Walkable Communities

One out of every two adults in the United States lives with a chronic disease.

Physical activity can help prevent chronic disease, but half of all adults get too little of it.

Treating chronic disease accounts for 75 percent of all health care spending, which is projected to reach $5.4 trillion a year by 2024.

Ouch. Ouch. Ouch.

Too bad there isn't a simple way to increase physical activity, improve public health and help reduce rising healthcare costs.

Ahhh, but there is.

Hippocrates connected the dots more than 2,400 years ago. "Walking," said the creator of the Hippocratic oath, "is man's best medicine."

Millenniums later, that prescription is more valid than ever. With obesity, diabetes and other chronic diseases taking a heavy toll in lives and dollars, the link between walking and health raises the stakes for creating safe and convenient places to walk.

Earlier this year U.S. Surgeon General Vivek Murthy sounded a call to action challenging all Americans to increase their physical activity through walking and challenging all communities to become more walkable.

It's a worthy goal, but a heavy lift.

Much of the built environment in America is designed with driving, not walking, in mind. While walking remains a popular form of recreation, it stopped being a routine part of everyday living decades ago, erasing an inherent source of physical activity that contributed greatly to public health.

"One of the biggest challenges is 50 years of automobile-dominated development," says Scott Bricker, executive director of America Walks, a nonprofit organization based in Portland, Ore. "A lot of development has basically engineered walkability out of the daily lifestyle of people."

The evidence is all around. Streets designed solely to move as much traffic as possible as fast as possible. Sidewalks and crosswalks missing in action. Families marooned in sprawling subdivisions miles from most destinations. Everybody totally dependent on their car to get around.

Times are changing, though. More and more people want to live where they can walk to stores, cafes, schools and work — or at least to a transit stop. They want to reduce their reliance on cars, live more sustainably and enjoy the perks of a vibrant and connected neighborhood.

Bottom line: They want to use their feet for transportation.

While market forces alone are enough to give walkability greater weight in transportation planning decisions, walkability has become more than a consumer preference. With the surgeon general's call to action, it's now a formal public health strategy for reducing healthcare costs and helping people live longer and healthier lives.

The beauty of walking as transportation is it requires no special skill, equipment or license, costs nothing and almost everyone can do it.

What matters most, though, is the health benefits it delivers. A brisk daily walk can provide the 150 minutes of moderate aerobic exercise per week recommended by the U.S. Department of Health and Human Services to protect against everything from heart disease to depression to some cancers.

"Walking has proven to be the best form of exercise there is for long-term health benefits (because) it's something you can do throughout your life," says Shawn McIntosh, program manager with the American Public Health Association. "Studies have shown that walking even 20 or 30 minutes a day can make a big difference." Nashville, Tenn., provides a blueprint for folding health and walkability into transportation planning.

Tennessee has one of the highest obesity rates in the country, according to the Centers for Disease Control (CDC), and its residents are among the least physically active of any state. In 2009, the agency that allocates federal dollars for roads, bridges and other transportation projects to cities and counties in the Nashville region revised its scoring system to favor projects that support active transportation — walking, biking, transit — and produce other positive health outcomes.

"We stopped thinking first about how to move cars up and down the corridor as fast as possible and started thinking about how to connect people to places in ways that would improve health," says Leslie Meehan, former director of healthy communities for the Nashville Area Metropolitan Planning Organization (NAMPO). "That shift ... really moved the needle."

Under the old scoring system, only 2 percent of the projects in Nashville's regional transportation plan included active transportation components such as sidewalks or bike lanes. After the new scoring system was introduced, nearly 70 percent supported active transportation in one way or another.

The NAMPO has since placed even greater weight on improving health — 80 points out of 100 versus 60 out of 100 — and is factoring in results from a landmark health and transportation survey the agency co-sponsored in 2012.

The Middle Tennessee Transportation and Health Study looked at the relationship between transportation, health and overall physical activity based on a survey of 6,000 households in the region — including a subset of 600 households who wore GPS devices and activity monitors.

Data from the study has become a north star for transportation planning in the region, steering support for active transportation to neighborhoods with high levels of health problems and low levels of physical activity. "It makes sure funding goes where it's needed most," Meehan says.

Improved health outcomes won't come overnight because the epidemic of chronic diseases didn't develop overnight, but the potential payback for even modest gains in physical activity is a game changer.

The Middle Tennessee Transportation and Health Study found the average person in the region walks or bikes just three minutes a day for transportation purposes — excluding any walking or biking they might do for recreation or exercise. Using a model developed in the United Kingdom, the NAMPO estimated the monetary impact if everyone in the region walked or biked 10 minutes a day for transportation.

"The results are preliminary ... but the savings are about $200 million a year in health care costs that wouldn't be expended because of diseases that wouldn't be incurred because people would be healthier," Meehan says.

As more data rolls in showing the return on investment of active transportation, more thought leaders and policy makers around the country are looking at the built environment in general — and transportation in particular — from a public health perspective.

"Everybody from all of these different fields — health, transportation, planning, housing — wants to play in the same sandbox and start figuring out how to work together on this issue," says Meehan, who is now assistant director for primary prevention at the Tennessee Department of Health. "This is still very much burgeoning, but we're headed down the right path."

The American Planning Association (APA) and the American Public Health Association (APHA) launched Plan4Health to combat chronic disease by changing the built environment — a natural mission for the two professions to share because planning originated with a public health focus.

"The long-term goal is to integrate public health with planning so that both fields are thinking about how to support one another's goals and really think about the health of the people they're serving," says Anna Ricklin, manager of the planning association's Planning and Community Health Center.

Plan 4Health is supported by the CDC and focuses on two major risk factors for chronic disease — lack of physical activity and lack of access to nutritious food. Plan4Health awarded $2.5 million in grants from the CDC to 18 local coalitions — anchored by APA and APHA members — to help them attack those problems.

In Columbus, Ind., for example, a coalition consisting of a dozen groups is working to increase physical activity by creating safer pedestrian and bicycle crossings at three intersections along a trail system and at three state highway intersections.

"If people don't feel safe, they don't enjoy walking. We need to make the healthy choice the easy choice for people," Ricklin says.

Complete streets policies are one way to weave walkability into a community. By adopting complete streets policies, communities direct transportation planners and engineers to routinely design and operate roadways with pedestrians, cyclists and transit riders — not just cars — in mind.

More than 700 local, regional and state agencies across the country have introduced complete streets policies, according to the National Complete Streets Coalition. (The NATIONAL ASSOCIATION OF REALTORS® is a member of the steering committee of the Coalition.)

The components of a complete street — sidewalks, crosswalks, curb extensions, median islands, narrower lanes, wider shoulders, lower speed limits and other measures — can vary from location to location, but the goal is always the same: to make all travel choices safer and easier.

A complete street policy is most effective when it applies to all projects whether new construction or ongoing maintenance. Even the smallest projects offer opportunities for incremental improvement such as adding time to the walk signal during routine work on traffic lights or completing a gap in a sidewalk when resurfacing a street.

"It really does come down to the details if you're looking at improving the pedestrian system so people walk as part of their day-to-day life," Ricklin says. "One of the best ways to think about all this is to think about the most vulnerable among us — children, older adults, disabled folks. If we've made it safe and accessible for them, we've made it safe and accessible for everybody."

Giving people reasons to walk in their day-to-day life is important, too. Strong transit systems play a critical role in the public health/active transportation dynamic by converting commutes into workouts. People can build 20 minutes of physical activity into their day just by walking to and from the bus or train, Bricker says.

"We're not talking about cut abs and beach bodies, but we are talking about incredible health outcomes," he says.

The opportunity to realize those outcomes is lost in many cases, though, because there are too few transit stops, no sidewalks leading to stops, no crossings near stops and other infrastructure shortcomings.

The problem is that many of those elements fall between cracks in jurisdiction that confine transit to one planning silo and pedestrian improvements to another, Bricker says.

"An important area of improvement for us (is to create) tighter connections between transit and departments of transportation in ensuring safe and accessible transit stops so you don't have to take your life in your own hands every time you get on and off a bus," he says.

Brad Broberg is a Seattle-based freelance writer specializing in business and development issues. His work appears regularly in the Puget Sound Business Journal and the Seattle Daily Journal of Commerce.