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JULY / AUGUST 2012 :: 73(4)
Promoting Healthy and Sustainable Communities

This issue explores collaborations to improve the health of communities across the state, which are paramount to a healthy population, workforce, and economy. The policy forum includes articles highlighting various state departments' visions for healthy communities, as well as articles on planning, health impact assessments, local food systems, and efforts to strengthen the built environment. Original research includes an evaluation of the North Carolina Violent Death Reporting System and Medicaid coverage cost for the uninsured. A farewell and welcome to NCMJ editors in chief and a perspective on the challenge for health policy are also included.


Economics, Physical Activity, and Community Design

David Chenoweth,

N C Med J. 2012;73(4):293-294.PDF | TABLE OF CONTENTS

The direct medical care cost of physical inactivity in North Carolina in 2010 was $3.67 billion [1]. When lost productivity costs such as those resulting from absenteeism and presenteeism are factored in, the economic tab rises to more than $8.38 billion. Yet these costs would actually have been even higher had it not been for a slight improvement in physical activity rates among North Carolina adults over the preceding few years [2]. And when medical care and lost productivity costs for excess weight—which typically coexists with physical inactivity—are added into this cost equation, North Carolinians are saddled with additional costs of $17.60 billion per year [1].

Certainly many factors contribute to the high prevalence of physical inactivity in North Carolina. Social, cultural, economic, and technological factors are commonly cited. We know that the inextricably interwoven nature of these factors shapes our ever-changing built environment and has profound influences on our health. The importance of these factors becomes apparent when one considers the inverse relationship between the substantial growth in our roadways (and dependence on motor vehicles) and the decline in physical activity rates over the past 50 years. Yet in contrast to the well-documented connection between physical activity and health, the effect of the built environment on physical activity levels is a relatively new area of inquiry [3]. Thus, it is fair to ponder the question of whether a community’s built environment—its land use patterns, transportation systems, building designs, and natural resources—influences the physical activity patterns and levels of its citizens.

The relationship between the built environment and physical activity is complex and operates through many mediating factors such as social and demographic characteristics, personal and cultural variables, safety and security, and time allocation [3]. Yet, physical activity levels tend to increase when physical activity venues are in close proximity to the places where people live, go to school, recreate, and work [4]. A study on the cost-effectiveness of readily-available bicycle and pedestrian trails found that the per capita annual cost of using the trails was nearly $210 compared to a per capita annual direct medical benefit of using the trails of approximately $564. This benefit-cost ratio of 2.94 to 1 means that every $1 investment in trails for physical activity led to $294 in direct medical benefit. The sensitivity analyses indicated the ratios ranged from 1.65 to 13.40. The most sensitive parameter affecting the cost-benefit ratios were equipment and travel costs; however, even for the highest cost, every $1 investment in trails resulted in a greater return. Therefore, building trails is cost-beneficial from a public health perspective. [5]. Other researchers, using actual construction and maintenance cost values provided by state recreational officials in Colorado, reported a benefit-cost ratio of nearly 3 to 1 (for the local economy) tied to existing bike and pedestrian trails [6]. And, a 2004 study of the annual economic impact of bicycling tourists on the northern Outer Banks of North Carolina found that an initial $6.7 million expenditure of public funds to construct bicycle facilities was yielding a return each year of 9 times the original investment [7].

Of course, the design and availability of various transportation modes within a built environment is an important consideration when studying physical activity levels. For example, communities adopting “smart growth” street designs (ie, those incorporating designated bike lanes, pedestrian-friendly sidewalks, below-ground utilities, tree-lined streets, a designated median for light rail, and mixed use [residential and commercial] zoning) generally show substantially higher rates of physical activity than areas without a smart-growth approach [3]. Some of the impetus for these particular smart-growth designs is provided by research showing that designated bike lanes can substantially increase the number of commuters bicycling to and from work and are likely to generate substantial health care cost savings and fuel savings [8, 9].

Worksites also make up an important part of our built environment, and their structural design and policies can spur or suppress physical activity. Many larger organizations have onsite fitness centers. Also, many worksites have successfully promoted the use of stairways as a viable strategy for boosting employees’ physical activity levels [10]. Innovative building design features such as “skip-stop” elevators, which stop only at every third floor, can increase stairway use [11].

North Carolina is one of the fastest-growing states in terms of population. This fast growth brings into question the level of prospective planning needed to ensure the built environment keeps pace with the size of the population so that physical activity can be adequately fostered. After all, the slight annual improvement (+1.045%) in physical activity rates over the past few years among North Carolina adults still lags behind the rate of annual population growth in the state (+1.85%). Taken together these trends imply an increase in the absolute number of physically inactive adults, rendering the importance of developing an infrastructure that supports physical activity even more critical. And based on physical activity percentage rates among North Carolina adults over the past decade, there is no guarantee that the slight improvement seen in the past few years will continue. Moreover, as the state’s population of older adults continues to grow, the prevalence of chronic diseases will also grow, and the need for increased access to physical activity will become even more important for citizens of all ages. Indisputably, these evolving forces provide us with a provocative opportunity to think about establishing appropriate venues in the built environment.

Of course, creating an expanded built environment that fosters physical activity for all ages is a logical, and essential, first-step toward meeting this challenge. At a minimum, a unified and sustained commitment from key decision makers, policymakers, and individual citizens will be needed to push the needle forward. Now is the time for decision makers in education, government, transportation, real estate, and industry to form nonpartisan partnerships in order to achieve this universal goal. Given that all of these individuals have the potential to positively influence the quality of our ever-evolving built environment, it is absolutely crucial for them to work together for the betterment of all North Carolinians. Of course, physicians and other health care practitioners can play an important role in addressing this evolving challenge as well. They command a high level of respect among their patients and thus should continue to push them to understand that exercise is the best medicine in preventing and mitigating many illnesses. As we navigate a new path to tackle today’s lifestyle and health care challenges, is it not time to transform the Good Roads State into a Good Health State? Building an environment for physical activity is a good start.

Potential conflicts of interest. D.C. has no relevant conflicts of interest.

1. Tipping the Scales: The High Cost of Unhealthy Behavior in North Carolina. Be Active North Carolina 2012 Report. Accessed May 9, 2012.

2. Centers for Disease Control and Prevention. State Indicator Report on Physical Activity, 2010. Atlanta, GA: US Department of Health and Human Services; 2010. Accessed May 9, 2012.

3. Committee on Physical Activity, Health, Transportation, and Land Use, Transportation Research Board, Institute of Medicine of the National Academies. Does the Built Environment Influence Physical Activity?: Examining the Evidence. TRB special report 282. Washington, DC: National Academy of Sciences; 2005. Accessed May 9, 2012.

4. Brownson RC, Baker EA, Housemann RA, Brennan LK, Bacak SJ. Environmental and policy determinants of physical activity in the United States. Am J Public Health. 2001;91(12):1995-2003.

5. Wang G, Macera C, Scudder-Soucie B, Schmid T, Pratt M, Buchner D. A cost-benefit analysis of physical activity using bike/pedestrian trails. Health Promotion Pract. 2006;6(2):174-179.

6. Flusche D. The economic benefits of bicycle infrastructure investments. Policy Research Reports. League of American Bicyclists Web site. Published June 2009. Accessed July 18, 2012.

7. Laurie J, Guenther J, Cook T, Meletiou MP, O’Brien SW. The Economic Impact of Investment in Bicycling Facilities: A Case Study of the Northern Outer Banks. Technical Report. North Carolina Department of Transportation, Division of Bicycle and Pedestrian Transportation; July 2004. Accessed May 9, 2012.

8. Gotschi T. Cost and benefits of bicycling investments in Portland, Oregon. J Phys Act Health. 2011;8(suppl 1):S49-S58.

9. Parker KM, Gustat J, Rice JC. Installation of bicycle lanes and increased ridership in an urban, mixed-income setting in New Orleans, Louisiana. J Phys Act Health. 2011;8(suppl 1):S98-S102.

10. StairWELL to better health. Centers for Disease Control and Prevention Healthy Worksite Initiative Web site. Accessed May 9, 2012.

11. Nicoll G, Zimring C. Effect of innovative building design on physical activity. J Public Health Policy. 2009;30(suppl 1):S111-S123.

David Chenoweth, PhD president, Chenoweth and Associates, New Bern, North Carolina, and professor emeritus, East Carolina University, Greenville, North Carolina.

Address correspondence to Dr. David Chenoweth, 128 St. Andrews Cr, New Bern, NC 28562 (