Executive Summary from Step It Up!: Surgeon General’s Call to Action
One out of every two U.S. adults is living with a chronic disease, such as heart disease, cancer, or diabetes.1 These diseases contribute to disability, premature death, and health care costs.2,3 Increasing people’s physical activity levels will significantly reduce their risk of chronic diseases and related risk factors.4,5 Because physical activity has numerous other health benefits—such as supporting positive mental health and healthy aging—it is one of the most important actions people can take to improve their overall health.4,5
Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities recognizes the importance of physical activity for people of all ages and abilities. It calls on Americans to be more physically active through walking and calls on the nation to better support walking and walkability. Improving walkability means that communities are created or enhanced to make it safe and easy to walk and that pedestrian activity is encouraged for all people.6 The purpose of the Call to Action is to increase walking across the United States by calling for improved access to safe and convenient places to walk and wheelchair roll and by creating a culture that supports these activities for people of all ages and abilities.
The Call to Action includes five strategic goals to promote walking and walkable communities in the United States: make walking a national priority; design communities that make it safe and easy to walk for people of all ages and abilities; promote programs and policies to support walking where people live, learn, work, and play; provide information to encourage walking and improve walkability; and fill surveillance, research, and evaluation gaps related to walking and walkability. Action by multiple sectors of society, as well as by families and individuals, will be needed to achieve these goals.
Physical Activity: An Essential Ingredient for Health
Being physically active is one of the most important steps that people of all ages and abilities can take to improve their health.5 Increasing people’s physical activity level will significantly reduce their risk of chronic disease and premature death and support positive mental health and healthy aging.4,5
Chronic Disease in the United States
Chronic diseases are the leading causes of death in the United States and major contributors to disability.3 In 2012, almost 50% of U.S. adults, or 117 million people, were living with a chronic disease, and of this group, about 60 million were living with two or more chronic diseases.1 Chronic diseases also ranked as four of the top five most costly medical conditions.7
Benefits of Physical Activity
Physical activity can reduce illness from chronic diseases and premature death.4,5 Regular physical activity helps prevent risk factors for disease (such as high blood pressure and weight gain) and protects against multiple chronic diseases (such as heart disease, stroke, some cancers, type 2 diabetes, and depression).4,5 In children and adolescents, physical activity can improve bone health, cardiorespiratory and muscular fitness, and body composition.4,5
People living with chronic disease also benefit from being physically active.4,8-20 For example, physical activity can lessen the severity of their condition, as well as prevent disease progression and premature death,4,12-16 help manage or reduce symptoms,8-11 and improve mobility.13,16
Among adults, physical activity is associated with improved quality of life,4,21,22 emotional well-being,4,23,24 and positive mental health.4,23-25 Regular physical activity is also important for healthy aging5 and may delay the onset of cognitive decline in older adults.4,26-28
In children and adolescents, some evidence suggests that physical activity can lower levels of anxiety and depression.4,29-31 When schools encourage participation in physical activity as part of physical education, recess, classroom lessons, or extracurricular activities, students can also improve their academic performance.32,33
Physical Activity Guidelines for Americans
To obtain substantial health benefits, the 2008 Physical Activity Guidelines for Americans recommends that adults get at least 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous-intensity physical activity, or an equivalent combination, each week and that children and adolescents be active for at least 60 minutes every day.5 People who are inactive and those who do not yet meet the guidelines are strongly encouraged to work toward this goal. Adults with disabilities who are unable to meet the guidelines should avoid inactivity and try to get regular physical activity according to their abilities.5
Physical Activity in the United States
Despite the health benefits, only one-half of U.S. adults reported levels of physical activity consistent with the guideline for aerobic physical activity in 2013.34 Adults who were male, younger, white, or Asian or who had higher levels of education were more likely to have met the aerobic physical activity guideline.34
Only 27% of high school students reported levels of physical activity that met the guideline for 60 minutes of physical activity a day in 2013. 35 Male high school students and students in lower grade levels were more likely to meet the guideline.34,35
Why Focus on Walking as a Public Health Strategy?
Strong evidence exists that physical activity has substantial health benefits.4,5 People can get these benefits through brisk walking or by adding brisk walking to other physical activities.5 Walking is an excellent way for most Americans to increase their physical activity. It is also a powerful public health strategy for several reasons.
Walking does not require special skills, facilities, or expensive equipment and is an easy physical activity to begin and maintain as part of a physically active lifestyle.36 Most people are able to walk, and many people with disabilities are able to walk or move with assistive devices, such as wheelchairs or walkers. Walking has a lower risk of injury than vigorous-intensity activities.5,37 Walking also may be a good way to help people who are inactive become physically active because walking can be easily adapted to fit one’s time, needs, and abilities.5,37
Walking is a common form of physical activity. In 2010, more than 60% of adults reported walking 10 minutes or more in the past week for transportation or leisure.38 Adults with more education, those who were white or Asian, and those who were younger were more likely than their counterparts to report any walking.38,39
People walk for many purposes, such as for transportation to get to school, work, a store, or the library or for leisure to have fun, socialize with friends or family, walk their dog, or improve their health. Because walking is multipurpose, it provides many opportunities for people to incorporate physical activity into their busy lives. In 2010, about half of U.S. adults reported walking during their leisure time and less than one-third reported walking for transportation.40
Communities can benefit when they implement strategies that make them more walkable and when more people walk. Communities designed to be walkable can improve safety not only for people who walk but for all community members.41-43 Walkable communities and communities where more people walk offer opportunities for personal interaction and social involvement.44 Communities designed to be walkable have the potential to reduce air pollution and greenhouse gases because people may choose to walk or bike rather than drive.45,46 Finally, walkable communities are attractive places for businesses to locate, which may help local economies thrive.47-49
Why Don’t People Walk More?
Many more people could meet the 2008 Physical Activity Guidelines for Americans5 by starting to walk or increasing the amount they walk. Although walking is a popular form of physical activity and can be easily done by most people, barriers to walking do exist.
People report lack of time as one challenge that prevents them from walking or doing other kinds of physical activity.50,51 People may struggle to meet the current guideline for regular aerobic physical activity as they cope with competing demands of work, school, home, and caring for themselves and others.
Safety concerns can be a barrier to walking. Several factors can influence pedestrian risk, such as unsafe driver41,52,53 and pedestrian behaviors41,52-55 and challenging physical environments.41,42,53 Perceived traffic dangers may also be barriers to walking. In surveys of parents, the most commonly reported barrier for walking to school was distance to school, followed by traffic-related dangers.56,57 Fear of crime or perceptions of an unsafe neighborhood may also be potential barriers to walking.58-61
In addition, the ways in which communities are designed and built can present barriers to walking. When everyday destinations are located too far away from home, walking will not be a convenient option.62-65 Because people are more likely to walk when they use public transportation, 62,66-73 the lack of an adequate public transit system may mean that opportunities to walk are lost.
Disability, chronic conditions, and age can be barriers to walking. During 2009–2012, 11.6% of U.S. adults aged 18–64 years reported a disability, and adults with disabilities were more likely to be physically inactive than adults without a disability.74 Chronic conditions and age can make it difficult for people to walk. For example, people with arthritis may find walking painful.75 Older adults and those who are frail may be reluctant to walk because of concerns about falls and subsequent injury.
How to Increase Walking and Improve Walkability
Ultimately, individuals make the decision to walk. However, the decision to walk can be made easier by programs and policies that provide opportunities and encouragement for walking and by improvements to community walkability. Improving walkability means that communities are created or enhanced to make it safe and easy to walk and that pedestrian activity is encouraged for people of all ages and abilities.6
Community and street design policies are recommended approaches for increasing physical activity, including walking.76,77 Community design can support physical activity, for example, by locating residences within short walking distance of stores, worksites, public transportation, essential services, and schools and by building and maintaining sidewalks or paths between destinations that are well-connected, safe, and attractive. 76,77 Street design can also support walking and enhance pedestrian safety through measures that improve street lighting and landscaping and reduce traffic speed.76,77 Transportation and travel policies and practices that create or enhance pedestrian and bicycle networks and expand or subsidize public transit systems can be another approach to encourage walking for transportation.78,79
Several program and policy strategies are recommended to increase physical activity, including walking. For example,
Creation of or Enhanced Access to Places for Walking with Informational Outreach. Creating or enhancing access to places for physical activity, combined with information to encourage use of these places, is a strategy recommended to increase physical activity.80,81 Examples of places for walking include public parks; health, fitness, and recreational facilities; schools, colleges, and universities; malls; senior centers; and worksites.
Social support interventions. Social support interventions increase physical activity by providing supportive relationships for behavior change.82 They include actions that provide friendship and support, such as buddy systems, contracts with others to complete specified levels of physical activity, or walking groups. 80,81
Individually-adapted health behavior change programs. These programs teach behavioral skills that help participants incorporate physical activity into their daily routines.80-82 Programs usually incorporate some form of counseling from a health professional or trainer to help participants set physical activity goals, monitor their progress toward these goals, seek social support, and use self-reward to reinforce progress.82,83
Community-wide campaigns. A community-wide campaign is a concentrated effort to promote physical activity that combines a variety of strategies such as media coverage, risk factor screening and education, community events, and policy or environmental changes.81,84
What Sectors Are Needed to Help Implement Community Approaches?
Many groups have a role to play to make the United States a nation with safe, easy, and desirable places to walk as part of our daily lives.
Transportation, Land Use, and Community Design
Decisions and plans made by the transportation, land use, and community design sector can affect whether communities and streets are designed to support walking. This sector can change the design of communities and streets through roadway design standards, zoning regulations, and building codes76 and improve the pedestrian experience through landscaping, street furniture, and building design.85 This sector is also integral in the planning and implementation of public transit systems.
Parks and Recreational and Fitness Facilities
Public parks offer access to places to walk.86,87 Health and fitness facilities offer group walking programs and access to places for walking, including places to walk indoors. Better access to parks, playgrounds, and recreational centers may encourage active transportation, such as walking to the location.88 Health and fitness facilities should be designed, built, and maintained to be accessible to the entire population, including people with mobility limitations or chronic conditions.
Schools can provide opportunities for physical activity through physical education, recess, after-school activity programs, and physical activity breaks, 89,90 and walking can be incorporated into these opportunities. Schools can encourage walking by promoting safe routes for students to walk to and from school. Opening school facilities, such as gyms, playgrounds, fields, and tracks, to the community during nonschool hours is a promising strategy to increase access to physical activity and recreational facilities91 and increase physical activity levels.92-94
Colleges and Universities
Walkable campus strategies help students, faculty, and staff members adopt active living behaviors on campus.95 Colleges and universities can also educate and train future professionals to recognize their role in promoting walking and walkable communities. This training can be directed to students in health disciplines, as well as to students in other relevant fields, such as architecture, transportation, urban design, and business.
Worksites can offer access to on-site facilities or employer-subsidized, off-site exercise facilities to encourage physical activity among employees. 96,97 They can adopt policies that include brief activity breaks, flexible schedules, and walking meetings as potential strategies to increase participation in worksite physical activity.98-100 Incentives and social support programs can also be used to encourage employees’ interest and participation in physical activity programs.81,100
Volunteer and Nonprofit Organizations
Volunteer and nonprofit groups can provide access to facilities, programs, and information to promote walking. For example, they can open their facilities and walking programs to the wider community for free or at low cost, or they can organize social support programs. These organizations can also serve as messengers to share information about the benefits of walking and walking programs and ways to improve walkability.
Health care professionals can assess patients' physical activity levels and educate patients across their lifespan about the importance of physical activity. Counseling may be especially important for adults who are at higher risk of chronic disease, such as those who are overweight or obese and have additional risk factors for cardiovascular disease.101,102 Walking is an especially good activity for health care professionals to promote because most of their patients can walk, and walking can be easily modified to a person’s abilities.
The media can be effective in influencing attitudes and changing behaviors, including health behaviors.103-106 Media campaigns can be part of effective multicomponent interventions designed to increase physical activity. However, evidence on the effectiveness of stand-alone mass media campaigns to increase physical activity at the population level is inconsistent.107
Public health professionals can conduct research and evaluate programs to determine what works to promote and sustain physical activity, including walking. They can summarize findings about what community approaches work to increase walking and walkability, and they can help other sectors design and implement interventions. They can convene partners across multiple sectors to learn from each other and to develop strategic action plans that efficiently use each partner’s expertise and resources. Public health professionals also collect data about walking and walkability to measure and monitor changes over time.
Gaps in Surveillance, Research, and Evaluation
Existing research provides an evidence base about what works to increase walking in the United States. However, additional surveillance, research, and evaluation work is needed to maximize the success of community approaches and address disparities in walking and walkability.
Walking among adults is assessed through self-report in several surveillance systems38,108,109 but not in a consistent manner. Surveillance systems that assess walking among children and adolescents mainly collect data on walking for transportation.108,110,111 Improvements to existing surveillance systems are needed to establish standard and valid measures of walking that can be used across systems at national, state, regional, and local levels.
No national surveillance system routinely and comprehensively monitors local neighborhood features of a walkable community. Brief survey and on-the-ground audit tools or technological approaches that capture the most important aspects of walkability are needed to increase the feasibility of routinely assessing key features of the environment as part of core questions in surveillance systems.
Existing research demonstrates that broadly defined or multicomponent interventions increase physical activity,77,81,82 but it is rarely known which set of individual elements are most effective, necessary, or sufficient to achieve a positive effect while minimizing any negative effects, such as injuries. Effective communication can also be an important component of physical activity programs.81 However, researchers are not sure which specific messages or combination of messages and other intervention components, such as walking programs and access to places to walk, are best for populations that vary in age, location, race/ethnicity, and socioeconomic status.
Communities across the country are implementing a variety of interventions that promote walking, but many of these interventions are not being adequately evaluated. Evaluation planning should occur early in the development process to identify key stakeholder questions and ensure that adequate resources are allocated to the evaluation.112 Evaluation data would be strengthened by the use of common metrics across studies to allow comparison of the relative cost and effectiveness of various interventions.
Additional research is needed to fully describe the economic benefits of adequate levels of physical activity in the United States.113 Research and evaluation studies should collect data to support economic analysis.114,115 In addition, to fully capture the range of costs and savings from changes in environmental design or program implementation, economic analyses may need to consider other potentially quantifiable savings that result from these types of interventions.116-118
The Call to Action
The Call to Action includes five goals, with related strategies to support walking and walkability in the United States. These strategies will make it easier and safer for people to walk and to use a wheelchair, ride a bike, and be active in other ways. Support for these goals and strategies is needed across many sectors of society, such as transportation, land use, and community design; parks, recreation, and fitness; education; business and industry; volunteer and nonprofit; health care; media; and public health.119 Families and individuals will also need to be involved to make the United States a walkable nation.
Goal 1. Make Walking a National Priority
- Encourage people to promote walking and make their communities more walkable.
- Create a walking movement to make walking and walkability a national priority.
Goal 2. Design Communities that Make It Safe and Easy to Walk for People of All Ages and Abilities
- Design and maintain streets and sidewalks so that walking is safe and easy.
- Design communities that support safe and easy places for people to walk.
Goal 3. Promote Programs and Policies to Support Walking Where People Live, Learn, Work, and Play
- Promote programs and policies that make it easy for students to walk before, during, and after school.
- Promote worksite programs and policies that support walking and walkability.
- Promote community programs and policies that make it safe and easy for residents to walk.
Goal 4. Provide Information to Encourage Walking and Improve Walkability
- Educate people about the benefits of safe walking and places to walk.
- Develop effective and consistent messages and engage the media to promote walking and walkability.
- Educate relevant professionals on how to promote walking and walkability through their profession.
Goal 5. Fill Surveillance, Research, and Evaluation Gaps Related to Walking and Walkability
- Improve the quality and consistency of surveillance data collected about walking and walkability.
- Address research gaps to promote walking and walkability.
- Evaluate community interventions to promote walking and walkability.
Promoting walking offers a powerful public health strategy to increase physical activity. With the Call to Action, the U.S. Surgeon General calls on Americans to be physically active and for the nation to better support walking and walkability for people of all ages and abilities. To improve walking and walkability, communities need to be designed to make walking safer and easier; programs and policies need to be available to support and encourage walking; and individuals and families need to support each other to become and stay active. Many partners are already involved, but more engagement is needed to increase the reach, breadth, and impact of these efforts. Walking is an easy and inexpensive way to improve the health and well-being of all Americans. Now is the time to step it up and make walking a national priority.
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