.walkamileinhershoes.org/ www.thewalkingsite.com www.walkingschoolbus.org/index.html www.gettheworldmoving.org http://www.imlwalking.org http://www.walk21.com www.walkeurope.org

3. ConClusions and r e C o m m e n d aT i o n s

get active gold Coast walk safely to school day walking with attitude Canada walks! healthy families bC, walking Challenge Canadian volkssport federation walkmetrovan

This report shows there is extensive evidence of the benefits of walking in promoting better mental health and physical wellbeing for people, while also contributing to a more sustainable planet through lowering pollution and fossil fuel use. at the same time there are also barriers whether real or perceived that stop people from walking more and using their cars less often. some of these are down to individual lifestyle choices or circumstances but, increasingly, they reflect a need to change the way our towns and cities are designed to improve pedestrian safety and support walking. however, awareness alone is not enough to encourage individuals to walk more. bupas view is that individuals, businesses, local authorities and health professionals can all take small steps to help promote more walking to support healthier lifestyles and combat the threatened international epidemic of non-communicable diseases such as diabetes, strokes and heart attacks. one size does not fit all any initiative must be adapted to suit the local circumstances and the people at whom it is aimed. bupa is calling for the following actions and we will be doing our best to support them being introduced in our communities. 1. Primary care doctors should prescribe supported group walking schemes to encourage people to be more active. regular walking can help reduce the risk of cardiovascular disease and other chronic disease, while for people with chronic obstructive pulmonary disease (Copd) undertaking more walking halves their risk of being admitted as an emergency admission. organised group walking activities such as nordic walking in the uk, or community walking in australia, provide support for patients, are more enjoyable, and less intimidating than formal exercise classes in gyms or leisure centres. as a consequence, retention rates are high. 2. Businesses of all sizes should introduce workplace schemes that encourage employees to walk more. Corporate challenge schemes are a win-win for both the organisation and the individuals. They result in health benefits for the individual (90% of participants in one

scheme said their overall wellbeing improved) while levels of staff engagement, job satisfaction, and productivity also increase. bupa already runs a number of health promotion schemes for staff including: healthy life plans in the uk to improve our staffs wellbeing by supporting them to set and achieve new health and wellness goals; bupa new Zealands b-fit programme, which is aims to empower our people to make healthy lifestyle choices; and bupa hong kongs Taking Care of ourselves initiative which focuses on emotional as well as physical wellbeing. 3. Parents and teachers should work together to create walking buses and park and stride schemes to encourage children to walk to school and be more active, lower traffic congestion and reduce pollution around schools. reducing car use decreases air pollution levels, which can be particularly harmful to childrens health. schools using walking buses show an increase in the amount of physical activity taken by children, higher levels of physical activity after school and a better cognitive performance. at the same time children learn about road safety while parents working together can build community ties. 4. Governments should ensure all new building developments are designed for people first to encourage more walking and less car use and adapt existing areas to increase walkability. The higher the speed and volume of traffic in an area, the lower the levels of walking. ensuring developments have wider, traffic-free pavements, fewer steps, good lighting and easy connections between homes, shops and public transport encourages greater walking studies have found that a 5% increase in walkability is associated with a 5.5% reduction in vehicle-emitted air pollution. 5. Health professionals should provide pedometers to key at risk groups. research has shown that people using pedometers to set daily step goals increase their physical activity by almost 27%, and decrease bmi and blood pressure. pedometer use also encourages people to maintain higher levels of walking even after the initial programme has ended and so continue to benefit from the resulting healthier lifestyles.

project smiles ramblers sustrans Join the movement walk the walk walking for health walking works (living streets) where 2 walk paths for all every body walk! see mommy run walk for lunch walk a mile in her shoes walking site walking school bus global Corporate Challenge iml walking association walk 21 pedestrian Quality needs

TA B L E B : o n l i n e wa l k i n g T o o l s Tool mapmywalk walkit Description Website

website that allows mapping (and sharing) of walking routes, using http://www.mapmywalk.com/ google maps. it tracks distance and elevation This urban walking route planner plots the best routes for walking in over 40 uk cities, giving a choice of the fastest or the least polluted route, calculating the time it will take to walk, the calories burned, steps taken, and the Co2 emissions offset. walk score gives a walkability score for an area, highlighting local shops, restaurants, open space, schools and commuting time www.walkit.com

walkscore

http://www.walkscore.com/

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