Impact of Physical Activity on Obesity and Health

Overview:
The Journal of the American Medical Association reports that in 2003-2004, 17.1% of US children and adolescents were overweight, with the rates continuing to increase. These children are at an increased risk for developing health problems such as heart disease, diabetes, cancer, and hypertension. Activity levels for many children have declined because of a built environment that is unsafe for walking and bicycling, the low percentage of children who take physical education in school, and the popularity of sedentary leisure-time activities.

Using Safe Routes to School as way to create environment, policy, and behavioral changes is one way to increase physical activity and promote the health of both children and adults. This section highlights academic literature that speaks to the overall health benefits of physical activity, specifically walking to and from school, as well as the impact that increased physical activity opportunities have on current obesity and health trends in the US. The implications of this research are valuable as they guide policy-makers and practitioners to implement effective strategies for improving physical activity opportunities and overall health.

Research Highlights:
• Walking and bicycling are far more common in European countries than in the United States, Australia, and Canada, where active transportation is inversely related to obesity (Bassett, et al., 2008).

• Research demonstrates that children who walk or bicycle to school have higher daily levels of physical activity and better cardiovascular fitness than do children who do not actively commute to school (Davison, et al., 2008).

• Two small lifestyle changes in diet (to eliminate 100 kcal/day) and physical activity (to walk an additional 2000 steps/day) could be useful for addressing childhood obesity by preventing excess weight gain in families (Hill, et al., 2007).

• Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap resulting in excessive weight gain (Wang, et al., 2006).

• In one study, researchers report that 100% of the students that walk both to and from school accumulate an average of 60 or more minutes of MVPA on weekdays (Alexander, et al., 2005)

• One study suggests that a 5% increase in neighborhood walkability is associated with 32.1% more minutes devoted to physically active travel and about one-quarter point lower BMI (0.228) (Frank, et al., 2006).

Academic Research Articles and Findings:

“Changes in State-Specific Childhood Obesity and Overweight Prevalence in the United States From 2003 to 2007” (2010)
• This study examines changes in state-specific obesity and overweight prevalence among US children and adolescents between 2003 and 2007 through a cross-sectional analysis of National Survey of Children’s Health data.
• Results indicate that in 2007, 16.4% of US children were obese and 31.6% were overweight.
• Mississippi has the highest prevalence of childhood obesity and overweight (21.9%) and Oregon has the lowest (9.6%).
• Between 2003 and 2007obesity prevalence increased by 10% for all US children.
• Individual, household, and neighborhood social and built environmental characteristics accounted for 45% and 42% of the state variance in childhood obesity and overweight.
• Researchers suggest that substantial geographic disparities in childhood obesity and overweight exist, indicating potential for considerable reduction in US childhood obesity.

Singh, Gopal K., Kogan, Michael, D., and van Dyck, Peter C. “Changes in State-Specific Childhood Obesity and Overweight Prevalence in the United States From 2003 to 2007.” Archives of Pediatrics and Adolescent Medicine. 164.7 (2010).

“The Association Between Community Physical Activity Settings and Youth Physical Activity, Obesity and Body Mass Index” (2010)
• This study examines the association between the level of physical activity (PA), friendliness of the built environment and adolescent physical activity and body mass index using a national sample of youth and data collected from the communities where they reside.
• Increased levels of area deprivation were associated with decreased physical activity and higher weight.
• A greater number of commercial physical activity facilities was associated with increased physical activity.
• More compact communities were associated with lower weight and less sports participation.
• Researchers suggest that it is important to explore these associations to help guide future development patterns and land use policies to create more active neighborhoods.

Slater, Sandy J., Ewing, Reid, Powell, Lisa M., Chaloupka, Frank J., Johnston, Lloyd D., and O’Malley, Patrick M. “The Association Between Community Physical Activity Settings and Youth Physical Activity, Obesity, and Body Mass Index. Journal of Adolescent Health. (2010): 1-8.

Neighborhood Racial Isolation, Disorder and Obesity” (2010)
• Recent research suggests that racial residential segregation may be detrimental to health.
• This study investigates the influence of neighborhood racial isolation on obesity and considers the role of neighborhood disorder as a mediator in this relationship.
• For the city of Philadelphia, researchers find that residence in a neighborhood with high black racial isolation is associated with a higher body mass index and higher odds of obesity among women, but not men, highlighting important sex differences in the influence of neighborhood structure on health.
• The influence of high racial isolation on women’s weight status is mediated, in part, by the physically disordered nature of such neighborhoods. Disorder of a more social nature (as measured by incident crime) is not associated with weight status.

Chang, Virginia W., Hillier, Amy E., and Mehta, Neil K. “Neighborhood Racial Isolation, Disorder and Obesity.” Social Forces. 87.4 (2009): 2063-2092.

“Aerobic Fitness and Mode of Travel to School in English Schoolchildren” (2010)
• This purpose of this study was to determine whether a positive association exists between active travel and aerobic fitness in English schoolchildren.
• Researchers collected data on mass and structure, BMI, and aerobic fitness (through 20-m shuttle run) on participants, school children ages 10-15.9 years old.
• Mode of travel to school and physical activity was assessed by a questionnaire.
• Results indicate that walking was the most common travel mode to school (50%), and cycling was the least frequent (8%).
• Walkers and cyclists were significantly fitter than passive transport users.
• No association was observed between travel mode and BMI
• Researchers suggest that this study supports existing literature that suggests that those who walk and cycle to school may be at a reduced risk for developing chronic diseases in adulthood.

Voss, Christine and Sandercock, Gavin. “Aerobic Fitness and Mode of Travel to School in English Schoolchildren.” Medicine and Science in Sports and Exercise. 42.2 (2010): 281-287.

“Mapping the Walk to School Using Accelerometry Combined with a Global Positioning System” (2010)
• This study combined accelerometer and GPS data to investigate the level and location of physical activity in children walking to school.
• Mean accelerometer counts per minute before school were 43% higher in children who walked to school than those traveling by car.
• 11% of daily moderate to vigorous physical activity occurred during the walk to school.
• Total activity during the walk to school was twice that in the playground, with the journey to school contributing three times as much moderate to vigorous physical activity as time in the playground.

Cooper, Ashley R., Page, Angie S., Wheeler, Benedict W., Griew, Pippa, Davis, Laura, Hillsdon, Melvyn, and Jago, Russell. American Journal of Preventive Medicine. 38.2 (2010): 178-183.

“Physical Activity: Health Outcomes and Importance for Public Health Policy” (2009)
• This brief summary of evidence of benefits from being physically active reveals that national surveillance data indicate a substantial portion of youth and adults in the United States do not meet recommendations.
• Available data indicate that various race and ethnic minorities, persons of very low income and those with mental or physical disabilities have even more to gain from increases in physical activity as they are among the least active in the population, but have limited access to needed resources.
• To realize the health-promoting benefits of increased activity by at-risk populations, major policies and programs need implementing that ensure:

the population at-large is educated about the health risks of inactivity and how best to reduce these risks,
lifestyle changes, including increases in physical activity, for chronic disease prevention and health promotion be given higher priority and increased funding by the US health care system,
schools at all levels enhance opportunities for students to be appropriately active,
employers develop ways to engineer physical activity back into the work day of sedentary employees while not decreasing worker productivity, and
the built environment throughout the community is made activity friendly for a greater portion of the population.

Haskell, William L., Blair, Steven N., and Hill, James O. “Physical Activity: Health outcomes and importance for public health policy.” American Journal of Preventive Medicine. 49 (2009): 280-282.

“Physical Activity Across the Curriculum (PAAC): A Randomized Controlled Trial to Promote Physical Activity and Diminish Overweight and Obesity in Elementary School Children” (2009)
• Physical Activity Across the Curriculum (PAAC) was a three-year cluster randomized controlled trial to promote physical activity and diminish increases in overweight and obesity in elementary school children.
• PAAC promoted 90 minutes/week of moderate to vigorous intensity physically active academic lessons delivered by classroom teachers.
• Results indicated that the PAAC approach may promote daily physical activity and academic achievement in elementary school children.
• 75 minutes of PAAC curriculum activities may attenuate increases in body mass index.

Donnelly, Joseph E., Greene, Jerry L., Gibson, Cheryl A., Smith, Bryan K., Washburn, Richard A., Sullivan, Debra K., DuBose, Katrina, Mayo, Matthew S., Schmelzle, Kristin H., Ryan, Joseph J., Jacobsen, Dennis J. and Williams, Shannon L. “Physical Activity Across the Curriculum (PAAC): A randomized controlled trial to promote physical activity and diminish overweight and obesity in elementary school children.” American Journal of Preventive Medicine. 49 (2009): 336-341.

“Active Living For Rural Youth: Addressing Physical Inactivity For Rural Communities” (2009)
• Active living has four domains: transportation, recreation, occupation, and household.
• Active living research incorporates an ecological approach to promoting physical activity by recognizing that individual behavior, social environments, physical environments, and policies contribute to behavior change.
• This study tests and refines a conceptual model between the individual and the environment in rural communities.
• Findings reveal a host of “predisposing” and “enabling” factors, including sociodemographic, environmental, policy, and programmatic elements that extend across the fours domains of active living.
• Researchers suggest that efforts to combat childhood obesity must consider rural residents a priority population because of the unique challenges that rural communities face.

Yousefian, A, Ziller, E, Swartz, J, and Hartley, D. “Active living for rural youth: addressing physical inactivity in rural communities.” Journal of Public Health Management and Practice. 15.3 (2009): 223-231.

“Research Brief: Walking and Biking to School, Physical Activity and Health Outcomes” (2009)
• This brief summarizes research on active transport to school, physical activity levels and health outcomes.
• It also explores the factors that influence walking and biking to school, including the impact of SRTS programs.

McMillan, TE. “Research Brief: Walking and Biking to School, Physical Activity and Health Outcomes.” Active Living Research. (2009): available at http://www.activelivingresearch.org/files/ALR_Brief_ActiveTransport.pdf

“Research Brief: Active Transportation, Making the link from Transportation to Physical Activity and Obesity” (2009)
• This research brief presents an overview of findings demonstrating the potential impact of infrastructure investments and other transportation programs on walking and bicycling for transportation, and on related health outcomes.
• It also focuses on public transit, greenways and trails, school-related infrastructure and programs, pedestrian and bicycle facilities, and efforts to manage car traffic.

Rodriquez, DA. “Research Brief: Active Transportation, Making the link from Transportation to Physical Activity and Obesity.” Active Living Research. (2009): available at http://www.activelivingresearch.org/files/ALR_Brief_ActiveTransportation.pdf

“Creating Physical Activity-Promoting Community Environments: Time for a breakthrough” (2009)
• This article highlights Safe Routes to School as a promising strategy for increasing youth physical activity and improving health equity.
• Joint use agreements to unlock school playgrounds after school and on weekends is another highlighted approach to promote physical activity, especially in poor communities and communities without access to other recreation facilities.
• Finally, this article reminds readers that The Recovery Act includes more than $45.5 billion to employ out of work Americans to improve public transit systems, making our communities more walkable and bikable and investing in projects that reduce reliance on automobiles – the source of close to 30% of total greenhouse gas emissions.

Solomon, Loel S., Standish, Marion B., and Orleans, C. Tracy. “Creating Physical Activity-Promoting Community Environments: Time for a breakthrough.” Preventive Medicine. 49.4 (2009): 334-335.

“Recommended Community Strategies and Measurements to Prevent Obesity in the United States” (2009)
• The CDC initiated the Common Community Measures for Obesity Prevention Project (the Measures Project) to identify and recommend a set of obesity prevention strategies and corresponding suggested measurements that local governments and communities can use to plan, implement, and monitor initiatives to prevent obesity.
• Strategies 17-23 suggest community improvements that are addressed by Safe Routes to School. These recommendations suggest that communities should:
- enhance infrastructure supporting bicycling
- enhance infrastructure supporting walking
- support locating schools within easy walking distance of residential areas
- improve access to public transportation
- zone for mixed-land use development
- enhance personal safety in areas where persons are or could be physically active
- enhance traffic safety where persons are or could be physically active

Khan, Laura Kettel, Sobush, Kathleen, Keener, Dana, Goodman, Kenneth, Lowry, Amy, Kazietek, Jakub, and Zaro, Susan. “Recommended Community Strategies and Measurements to Prevent Obesity in the United States.” Center for Disease Control. (2009): 58(RR07); 1-26.

“Transit and Health: Mode of Transport, Employer-Sponsored Public Transit Pass Programs, and Physical Activity” (2009)
• This study analyzes data from a sample of 4,156 metropolitan Atlanta residents who were interviewed by telephone and kept two-day travel diaries.
• 10.9% of the sample reported walking for transportation, 2.6% did enough to meet the recommended 30 minutes per day.
• Participants who took more trips by any mode are more likely to do some walking, additional trips by transit were significantly associated with greater odds of walking.
• On average, transit users walked 1.72 km per day, but those who did not use transit walked only 0.16 km per day.
• This study implies that use of transit increases distance walked per day.

Lachapelle, Ugo and Frank, Lawrence D. “Transit and Health: Mode of Transport, Employer-Sponsored Public Transit Pass Programs, and Physical Activity.” Journal of Public Health Policy. 30 (2009): S73-S94.

“Bicycling for Transportation and Health: The Role of Infrastructure” (2009)
• This paper provides insight on whether bicycling for everyday travel can help US adults meet the recommended levels of physical activity and what role public infrastructure may play in encouraging this activity.
• 60% of the participants rode for more than 150 minutes per week during the study and nearly all of the bicycling was for utilitarian purposes, not exercise.
• A disproportionate share of the bicycling occurred on streets with bicycle lanes, separate paths, or bicycle boulevards.
• The study suggests that well-connected neighborhood streets and a network of bicycle-specific infrastructure encourages more bicycling among adults.

Dill, Jennifer. “Bicycling for Transportation and Health: The Role of Infrastructure”. Journal of Public Health Policy. 30 (2009): S95–S110.

“Active School Transport. Physical Activity Levels and Body Weight of Children and Youth: A Systematic Review” (2009)
• This article reviews 13 studies that explore whether children who actively commute to school have increased physical activity levels or a healthier body weight.
• Studies demonstrate that children who actively commute to school accumulate more physical activity then passive commuters.
• Evidence for the impact of active school transport promoting healthy body weights for children and youth requires more attention.

Faulkner,Guy E,J,. Buliung, Ron M., Flora, Parminder K. and Fusco, Caroline. “Active School Transport, Physical Activity Levels and Body Weight of Children and youth: A Systematic Review.” Preventive Medicine. 48 (2009): 3-8.

“Children Living Near Green Spaces Are More Active” (2009)
• In this study of children aged 8-10, for every additional park located within a half-mile of their home, girls are twice as likely to walk to school.
• Boys are 60 percent more likely to walk in leisure time when a park is located within a half-mile of their home.
• This study supports a statement from the American Heart Association made in June of 2008 stating, “walkable” neighborhoods, with adequate sidewalks and areas for physical activity, can play an important role in combating the rise in obesity rates by making it easier to get daily exercise.

Lamber, Marie, Kestens, Yan, Gauvin, Lise, Van Hulst, Andraea and Danie, Mark. “Children Living Near Green Spaces are More Active.” American Heart Association, 2009.

“Changes in the Percentage of Students Who Walk or Bike to School – United States, 1969 and 2001” (2008)
• Data from the 1969 and 2001 National Household Transportation Survey report that a smaller percentage of students lived within 1 mile of school in 2001 than in 1969.
• The percentage of students who walked or biked any distance decreased from 42.0% to 16.2%.
• Nearly half of students used more than 1 travel mode or went to an additional destination en route between home and school in 2001.
• Implications from this study indicate that a multidisciplinary effort is needed to increase the percentage of students who walk or bike to school, as well as decrease the distances that students travel.

Ham, Sandra A., Martin, Sarah, and Kohl III, Harold W. “Changes in the Percentage of Students Who Walk or Bike to School – United States, 1969 and 2001.” Journal of Physical Activity and Health. 5.2 (2008): 205-215

“Walking, Cycling, and Obesity Rates in Europe, North America, and Australia” (2008)
• This study examines the relationship between active transportation and obesity rates.
• Walking and bicycling are far more common in European countries than in the United States, Australia, and Canada, where active transportation is inversely related to obesity.
• The results do not prove causality although they suggest that active transportation could be one factor that explains international differences in obesity rates.

Bassett, David R., Pucher, John, Buehler, Ralph, Thompson, Dixie L. and Crouter, Scott E. "Walking, Cycling, and Obesity Rates in Europe, North America, and Australia." Journal of Physical Activity and Health. 5.6 (2008):795-814.

"The Built Environment, Climate Change, and Health Opportunities for Co-Benefits" (2008)
• Incorporating a health promotion approach in the design and development of the built environment can ease climate change and promote healthier living.

Dannenberg, Andrew L., Morrow Almeida, Heather, Vindigni, Stephen M. and Younger,
Margalit. "The Built Environment, Climate Change, and Health Opportunities for Co-Benefits." American Journal of Preventive Medicine. 35.5 (2008): 517-526.

"Children’s Active Commuting to School: Current Knowledge and Future Directions” (2008)
• This article summarizes research on predictors and health consequences of active commuting to school and evaluates programs specific to children’s walking and bicycling to school, including Safe Routes to School.
• Research demonstrates that children who walk or bicycle to school have higher daily levels of physical activity and better cardiovascular fitness than do children who do not actively commute to school.
• A review of the literature identifies a wide range of predictors of children’s active commuting behaviors, including demographic factors, individual and family factors, school factors (including the immediate area surrounding schools), and social and physical environmental factors.
• Safe Routes to School and the Walking School Bus are two public health efforts that promote walking and bicycling to school.
• Evidence suggests that these activities are viewed positively by key stakeholders and have positive effects on children’s active commuting to school.

Davison, Kirsten K., Werder, Jessica L. and Lawson, Catherine T. “Children’s Active Commuting to School: Current Knowledge and Future Directions.” Preventing Chronic Disease. 5.3 (2008): A100.

"Investment in Safe Routes to School Projects: Public Health Benefits for the Larger Community” (2008)
• This study estimates of the amount of land area and population in the United States that could be affected by Safe Routes to School programs, and examines the types of locations where such improvements are likely to affect the greatest number of people and the improvements it could have on the larger community.
• Communities with limited funds may be able to improve their overall walkability for all citizens by using federal Safe Routes to School funding to improve walking and cycling routes to schools.

Watson, Margaret and Dannenberg, Andrew. “Investment in Safe Routes to School Projects: Public Health Benefits for the Larger Community.” Preventing Chronic Disease. 5.3 (2008).

“Estimating the Number of Children Who Can Walk to School” (2007)
http://www.ajpm-online.net/article/S0749-3797(07)00350-9/abstract
or
http://www.saferoutespartnership.org/media/file/AmericanJournalStudy.pdf
• National estimates suggest that 14%-19% of children walk to school while state and local estimates suggest that 4% to 20% of children walk to school.
• The most commonly reported reason by parents why children do not walk to school is distance (62%).
• This study estimates the percentage of children in Georgia who live within a safe and reasonable walking distance from school.
• Results report that the estimated percentage of potential walkers is well below 50% for all but the 1-mile radius for early and late elementary school students.
• This study suggests that increasing the percentage of students who walk will require educational efforts and changes to the built environment.

Falb, Matthew D., Kanny, Dafna, Powell, Kenneth E., and Giarrusso, Anthony J. “Estimating the Number of Children Who Can Walk to School.” American Journal of Preventive Medicine. 33.4 (2007): 269-275.

“Small Changes in Dietary Sugar and Physical Activity as an Approach to Preventing Excessive Weight Gain: The America on the Move Family Study” (2007)
• Two small lifestyle changes, as promoted by the America on the Move initiative, in diet (to eliminate 100 kcal/day) and physical activity (to walk an additional 2000 steps/day), could be useful for addressing childhood obesity by preventing excess weight gain in families.

Hill, James O., Ogden, Lorraine G., Rodearmel, Susan J., Stroebele, Nanette and Wyatt,
Holly R. “Small Changes in Dietary Sugar and Physical Activity as an Approach to Preventing Excessive Weight Gain: The America on the Move Family Study.” Pediatrics. 120 (2007): e869-e879.

“Many Pathways from Land Use to Health” (2006)
• This article examines single-use, low-density land use patterns and reports that a 5% increase in neighborhood walkability is associated with:
     o 32.1% more minutes devoted to physically active travel
     o About one-quarter point lower BMI (0.228)
     o 6.5% fewer vehicle miles traveled (VMT) per capita
     o 5.6% fewer grams of Nitrogen Dioxide per capita
     o 5.5% fewer grams of volatile organic compound (VOC) emitted per capita

Frank, Lawrence D., Sallis, James F., Conway, Terry L., Chapman, James E., Saelens, Brian E. and Bachman, William. “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. 72.1 (2006): 75-87.

“Prevalence of Obesity and Overweight in the United States: 1999-2004” (2006)
• In 2003-2004, 17.1% of US children and adolescents were overweight.
• Research indicates an increase in the prevalence of overweight in female children and adolescents from 13.8% in 1999-2000 to 16.0% in 2003-2004 and an increase in the prevalence of overweight in male children and adolescents from 14.0% to 18.2%.
• From 1999-2004 the prevalence of overweight among children and adolescents increased. This suggests that increases in body weight are continuing in children and adolescents.

Ogden, Cynthia L., Carroll, Margaret D., Curtin, Lester R., McDowell, Margaret A.,Tabak, Carolyn J. and Flegal, Katherine M. “Prevalence of Obesity and Overweight in the United States: 1999-2004.” Journal of the American Medical Association. 295 (2006):1549-1555.

“Estimating the Energy Gap Among US Children: A Counterfactual Approach” (2006)
• By quantifying the magnitude of energy imbalance responsible for the increase in body weight among US children, this study looks to provide salient targets for population intervention.
• Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap.

Wang, Claire Y., Gortmaker, Steven L., Sobol, Authur M. and Kuntz, Karen M. “Estimating the Energy Gap Among US Children: A Counterfactual Approach.” Pediatrics. 118 (2006): 1721-1733.

"Physical Activity Levels of Children Who Walk, Cycle, or Drive to School” (2005)
• This study uses an accelerometer and questions describing travel habits to evaluate physical activity levels among primary school children.
• Results reveal that children who walk to school are significantly more physically active than those who travel by car.
• Children who cycle to school record higher accelerometer counts than those who travel by car.

Cooper, Ashley R., Anderse, Lars Bo, Wedderkopp, Niels, Page, Angie S., and Frober, Karsten. “Physical Activity Levels of Children Who Walk, Cycle, or Drive to School.” American Journal of Preventive Medicine. 29.3 (2005): 170-184.

“The Broader Impact of Walking to School Among Adolescents: Seven Day Accelerometry Based Study” (2005)
• This study reports that students who walk both to and from school accrue the most minutes of moderate to vigorous physical activity (MVPA).
• 90% of the students that walk one way to school accumulate an average of 60 or more minutes of MVPA on weekdays.
• 100% of the students that walk both to and from school accumulate an average of 60 or more minutes of MVPA on weekdays.

Alexander, Leslie M., Inchley, Jo, Todd, Joanna, Currie, Dorothy, Cooper, Ashley R. and Currie, Candace. “The Broader Impact of Walking to School Among Adolescents: Seven Day Accelerometry Based Study”. British Medical Journal. 331 (2005): 1061-1062.

"Multiple Impacts of the Built Environment on Public Health: Walkable Places and the Exposure to Air Pollution” (2005)
• This article focuses on the relationship between the built environment, travel behavior, and public health outcomes.

Frank, Lawrence D. and Engelke, Peter. “Multiple Impacts of the Built Environment on Public Health: Walkable Places and the Exposure to Air Pollution.” International Regional Science Review. 28(2) (2005): 193-216.

"Contribution of School Programmes to Physical Activity Levels and Attitudes in Children and Adults” (2005)
• This review analyzes the effects of school physical education programs on physical activity levels and attitudes toward physical education and physical activity in children and adults.
• This study suggests that schools have the potential to influence habitual physical activity among children by encouraging increased participation in extracurricular sports activities, by favoring active commuting to school, and by providing exercise equipment and supervision for youth in their neighborhoods.
• Additionally, this study suggests that most young children have a very positive attitude towards physical education although as they grow older, their perception of physical education as a positive experience seems to become more ambiguous.

Trudeau, Francois and Shephard, Roy J. “Contribution of School Programmes to Physical Activity Levels and Attitudes in Children and Adults.” Sports Medicine. 35.2 (2005): 89-105.

"Commuting to School: Are Children Who Walk More Physically Active?” (2003)
• Using objective measurement to investigate the physical activity patterns of children by mode of travel to school, this study reports that children who walk to school are significantly more active than those who travel by car.
• A valuable implication of this study is that active transport may contribute to increased physical activity, supporting walk-to-school initiatives to increase children’s physical activity.

Cooper, Ashley R., Page, Angie S., Foster, Lucy J. and Qahwaji, Dina. “Commuting to School: Are Children Who Walk More Physically Active?” American Journal of Preventative Medicine. 25.4 (2003): 273-276.

"Promoting Safe Walking and Cycling to Improve Public Health: Lessons from the Netherlands and Germany” (2003)
• Walking and cycling are dangerous ways to get around American cities. Walking and cycling can be made safer, demonstrated by the lower fatality and injury rates in the Netherlands and Germany.
• Benefits of safer cities include reduced risk of death and injury from walking and cycling, providing valuable exercise options, mobility and independence.
• This study urges Americans to address the safety issue by public campaigns emphasizing the direct impacts on individuals, their families, and their friends.

Pucher, John and Dijkstra, Lewis. “Promoting Safe Walking and Cycling to Improve Public Health: Lessons From The Netherlands and Germany.” Public Health Matters. 93.9 (2003): 1509-1516.