1. Health benefits of walking and cycling
Francesca Racioppi, Christian Schweizer World Health Organization, Regional Office for Europe

2. In this presentation: Physical activity and health: what do we know?
WHO Global Recommendations on Physical activity for Health
Why cycling and walking?

3. Physical activity and health: what do we know?

4. Disability adjusted life years lost due to risk factors in EURO, 2004
Physical inactivity is a leading risk factor for health in Europe, associated to nearly 1 million deaths/year
The combined burden of physical inactivity, diet-related risks (f&veg + cholesterol) and overweight and is similar to that caused by tobacco and alcohol use.
Notes on methods:
For this update, four exposure categories were used: dividing the “sufficiently active” exposure group into “moderately active” and “highly active”. The threshold for “highly active” was physical activity levels equivalent to at least 1 hour per week of vigorous activity and a total energy expenditure of 1600 MET minutes per week.
The theoretical minimum risk exposure distribution was chosen as the whole population being in the “highly active” category to increase consistency of the counterfactual exposure distribution with those for other risk factors and with the definition of theoretical minimum risk (50, 55).
For this update, we used regional prevalence distributions estimated for the CRA 2000 study, with the “sufficiently active” prevalence split into “moderately” and “highly” active using data from the Global Physical Activity Questionnaire (GPAQ), implemented in 28 countries using the WHO Stepwise approach to chronic disease risk factor surveillance (STEPS) approach (56). Age-specific and sex-specific fractions for the “highly active” as a proportion of the “sufficiently active” were estimated for the CRA 2000 subregions based on the subregional average income per capita in 2004, using the GPAQ data for 28 mainly low- and middle-income countries, together with recent data for the USA (50) to fit age-specific and sex-specific linear regressions on the log of gross national income per capita. The regression slopes were quite consistent across age and sex groups.
The revised estimates for mortality and DALYs attributable to physical inactivity for 2004 are higher than the 2000 estimates, with most of the increase being due to mortality among the “inactive” and “insufficiently active” groups assessed against the new referent category. Improved estimates of population distributions of physical activity from the GPAQ and other new survey data sources may result in future revisions to these estimates.
Disability adjusted life years lost due to risk factors in EURO, 2004
Source: Global Health Risks.. Geneva, World Health Organization, 2009 (

5. Inactivity status in the European Region
WHO estimates that in adults :
63% are not reaching the minimum recommended level of physical activity
20% of those are rated as “inactive”
38% are sufficiently/highly active
40% of EU citizens say that they play sport at least once a week
Citizens of Mediterranean and central European countries tend to exercise less
22% of 11-year old girls and 30% of boys report at least one hour of daily moderate to vigorous PA (MVPA)
Please note that 63+38=101% -> they have not rounded to 100% in the Global Health Risk Report unfortunately
Say that you will explain in a moment what “the minimum recommended level of physical activity” means
Definitions WHO global risk report:
Based on: Danaei G, Ding E, Taylor B, Mozaffarian D, Rehm J, Murray CJL et al. Mortality effects of lifestyle, dietary, and metabolic risk factors in the United States: comparative risk assessment. PLoS Medicine, 2009, 6(4):e
Categories of PA were defined using responses regarding PA during the past 30 Days:
Inactive : no moderate or vigorous PA
Low-active: <2.5h/wk of moderate activity or <600 MET mins/week
Moderately active: either >= 2.5h/wk of moderate or >= 1 h of vigorous activity and >= 600 MET mins /week
Highly active: >= 1 h/wk of vigorous activity and >= MET mins/week
According to WHO (and US) reocmmendations: BUT YOU WILL GET TO THAT
Moderately active is 150 minutes to 300 (5 hours) minutes of moderate-intensity activity a week (or 75 to 150 minutes of vigorous-intensity physical activity a week). In scientific terms, this range is approximately equivalent to 500 to 1,000 metabolic equivalent (MET) minutes a week.
A range is necessary because the amount of physical activity necessary to produce health benefits cannot yet be identified with a high degree of precision; this amount varies somewhat by the health benefit. For example, activity of 500 MET-minutes a week results in a substantial reduction in the risk of premature death, but activity of more than 500 MET-minutes a week is necessary to achieve a substantial reduction in the risk of breast cancer.
Global Health Risk Report, World Health Organization, 2009
Eurobarometer Special Eurobarometer 334: Sport and PA
Health Behaviour in School Aged Children 2005/06 Survey

6. Physical inactivity estimated to cause: 21–25% of breast and colon cancer burden 27% of diabetes burden 30% of ischaemic heart disease burden
Magnitude of benefits from reaching minimum recommendations for physical activity
Risk reductions for:
20-30% for CHD and CVD morbidity and mortality
Cancer risks:
30% for colon cancer
20% - 40% for breast cancer
20% for lung cancer
30% for endometrial cancer
20% for ovarian cancer
30% for developing functional limitations
30% for premature all-cause mortality
Not all benefits found have been quantified, ie. Refer back to the overview of health effects first (e.g. risk reduction for overweight not quantified)
Or e.g.:
Does Physical Activity Protect Against the Onset of Depression Disorders or Depression Symptoms?
Conclusions
Population-based, prospective cohort studies provide substantial evidence that regular physical activity protects against the onset of depression symptoms and major depressive disorder.
Does Physical Activity Reduce Symptoms of Depression?
The results of RCTs indicate that participation in physical activity programs reduces depression symptoms in people diagnosed as depressed, healthy adults, and medical patients without psychiatric disorders.
All from US guidelines committee report, 2008
Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, Washington, DC: U.S. Department of Health and Human Services, 2008. 6

7. WHO Global recommendations on physical activity for health

8. Adults aged 18-64
At least 150 minutes of Moderate intensity PA spread throughout the week OR
at least 75 minutes of Vigorous PA spread throughout the week
an equivalent combination of those two
Bouts of at least 10 minutes.

9. WHY CYCLING AND WALKING?

10. Cycling and walking: a great way to meet the recommendations for healthier life!
Do not require making a time slot available for that
“I have no time for physical activity”
Equitable and accessible options
Feasible
10% of trips made in car in Europe cover distances of less than 1 km
more than 30% less than 3 km and 50% of less than 5 km
Most people can do it
Is enjoyable!!!!
Photo courtesy of BASPO

11. The benefits of physical activity come as a “package” and are reflected on overall reduction in total mortality - 1/2
Cycling and effects on total mortality

12. The benefits of physical activity come as a “package” and are reflected on overall reduction in total mortality - 2/2
Meta-analysis results show nearly 30 % reduced all-cause mortality for regular walkers
As basis of HEAT walking updated meta-analysis done, including 9 studies that studied the independent effect of walking by adjusting for other forms of physical activity. 4 of these studies came out in the last 4 years, increasing evidence becoming available
+Hakim, 1998
+Wannamathee, 1998
+Stessman, 2000
Lee, 2000
+Gregg, 2003a
Smith, 2007
Landi, 2008
Stamatakis, 2009
Sun, 2010
Source: Hamer and Chida, 2008 12

13. Tourism and leisure industry Economy, welfare, labour
Walking and cycling: an option that helps different sectors achieving their own goals
Goals
Interest
Reduce emissions of:
air pollutants;
greenhouse gases;
noise
Environment
Health
Reduce congestion
Transport
Reduce road traffic injuries
Transport, Health
Reduce investments in infrastructure for more cars
Improve accessibility and quality of urban life
Complement improvements to vehicles and fuels
Increase physical activity
Promote tourism
Tourism and leisure industry
Creation of new jobs
Economy, welfare, labour

14. What about the balance of of benefits vs. risks?

15. What about the balance of benefits vs. risks? Recent new evidence (1):
Modeled impact both on society and for individuals when 500,000 people would make a transition from car to bicycle for short trips on a daily basis in the Netherlands
increased inhaled air pollution doses: days lost
traffic accidents: 5-9 days lost
increased physical activity: 3-14 months of life gained
societal benefits even larger
positive effects of active transport far greater than risks
For maximum positive effects: promote physical activity, road safety and clean air together!
Source: Johan de Hartog J, Boogaard H, Nijland H, Hoek G.: Do the health benefits of cycling outweigh the risks? Environ Health Perspect Aug;118(8): Epub 2010 Jun 11.

16. What about the balance of benefits vs. risks? Recent new evidence (2):
The health benefits of physical activity from cycling using the bicycle sharing scheme (Bicing) in Barcelona, Spain, were large compared with the risks from inhalation of air pollutants and road traffic incidents.
Source:Rojac-Rueda, D et al „The health risks and benefits of cycling in urban environments compared with car use: health impact assessment study“ BMJ 2011; 343: d4521 doi: /bmj.d4521

17. Active transport as part of policies to reduce greenhouse gases emissions provides important health benefits
Scenarios for urban transport in London
* Health effects attributable to physical activity, air pollution, injuries per million population in 1 year, compared to “business as usual”. Negative numbers indicate a reduction in the disease burden.
The total is not equal to the sum, as it needs to be adjusted for double counting for the effect on cardiovascular diseases.
Source: Woodcock et al – Public health benefits of strategies to reduce greenhouse-gas emissions - :urban land transport – 2009 Lancet published online November 25, 2009

18. Health Dividends from Green Growth
Much greater health gains from shifting to rapid transit/public transport walking and cycling
than from improving fuel and vehicle efficiency
Consider all costs and benefits of Green Growth strategies!

19. Introducing HEAT, the WHO Health Economic Assessment Tool
How much is reduced mortality from regular walking and cycling worth?

20. Integration of health effects in transport assessments: challenges
Complex methodological questions for transport planners:
which health endpoints to include?
form of the relationship between exposure and effect?
activity substitution
which costs to include?
how to calculate costs?
which time lag periods to apply before benefits/costs occur?
 easy to use tools needed!

21. The question
If x people walk/cycle a distance of y kilometers on most days, what is the economic value of the health benefits that occur as a result of the reduction in mortality due to their physical activity? 21

22. The answer

23. The Health Economic Assessment Tool for walking and cycling (HEAT)
Easy tool to calculate the economic value of the health benefits of regular walking and cycling
Recognises importance of economic analysis in transport: benefit-cost ratio is king
Evidence-based, transparent and adaptable
Conservative
New and updated version launched in 2011 at the International Transport Forum in Leipzig

24. 24

25. Results for Moscow Only effects from physical activity Only mortality
No co-benefits considered

26. Use of HEAT worldwide
Austria: currently USD 570 million per year saved due to cycling
City of Pilsen: USD 1.2 million if 2% of population took up regular cycling
Sweden and England: adopted HEAT for cycling as part of official toolbox for the economic assessment of cycling infrastructure
New Zealand: adding cycling and pedestrian facilities to the Auckland Harbour Bridge is worth USD 900,000 per 1000 regular bike commuters
United States: adaptation of tool for the US underway

27. HEAT in Russian
Complete HEAT for walking and cycling website and guide to be available in English, French, German, Spanish and Russian by end 2012
We welcome further offers for translation!

28. Collaborative project
Core group
Sonja Kahlmeier, Nick Cavill, Hywell Dinsdale, Harry Rutter, Thomas Götschi, Charlie Foster, Paul Kelly, Dushy Clarke, Pekka Oja, Richard Fordham, Dave Stone, Francesca Racioppi
Contributors
Lars Bo Andersen, Andy Cope, Mark Fenton, Mark Hamer, Max Herry, I-Min Lee, Brian Martin, Markus Maybach / Christoph Schreyer, Marie Murphy, Gabe Rousseau, Candace Rutt / Tom Schmid, Elin Sandberg/ Mulugeta Yilma, Daniel Sauter, Peter Schantz, Peter Schnohr, Christian Schweizer, Heini Sommer, Jan Sørensen, Gregor Starc, Wanda Wendel Vos, Paul Wilkinson
© WHO Regional Office for Europe, 2011
Need new acknowledgements here
Financially supported by the European Union in the framework of the Health Programme (Grant agreement ). The views expressed herein can in no way be taken to reflect the official opinion of the European Union 28

29. “I thought of that while riding my bicycle.”
Albert Einstein
on the theory of relativity