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More Walking and Biking, Better Health: New Evidence From American Cities

States with higher rates of walking and biking to work tend to have lower rates of diabetes. Click to enlarge. All graphics: Alliance for Biking and Walking

New data from the Alliance for Biking and Walking’s 2014 Benchmarking report bears out the notion that people tend to be healthier in cities where walking and biking are more prevalent.

The Alliance compiled active commuting rates in the 50 largest American cities as measured by the U.S. Census. Then it compared that data with health information from the CDC. On health outcomes like diabetes, obesity, and high blood pressure, a pretty clear correlation emerges.

Not all of it can be explained by active commuting, of course. But notice how, in the top chart, as statewide active transportation rates increase, diabetes rates decline.

About 9 percent of Americans have diabetes, but the incidence varies greatly between different places. Diabetes tracks closely enough with walk and bike commute rates that the Alliance and other researchers have concluded there’s a strong correlation.

Rates of elevated blood pressure display a similar pattern:

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Boston Doctors Now Prescribing Bike-Share Memberships

The newest tool for doctors in the fight against obesity? That’s right: Bike-share.

Doctors in Boston are now prescribing Hubway memberships. Photo: Hubway

Doctors in Boston are now prescribing Hubway memberships. Photo: Hubway

This week in Boston, doctors introduced a program called Prescribe-a-Bike, offering low-income residents struggling with obesity an annual Hubway bike sharing membership for the low price of $5. The program is being administered by Boston Medical Center in partnership with the city of Boston. Qualifying patients will have access to Hubway’s 1,100 bikes at 130 locations. Participants will also receive a free helmet.

“There is no other program like this in the country,” Mayor Marty Walsh told Boston Magazine. “Prescribe-a-Bike makes the link between health and transportation, and ensures that more residents can access the Hubway bike-share system.”

Local officials hope the program will result in about 1,000 additional memberships, according to the Boston Globe.

In the medical community this type of recommendation is known as an exercise prescription, and it is a growing practice. More doctors are prescribing exercise, the CDC says, as “lifestyle diseases” like obesity, heart disease and diabetes have become some of the leading killers in the United States. In addition, police measures like the Affordable Care Act are providing incentives for the healthcare industry shift focus from treatment of disease to the promotion of wellness.

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Poor NYC Neighborhoods “Less Conducive to Walking” Than They Appear

A fact sheet [PDF] released by the city’s health department today makes the case that New York City’s walkability contributes to the health of residents — but a deeper look into the research shows that not all New Yorkers are benefitting equally from walkable neighborhoods.

The more walkable your NYC neighborhood, the more likely you are to engage in physical activity. Image: DOHMH

The more walkable your neighborhood, the more likely you are to engage in physical activity. Image: DOHMH

The brief draws on recent data from two sources: Research by Columbia University academics on the walkability of the city’s neighborhoods and the health department’s own survey of 3,800 New Yorkers about physical activity and transit.

The Columbia researchers measured walkability using five components: Residential density, density of street intersections and subway stops, land use mix, and an estimate of the prevalence of large retail parking lots. The health department tracked the health and transportation behaviors of New Yorkers through surveys, accelerometers, and GPS devices. By looking at the two datasets together, the bottom line became clear: ”Physical activity levels were substantially higher in people living in higher-walkability neighborhoods,” the report says.

People in the most walkable neighborhoods averaged 233 minutes of moderate physical activity per week, burning 1,200 calories, while people living in the least walkable areas averaged 134 minutes of activity per week, burning only 690 calories.

The Columbia academics, based in the university’s Built Environment and Health Research Group, dove deeper by adding income to the equation. Matching places with the same walkability scores, they compared neighborhoods where at least 20 percent of the residents live in poverty with neighborhoods where fewer than 20 percent of residents live in poverty.

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What Sets Apart the Places Where People Walk More?

A lot of research has shown a link between living in a walkable community, active transportation habits, and better health outcomes.

Image: PLOSE ONE

As residential density increases, so do walking and biking. Image: PLOS ONE

But what aspects of “walkability” are tied to better health? Is it the mix of uses, the connected street grid, the density of housing, or all of the above? It’s an important question to understand if we want to design places that encourage healthier habits.

Researchers at St. Michael’s Hospital in Toronto set out to determine what features of urban neighborhoods lead to more activity and thus better health outcomes. Their study of Toronto-area residents, published in the peer-reviewed science and medical journal PLOS-ONE, examined the link between four built environment factors and people’s health records and transportation habits.

Researchers started by looking at street connectivity, population density, residential density (which measures occupied housing units), and “availability of walkable destinations” (a measure of non-residential uses).

They found that street connectivity was not an especially strong predictor of active transportation habits, but the other three factors were. Basically, if you live in a dense area, you are more likely to walk and bike often, and you’re even more likely to get physical activity if there are a lot of destinations close to your house.

The team found that both residential density and the presence of walkable destinations were strongly predictive of residents’ transportation habits, and that walking and biking trips per person seem to be linked most strongly to residential density. Even in low-residential-density areas with a high number of destinations, people were unlikely to walk or bike.

More often than not, however, the places that were densely settled also had a high number of destinations. And while both factors make pretty good predictors of how much activity residents get, the combination of the two — places that are both dense with residences and full of other types of uses — is especially powerful. Street connectivity was found to be a weaker predictor of travel behavior than the other measures, but was also strongly correlated with density and number of attractions.

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For One Reckless Driving Survivor, “Life Looks a Lot Different Than Before”

Traffic fatality numbers usually get the headlines, but as a measure of how safe or dangerous it is to walk and bike, injuries are the more stable metric. Since 2003, according to state DMV data, an average of just under 14,000 people were injured by motorists while walking and biking in the city each year.

Lalita Rao. Photo: Brad Aaron

Lalita Rao, left, with her daughter Amita. Photo: Brad Aaron

Of the 38 pedestrian and cyclist injury crashes in NYC on an average day, few are investigated by NYPD. Not all pedestrian and cyclist injuries are classified as “serious,” but traffic violence disrupts the lives of thousands of victims — and their loved ones — permanently. For every victim’s story the public sees or hears in the press, dozens go untold.

On May 28 of last year, Lalita Rao was walking home from Elmhurst Hospital, where she worked, when she was hit by a school bus driver making a turn. Lalita got up from the pavement and, believing she was not seriously hurt, was prepared to continue on her way. The bus driver, too, was about to leave the scene before a neighbor intervened. Responders arrived, and Lalita was taken back to Elmhurst, where she would undergo emergency brain surgery to save her life.

Lalita, who spoke at the Elmhurst pedestrian injury summit in December, suffered two brain hematomas. “The fact that I am alive is a miracle,” she said. “I never thought my life would change totally like this.”

Before the crash, Lalita ran every day — she’s run the New York marathon. She was a gardening enthusiast and loved to cook. She traveled a lot. After the crash, Lalita had to relearn how to walk, and how to use her arms and hands. She uses a walker now, and even so needs help keeping her balance. She suffered a seizure and may be on seizure medication the rest of her life.

Lalita can’t cook anymore because of her unstable balance. She can no longer tend to her garden. “Instead of going to work,” she said, “I go to rehab twice a day.”

According to Lalita, the driver who hit her was talking on a cell phone. Because of this, and since there were children on the bus at the time of the crash, she said the bus driver lost his job. But he was not arrested for hitting Lalita, and she does not know if he got a traffic ticket. Lalita and her family members said they didn’t hear much from NYPD after the crash.

“Because of a distracted driver,” said Lalita, “I need help for everything. I went from being independent to total dependency.”

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What Should Doctors Do to Prevent Traffic Deaths?

When cars first became a common presence in American cities, doctors were shocked by the carnage. In 1925, editors of the New England Journal of Medicine called the bloodshed caused by motorists “appalling” and lamented children’s loss of life as “a massacre of the innocent.” The sense of urgency was still detectable a few decades later. In a 1957 report, Harvard researchers called the public health threat posed by automobiles a “mass disease of epidemic proportions.”

The medical profession was alarmed about the bloodshed that accompanied the introduction of cars into mainstream society in the early part of the last century. Since then, views have evolved considerably. Image: New England Journal of Medicine

The medical profession was alarmed about the bloodshed that accompanied the ascent of cars in the early part of the last century. Since then, views have changed considerably. Image: New England Journal of Medicine

But as time went on, the medical establishment became much more muted in its response. Public health research gravitated to relatively minor risks — like the connection between traffic collisions and diabetes or sleep apnea — instead of more significant dangers like drunk or distracted driving. In 1987, some doctors took to the pages of the Journal to criticize their colleagues for being “relatively silent about the relation between alcohol and motor vehicle accidents.”

These shifts are charted by David Jones, a doctor who studies the history of medicine at Harvard, in a recent review of how American physicians have addressed the public health threats posed by automobiles. Looking at the last century of articles about cars and public health published in the New England Journal of Medicine, Jones charted the fascinating historical trajectory of how physicians’ views on driving-related health risks have shifted, in an article that was itself published in the Journal earlier this month.

Despite an article in the most recent edition of the Journal finding that distracted driving is associated with significantly increased crash rates among both novice and experienced drivers, Jones says doctors still don’t seem to be comfortable taking decisive action to prevent these kinds of collisions.

I recently spoke to Jones about his research. Below is an edited transcript of our interview.

It sounds like doctors have been a little bit hesitant to intervene.

Because of their position on the front line of disease, doctors become aware very early on of what types of things in our society are causing threats to life and health. The question is: What’s the appropriate response?

When the first cars started showing up on the roads in the 1890s, within 10 years doctors at medical journals were astonished by the rising numbers of people who were killed in driving accidents.

Pretty early on, probably by the 1920s or 1930s, most doctors would say the biggest problem with driving is drunk driving. That’s totally clear now. If you look at the leading cause of car accidents, it’s alcohol. Society has responded by criminalizing drunk driving, which is probably appropriate — although there are a lot of people who would say that the sanctions aren’t nearly strong enough.

What’s the role of doctors in all of this? One question that came up in the 1920s: Should everyone who wants a driver’s license undergo a medical examination? And many states considered those laws but none of them were seriously enacted. The doctors who responded to the New England Journal didn’t want to do that. That would have been a huge burden on physicians.

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TED Talk: OKC Mayor Mick Cornett on Designing a City for Fitness

I got to know Oklahoma City Mayor Mick Cornett last year, when I interviewed him at the annual meeting of the United States Conference of Mayors. We talked about his realization that he and his constituents (generally speaking) were obese, and how he stood in front of the elephants at the zoo on New Year’s Eve six years ago and announced that the city was going on a diet. He set out to have the residents of Oklahoma City lose a million pounds — and the city achieved it.

In a TED talk taped in April and posted online last week, Cornett tells the story of how OKC went from being ranked by Men’s Fitness magazine among America’s fattest cities to being ranked as one of the fittest.

“I started examining my city — its culture, its infrastructure — trying to figure out why our city seemed to have a problem with obesity,” Cornett says. “And I came to the conclusion that we had built an incredible quality of life if you happened to be a car. But if you happened to be a person, you were combating the car seemingly at every turn.”

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The Health Care Cost of Traffic Crashes, and More Ped Injury Summit Tidbits

Here is more from last week’s pedestrian injury summit at Elmhurst Hospital.

NYC DOT Infrastructure: Ann Marie Doherty, NYC DOT chief of research for implementation and safety, highlighted the agency’s 2010 pedestrian safety study and action plan. Doherty said DOT is working to get laws passed related to side guards on trucks, to keep people from being crushed under wheels, and tougher penalties for recidivist reckless drivers and people who drive without a license. A split-phase signal, which gives pedestrians exclusive crossing time, has brought a 63 percent reduction in pedestrian injuries at W. 23rd Street and Seventh Avenue, Doherty said. Streetsblog asked if DOT would be replicating the successful split-phase model at other intersections. Doherty said such decisions are made on a case by case basis, depending on pedestrian activity and other engineering considerations. Doherty said DOT has funding to install pedestrian countdown clocks citywide.

Safe Routes to School: Charles DiMaggio, epidemiologist from Columbia, presented findings from a Safe Routes to School study. Schools that get the Safe Routes treatment show a 44 percent decrease in injuries, DiMaggio said, while those that don’t show no change. DiMaggio estimates the program has saved $19 million in health care costs, and will mean 6,228 additional quality-adjusted life years over 50 years. “Kids can still be kids and be safe,” said DiMaggio.

National Data: Reps from the National Highway Traffic Safety Administration talked up the agency’s “Everyone Is a Pedestrian” program, which awards small grants to help cities develop pedestrian safety plans, and the Data-Driven Approach to Crime and Traffic Safety, developed in partnership with the Department of Justice to study links between traffic violence and other types of crime. Traffic crashes are the leading cause of injury deaths in the U.S., said NHTSA regional administrator Thomas Louizou and highway safety specialist Shannon Purdy. In 2012 pedestrian deaths accounted for 14 percent of all traffic deaths, the highest percentage since 2003. NHTSA data show 48 percent of fatal pedestrian crashes in 2012 involved alcohol — but that stat equates drunk drivers with alcohol use by deceased pedestrians. Though there is no legal BAC limit for walking, NHTSA classified 36 percent of pedestrians killed by drivers in 2012 as “legally drunk.” Fielding a question on what the feds are doing about factory-installed driver distraction systems that now come standard on many U.S. vehicles, Louizou cited voluntary guidelines issued earlier this year by U.S. DOT. Louizou said traffic crashes are ”one of the leading causes of rising health care costs in America.”

FDNY EMS: Deputy Chief Janice Olszewski, EMS borough commander in Queens, said FDNY responds to over 24,000 “pedestrian struck” calls per year. That figure includes people who are hit by trains and other crashes that don’t involve cars and trucks, Olszewski said. (Over 14,000 pedestrians and cyclists were injured by NYC drivers in 2012.) Two-thirds of victims are transported. To help determine the type and extent of injuries, Olszewski said, responders interview the patient (if possible), inspect vehicles, and get witness accounts — which is more than NYPD precinct officers are trained or authorized for at the scene of an injury crash. (An NYPD official slated to speak at the summit was a no-show.)

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Doctors Relate the Horror of Traffic Violence at Pedestrian Injury Summit

Medical professionals and transportation experts convened Thursday for the third New York City Summit on Pedestrian Injury, hosted by Elmhurst Hospital. The day-long event brought transportation officials and advocates together with doctors who witness the destruction caused by reckless drivers in the city every day.

Queens Boulevard continues to be "a problem" for emergency physicians at Elmhurst and Jamaica Hospitals, along other area streets. Photo: ##http://en.wikipedia.org/wiki/File:QueensBlvd-GrandAve_PedWarning_Sign-Elmhurst.jpg##Wikipedia##

Along with other streets, Queens Boulevard continues to be “a problem” for emergency physicians at Elmhurst and Jamaica Hospitals. Photo: Wikipedia

The summit is chaired by Dr. Jamie Ullman, director of neurosurgery at Elmhurst, and Anju Galer, trauma coordinator for the hospital’s departments of surgery and nursing. Elmhurst is in year two of a three-year pedestrian and cyclist injury study. Ullman said 2012 marked an all-time high in the number of injuries within the hospital catchment area, and in 2013, she said, it’s a trend that shows “no signs of stopping.”

Dr. Kaushal Shah is the principal investigator for the study. Shah noted that media reports usually offer only the barest details of what happens in a traffic crash. To illustrate, he showed a slide of a recent story that reduced the deaths of two pedestrians to one short paragraph.

When a person is struck by a motorist, said Shah, it is “the worst day of their life.” For example, the first child hit by curb-jumping driver Francis Aung Lu in Maspeth in September was in the operating room for 10 hours, Shah said. Senior Cui Ju Yu, struck by a hit-and-run driver in Corona two weeks later, died from a brain hematoma*.

Most adult pedestrians who die are killed due to trauma to the head and neck, said Dr. George Agriantonis, director of trauma at Elmhurst. Injuries to the lower extremities often lead to significant disability. Flipping through slides of x-rayed and photographed images of grievous injuries, Agriantonis said compound fractures of the legs and shattered pelvises are common.

Injury patterns depend on the speed and type of vehicle, Agriantonis said. When an adult is struck by a passenger vehicle, there are usually three incidents of impact. The front of the vehicle hits the legs, which throws the victim onto the hood and windshield. The third impact occurs when the victim falls off the vehicle and hits the pavement or sidewalk.

Small children take the brunt of a collision to the torso and pelvis. Rather than being whipped onto the hood, said Agriantonis, because of their height children are thrown forward, and remain in the path of the vehicle.

Shah said researchers are seeing an increase in sidewalk crashes. Said Ullman: “I don’t know why these people are driving on the sidewalk.”

The Elmhurst catchment area is populated by 1.5 million people, Ullman said. Pedestrians hit by drivers were the leading injury category of emergency patients at Elmhurst from 2000 to 2009, and at 296, the number of pedestrians and cyclists admitted in 2012 was the hospital’s highest ever.

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MIT Study: Vehicle Emissions Cause 58,000 Premature Deaths Yearly in U.S.

Just when you thought it was safe to breathe, a pair of studies underscore the grave threat that air pollution poses to public health.

Air pollution from cars claims more than 58,000 lives in the U.S. every year, according to new research from MIT. Image: The Telegraph

According to new research from MIT, in 2005 air pollution accounted for a staggering 200,000 premature deaths in the United States, more than 58,000 of which can be attributed to vehicle emissions. Air pollution-related mortality shortened the average victim’s lifespan by 12 years, the study estimates.

The research team used air quality modeling and epidemiological evidence to estimate the mortality effects of six polluting sectors across the United States. Vehicle emissions caused more deaths than any other category of polluter. The next greatest killer was power generation emissions — 54,000 deaths — and industrial emissions — 43,000.

Though city dwellers typically have a smaller emissions footprint per capita, the concentration of people and activities make major East Coast cities the worst for deadly vehicle pollution. In Baltimore, air pollution-related deaths were the highest in the country, at 130 per 100,000 residents. New York and Washington, DC, also have alarmingly high levels of fine particle pollution. Meanwhile, people who live in heavily industrial areas are vulnerable as well. Donaldsonville, Louisiana, with its nine oil refineries, has the highest rate of mortality related to fine particle pollution in the U.S.

“The results are indicative of the extent to which policy measures could be undertaken in order to mitigate the impact of specific emissions from different sectors,” wrote lead author Fabio Caiazzo and his team, “in particular black carbon emissions from road transportation and sulfur dioxide emissions from power generation.”

As troubling as these findings are, they’re not too far out of line with other research on the topic. In 2010, the EPA estimated that there were 160,000 premature deaths due to fine particle pollution alone. An additional 4,300 deaths were attributed to ozone pollution.

Meanwhile, the World Health Organization recently added air pollution to its list of carcinogens. The WHO’s determination comes from experts at its International Agency for Research on Cancer, who, after reviewing thousands of studies, concluded air pollution could be linked to both lung and bladder cancer [PDF].

“The air most people breathe has become polluted with a complicated mixture of cancer-causing substances,” Kurt Straif of the IARC told the Associated Press. He added that the WHO now considers air pollution “the most important environmental carcinogen,” ahead of second-hand smoke.