Select Committee on Environment, Transport and Regional Affairs Memoranda


Memorandum by the Health Development Agency (WTC 34)

WALKING IN TOWNS AND CITIES

1.  BACKGROUND

  The Health Development Agency (HDA) is a special health authority with a remit to improve the health of people in England—in 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 practice.

2.  CONTRIBUTION OF WALKING TO HEALTHY LIVING

  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 mortality;

    —  reduced levels and risk of high blood pressure;

    —  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 weight control;

    —  improved health-related quality of life.

  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 lost.

  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 (HEA, 1999a).

  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 OF THE BENEFIT OF PHYSICAL ACTIVITY

  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.

   
RR
Activity level
CHD
Colon cancer
Diabetes
Sedentary
2.0
1.8
1.8
Irregular
1.5
1.5
1.6
Regular
1.1
1.1
1.3
Vigorous
1.0
1.0
1.0

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, 2000).

4.  HOW MUCH PHYSICAL ACTIVITY IS NEEDED?

  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 PROFESSIONALS HAVE THE APPROPRIATE SKILLS AND TRAINING?

  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).

Recommendations

  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 and exchanged.

  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 role.

  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

REFERENCES

  Amos A, McCarty DL, Zimmet P, 1997. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabetic Medicine 14: S1-S85.

  British Heart Foundation 2000 Coronary heart disease statistics. London: BHF.

  HDA 2000a. Coronary heart disease: guidance for implementing the preventive aspects of the National Service Framework. London: HDA

  HDA 2000b. A National Review and Analysis of Health Improvement Programmes 1999-2000. London HDA.

  HDA 2000c. HDA's evidence to the health select committee's enquiry into public health. London: HDA.

  HEA 1999a. Physical activity and mental health: National consensus statements and guidelines for practice. London: HEA.

  HEA 1999b. Making THE links: integrating sustainable transport, health and environmental policies: a guide for local authorities and health authorities. London: HEA.

  Morris JN, Hardman AE 1997. Walking to health. Sports Medicine 23, 306-332. Petersen S, Mockford C, Rayner M 1999. Coronary heart disease statistics. London: BHF.

  Powell KE, Blair SN 1994. The public health burdens of sedentary living habits: theoretical but realistic estimates. Medicine and science in sports and exercise, 26, 851-856.

  Ramsay LE, Williams B, Johnston GD, MacGregor GA, Poston L, Potter, JF, Poulter NR, Russell G, 1999 Guidelines for management of hypertension: report of the third working party of the British Hypertension Society. Journal of Human Hypertension 13; 569-592.

  US Department of Health and Human Services, 1996. Physical activity and health: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention.


 
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