Memorandum by the Health Development Agency
WALKING IN TOWNS AND CITIES
The Health Development Agency (HDA) is a special
health authority with a remit to improve the health of people
in Englandin particular to reduce inequalities in health
between those who are well off and those on low incomes or reliant
on state benefits. The HDA's role is to: gather evidence of what
works, advise on good practice and support all those working to
improve the public's health.
This paper will contribute to the first of the
committee's areas of interest: the contribution of walking to
Urban Renaissance, healthy living and reducing dependency on cars.
Section 5 considers whether the relevant professionals
have the appropriate skills and training, highlights a number
of current activities and presents recommendations for improving
Walking has been described as "the nearest
activity to perfect exercise" (Morris and Hardman, 1997).
It is common to virtually everyone, does not need special skills
or equipment. It is convenient and may be fitted into daily routines.
It can be self-regulated in intensity, duration and frequency
and is inherently safe. The evidence suggests that programmes
that encourage walking and do not require attendance at a facility
are most likely to lead to sustained increases in physical activity.
Promotion of lifestyle physical activity such as walking leads
to similar changes in coronary heart disease risk factors, as
does promoting structured, facility based, interventions.
Walking has the potential to influence health
in a variety of ways. These include the potential benefit of walking
as enjoyment and in providing contact with natural environments,
social contact, economic benefits through promotion of local economies,
exposure to environmental (including road traffic) danger and
the influence of physical activity. This paper will consider the
major benefits of walking as a form of physical activity, an area
for which there is considerable evidence.
The Surgeon-General's report (US Department
of Health and Human Services, 1996) (http://www.cdc.gov/nccdphp/sgr/sgr.htm)
reviewed the evidence on physical activity and health noted that
the benefits of physical activity include:
lower overall mortality;
reduced risk of cardiovascular disease
reduced levels and risk of high blood
improved mood and reductions in symptoms
of depression and anxiety;
decreased risk of cancer of the colon;
lower risk of developing diabetes;
reductions in falls in older adults;
reductions in obesity, and better
improved health-related quality of
One of the most significant aspects of the health
benefit of physical activity is reduction of cardiovascular disease
mortality and morbidity. In particular physically inactive people
have double the risk of coronary heart disease and up to three
times the risk of stroke. Physical activity influences blood pressure.
The current guidelines for management of hypertension issued by
the British Hypertension Society (Ramsay et al, 1999) notes that
the current strategy for prevention of cardiovascular complications
of hypertension, relying on identification and lifelong drug therapy
of a large proportion of the adult population, is unsatisfactory.
A population strategy, based on dietary changes, reductions in
weight and increased physical activity, could prevent the rise
of blood pressure with age. The US Surgeon General's report (US
Department of Health and Human Services, 1996) notes that estimates
put the increased risk of developing hypertension among the least
active groups compared with the most active at around 30 per cent.
Physical activity reduces the likelihood of
developing type II diabetes, the more common form of the disease.
It is also helpful in improving control of the disease. Diabetes
is a very common disease, and its prevalence in the population
is rising. One estimate predicts 50 per cent more people with
type II diabetes in 2010 compared to 2000, an increase from around
1,800,000 to 2,800,000 people in this country (Amos et al, 1997).
Obesity and overweight is an increasing problem
in the UK in recent decades. Currently around 45 per cent of men
and 33 per cent of women are overweight, and 17 per cent and 20
per cent obese (Petersen et al, 1999). Obesity is linked to a
number of health problems, including coronary heart disease and
diabetes. The increase in obesity has occurred at a time when
sedentary lifestyles have increased and energy intake has probably
decreased. Effective strategies to reduce weight generally include
both diet and physical activity changes, and habitual physical
activity is important to keeping weight off after it has been
An academic symposium in 1999 reviewed the evidence
surrounding physical activity and mental health. It produced consensus
statements for six areas relating to mental health and wellbeing
The greatest effects for exercise on mental
health have been found in terms of improved well-being and self-esteem,
and reduction in symptoms of anxiety and depression. Clinically
significant reductions of anxiety and depression have been found
in some groups of people. Mental Health benefits have been noted
following various types and intensities of physical activity and
appear to be due to a combination of physiological and psychological
factors. These include perceived improvements in fitness and health,
an increased sense of mastery and improved self-esteem.
3. THE SIZE
The extent of health benefit of physical activity
varies dependent on what outcomes are examined and the level of
physical activity. A number of authors have attempted to look
at the public health burdens of sedentary living habits, generally
using a population attributable risk (PAR) approach.
Calculation of a PAR for a specific risk factor
relies upon two elements. Firstly, knowledge of the strength of
the association between the risk factor and the outcome, usually
expressed as a relative risk (RR). Secondly, the extent of the
risk factor in the population under scrutiny. Relative risks have
been produced in the literature for a number of causes of death
connected with physical activity. In an attempt at quantification
of the burden of sedentary living in the US, Powell and Blair
(1994) provided estimates of the RR for CHD, colon cancer and
diabetes from the literature for four different activity categories.
These are set out in table 1.
Source: Powell and Blair, 1994.
Using these RRs and estimates of levels of activity in the
US they estimate PARs from sub-optimal levels of physical activity
of 35 per cent for CHD, 32 per cent for colon cancer and 35 per
cent for diabetes. Using more realistic estimates of potential
increases in physical activity they estimate mortality from these
three conditions could be reduced by up to 5-6 per cent, and overall
mortality in the US could be reduced by 1-1.5 per cent.
The RRs derived from the literature for physical inactivity
are similar in magnitude for those of other well established CHD
risk factors such as hyperlipidaemia and smoking. The greater
percentage of the population who are inactive (see below) means
that from a public health standpoint physical activity accounts
for a relatively larger percentage of coronary heart disease.
The British Heart Foundation estimates that around 37 per cent
of CHD deaths under 75 are attributable to inactivity, compared
to 46 per cent to raised cholesterol, 19 per cent to smoking and
13 per cent to hypertension (BP > 140/90) (British Heart Foundation,
4. HOW MUCH
Studies looking at the relationship between the amount of
activity and the benefit (a "dose-response" relationship)
show that the benefit is directly related to the amount of physical
activity rather than showing a threshold level necessary before
benefits accrue. This suggests that any activity is better than
none. However, the current consensus is that substantial health
benefits are associated with an activity level of around 30 minutes
moderate activity on most days of the week. At the same time,
the dose-response relationship shows that further increases in
activity confer additional benefits. This increase in activity
can come from an increase in intensity, frequency or duration
of periods of activity. Moderate activity is that which makes
the individual feel warm and slightly out of breath and is equivalent
to brisk walking. Although a greater intensity of activity may
provide more benefit, moderate activity is more achievable for
most people and the greatest health benefit is achieved by moving
from being sedentary to being moderately active.
5. DO RELEVANT
The appreciation of the importance of walking is increasing
among health professionals. Examples include: the emphasis of
the role of physical activity in preventing coronary heart disease
in the guidance for implementing the preventive aspects of the
National Service Framework produced by the Health Development
Agency (HDA 2000a); the British Heart Forum and the Countryside
Agency Health Walks project; and work by the Health Development
Agency and the DETR to develop information and resources about
the promotion of walking and its benefits for health. Development
of links between Health Improvement Programmes and local transport
plans offer examples and opportunities to develop effective action
on walking locally.
Despite the increased interest in physical activity generally
and walking in particular understanding among health professionals
needs to be addressed. Surveys by the Health Education Authority
suggested that recall of the current guidelines for activity levels
(30 minutes moderate activity on most days of the week) were low
among General Practitioners. Furthermore, there is difficulty
converting this information into a form that is meaningful in
interactions with patients.
Action to encourage walking is appropriate for a range of
agencies. These include agencies responsible for ensuring the
physical infrastructure is conducive to walking and those for
encouraging walking among individuals. A key element will be to
ensure co-ordination between health and local authorities to develop
local plans. In 1999, the Health Education Authority published
a document based on a review of transport and health issues (HEA
1999b). Entitled "Making THE links" it looked at integrating
local sustainable transport, health and environment policies.
The research project also produced a range of recommendations
for different players. Although the project looked at transport
as a whole, walking is a key element of this. It is an important
mode of transport in its own right and is a significant part of
all public transport journeys. The document produced recommendations
for local action. The following section is developed from the
research for the document, a review of Health Improvement Programmes
(HDA 2000b) and evidence provided by the HDA to the Health Select
Committee (HDA 2000c).
We have identified the following challenges for local integration
of transport and health policies.
1. Transport and health professionals have identified
a range of knowledge barriers which inhibit their thinking and
practice in this area. Firstly, and most commonly, there is a
lack of knowledge of the structures and roles within Health Authorities
and Trusts among Local Authority employees and of Local Authority
structures and roles among health professionals. Data sharing
is the other main barrier at the institutional level. Data on
the health impacts of transport, on accidents, levels of walking/cycling,
access and travel survey data to sites and the environmental impacts
of transport are all areas of information which need to be developed
2. Lack of co-terminosity is a major problem for many
Authorities. Joint policies and funding are less likely where
Authorities are not serving the same population groups. The lack
of mechanisms and communications systems between Authorities are
a further barrier. Local Transport Plans and Health Improvement
Programmes provide a real opportunity for joint implementation.
3. The NHS has a "service-focused" view of
health, and transport issues have traditionally been a very low
priority. Work to influence the wider determinants of health (such
as transport) is not seen as core business. In the Local Authority,
there is often a limited view of the role that transport professionals
can play in promoting health. Prevention is well understood in
terms of road safety, but broader work focused on reducing health
inequalities or encouraging physical activity through cycling
and walking is not often perceived as a traditional transport
4. Institutional "inertia" is seen as a problem
in changing some of these attitudes. They are fuelled by a certain
amount of "professional territorialism" and "inside"
terminology which is not shared outside a profession. Leadership
and management support are felt to be crucial, if pilot transport
and health projects are to become mainstream policies.
5. Further work to develop cross governmental initiatives
such as the Schools Travel Advisory Group would both provide national
examples of opportunities and encourage the production of joint,
cross sectoral guidance.
6. Integration of local planning through the development
of Health Improvement Programmes and local transport plans has
improved recently. Further work, particularly around development
of health impact assessment, standard setting and evaluation frameworks
will be needed to ensure the full benefits are achieved. This
needs to be carried out jointly between local and health bodies.
Health Development Agency
8 January 2001
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