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Nutritional and metabolic benefits associated with active and public transport: Results from the Chilean National Health Survey, ENS 2016–2017

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Background Physical inactivity is one of the main risk factors for death worldwide. There is a paucity of studies about the association between transport and objective health measures using nationally representative samples worldwide, especially from Latin American countries. The aim of this research is to explore the relationship between active transportation and objective health measures in Chile. Methods We analysed the Chilean National Health Survey (ENS) 2016–2017, based on a nationally representative sample of non-institutionalised adults aged ≥15 years (n = 6,113). ENS included anthropometric measures (weight, height, waist circumference), a specific question about the main mode of transportation and several metabolic markers. Results 41%, 38% and 21% of participants used public transport, motor vehicles and active (cycling and walking) transport respectively. Higher levels of active transport were observed in males, younger groups, less educated and rural populations. Both active and public transport were associated with multiple nutritional and metabolic benefits such as lower BMI, lower waist circumference, less obesity, higher vitamin D, lower cholesterol and lower hepatic inflammation. Associations persisted after adjusting for other healthy lifestyles. Stronger benefits were observed in males than in females. Conclusions Promoting active transportation in urban planning policies may help Chile tackle the growing burden of chronic diseases.
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Journal of Transport & Health 17 (2020) 100819
Available online 9 April 2020
2214-1405/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Nutritional and metabolic benets associated with active and
public transport: Results from the Chilean National Health Survey,
ENS 20162017
Alvaro Passi-Solar
a
,
b
, Paula Margozzini
b
,
*
, Andrea Cortinez-ORyan
b
,
c
,
Juan C. Mu~
noz
d
, Jennifer S. Mindell
a
a
Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK
b
Department of Public Health, School of Medicine, Ponticia Universidad Cat
olica de Chile, Diagonal Paraguay 362, CP 88330077, Santiago, Chile
c
Department of Physical Education, Sports and Recreation, Universidad de La Frontera, Av Francisco Salazar, 01145, Temuco, Chile
d
Department of Transport Engineering and Logistics, Centre for Sustainable Urban Development (CEDEUS), Ponticia Universidad Cat
olica de Chile,
Av. Vicu~
na Mackenna 4860, CP 7820436, Macul, Santiago, Chile
ARTICLE INFO
Keywords:
Active transport
Anthropometry
Public transport
Transport mode
Biomarkers
National Health survey
ABSTRACT
Background: Physical inactivity is one of the main risk factors for death worldwide. There is a
paucity of studies about the association between transport and objective health measures using
nationally representative samples worldwide, especially from Latin American countries. The aim
of this research is to explore the relationship between active transportation and objective health
measures in Chile.
Methods: We analysed the Chilean National Health Survey (ENS) 20162017, based on a na-
tionally representative sample of non-institutionalised adults aged 15 years (n ¼6,113). ENS
included anthropometric measures (weight, height, waist circumference), a specic question
about the main mode of transportation and several metabolic markers.
Results: 41%, 38% and 21% of participants used public transport, motor vehicles and active
(cycling and walking) transport respectively. Higher levels of active transport were observed in
males, younger groups, less educated and rural populations. Both active and public transport were
associated with multiple nutritional and metabolic benets such as lower BMI, lower waist
circumference, less obesity, higher vitamin D, lower cholesterol and lower hepatic inammation.
Associations persisted after adjusting for other healthy lifestyles. Stronger benets were observed
in males than in females.
Conclusions: Promoting active transportation in urban planning policies may help Chile tackle the
growing burden of chronic diseases.
RESUMEN
Antecedentes: La inactividad física es uno de los principales factores de riesgo de muerte en todo el
mundo. Hay una escasez de estudios sobre la asociaci
on entre el transporte y las medidas obje-
tivas de salud utilizando muestras representativas a nivel nacional en todo el mundo,
* Corresponding author.
E-mail addresses: arpassi@uc.cl (
A. Passi-Solar), pmargozz@uc.cl (P. Margozzini), andrea.cortinez@uc.cl (A. Cortinez-ORyan), jcm@ing.puc.cl
(J.C. Mu~
noz), j.mindell@ucl.ac.uk (J.S. Mindell).
Contents lists available at ScienceDirect
Journal of Transport & Health
journal homepage: http://www.elsevier.com/locate/jth
https://doi.org/10.1016/j.jth.2019.100819
Received 24 April 2019; Received in revised form 27 December 2019; Accepted 28 December 2019
Journal of Transport & Health 17 (2020) 100819
2
especialmente de países latinoamericanos. El objetivo de esta investigaci
on es explorar la relaci
on
entre el transporte activo y las medidas de salud objetivas en Chile.
M
etodos: Analizamos la Encuesta Nacional de Salud de Chile (ENS) 20162017, basada en una
muestra representativa a nivel nacional de adultos no institucionalizados con edades 15 a~
nos (n
¼6.113). ENS incluy
o medidas antropom
etricas (peso, altura, circunferencia de la cintura), una
pregunta especíca sobre el modo principal de transporte y varios marcadores metab
olicos.
Resultados: 41%, 38% y 21% de los participantes usaron transporte público, vehículos de motor y
transporte activo (ciclismo y caminata) respectivamente. Se observaron niveles m
as altos de
transporte activo en hombres, grupos m
as j
ovenes, poblaciones menos educadas y rurales. Tanto
el transporte activo como el público se asociaron con múltiples benecios nutricionales y meta-
b
olicos, como un IMC m
as bajo, una circunferencia de cintura m
as baja, menos obesidad, m
as
vitamina D, menos colesterol y una menor inamaci
on hep
atica. Las asociaciones persistieron
despu
es de ajustar por otros estilos de vida saludables. Se observaron benecios m
as fuertes en
hombres que en mujeres.
Conclusiones: Promover el transporte activo en las políticas de planicaci
on urbana puede ayudar
a Chile a enfrentar la creciente carga de enfermedades cr
onicas.
ABSTRATO
Antecedentes: A inatividade física
e um dos principais fatores de risco para a mortalidade no
mundo. H
a uma escassez de estudos sobre a associaç~
ao entre transporte e medidas objetivas de
saúde, utilizando amostras nacionalmente representativas em todo o mundo, principalmente de
países da Am
erica Latina. O objetivo desta pesquisa
e explorar a relaç~
ao entre transporte ativo e
medidas objetivas de saúde no Chile.
M
etodos: Analisamos a Pesquisa Nacional de Saúde do Chile (ENS) 20162017, com base em uma
amostra nacionalmente representativa de adultos n~
ao institucionalizados com idade 15 anos (n
¼6.113). A ENS incluiu medidas antropom
etricas (peso, altura, circunfer^
encia da cintura), uma
pergunta especíca sobre o principal meio de transporte e v
arios marcadores metab
olicos.
Resultados: 41%, 38% e 21% dos participantes usaram transporte público, veículos motorizados e
transporte ativo (ciclismo e caminhada), respectivamente. Níveis mais altos de transporte ativo
foram observados em homens, grupos mais jovens, populaç~
oes menos instruídas e rurais. Tanto o
transporte ativo quanto o público foram associados a múltiplos benefícios nutricionais e meta-
b
olicos, como menor IMC, menor circunfer^
encia da cintura, menos obesidade, maior vitamina D,
menor colesterol e menor inamaç~
ao hep
atica. As associaç~
oes persistiram ap
os o ajuste para
outros estilos de vida saud
aveis. Benefícios mais fortes foram observados nos homens do que nas
mulheres.
Conclus~
oes: A promoç~
ao do transporte ativo nas políticas de planejamento urbano pode ajudar o
Chile a enfrentar o crescente fardo das doenças cr^
onicas.
1. Introduction
According to the World Health Organization, physical inactivity is one of the main risk factors for death worldwide, responsible for
13.4 million DALYs worldwide and causing a higher burden among low-income and middle-income countries (75% of attributable
DALYs) (Ding et al., 2016). Motor vehicle trafc is associated with premature mortality and morbidity through trafc injuries, physical
inactivity and trafc-related environmental exposures including increases in air pollution, noise and temperature levels, as well as
reductions in green space (Khreis et al., 2016). Active modes of transport (e.g. cycling, walking) are those ways of travelling involving
physical activity during the whole trip or as a part of it. Evidence indicates that shifting from a non-active to active transport increases
physical activity, reduces obesity, noise and air pollution, trafc injuries and social isolation (Brown et al., 2017; de Nazelle et al.,
2011; Maizlish et al., 2017; Martin et al., 2015; Sugiyama et al., 2013).
Additionally, studies have shown that health benets of cycling outweigh risks of injuries and mortality (Andersen et al., 2018; de
Hartog et al., 2010; Mueller et al., 2015). Public transport is also associated with increased physical activity (Besser and Dannenberg,
2005; Voss et al., 2016) since most transit trips involve walking to/from transportation stops or between transport modes (van Soest
et al., 2019). Probably because of this, public transport use is related to other health benets such as reduced obesity, hypertension,
diabetes, and mental disorders when compared with travel by private motor vehicles modes (Tajalli and Hajbabaie, 2017). Cel-
is-Morales et al. (2017) examined a sample of 263,000 participants from the prospective UK Biobank study and found that commuting
by bicycle was associated with a lower risk of cardiovascular disease, cancer, and all-cause mortality, while walking was associated
with a lower risk of cardiovascular disease only. The authors argue that active commuting should be encouraged to reduce the risk of
death and the burden of important chronic conditions. Prior research using objective measures of health outcomes, such as BMI, waist
circumference (Tajalli and Hajbabaie, 2017), lipid prole (Xu et al., 2013) and mortality (Celis-Morales et al., 2017) are valuable since
they helped to show some health benets related to transport modes and overcome the limitations of self-reported data. Research using
metabolic biomarkers has not been extensively explored, and it would provide more strength to the evidence of the health impacts
related to transport modes. For instance, vitamin D levels are higher among those with more outdoorsactivities and active
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
3
commuting (Donneyong et al., 2016; Solis-Urra et al., 2019). Since vitamin D synthesis is mainly based on sunlight, both active and
public transport modes can be expected to increase vitamin D levels. Physical activity has been associated with lower levels of hepatic
inammation markers (Keating et al., 2012). It could be suggested that those using more active modes of transport could have a better
hepatic prole. To our knowledge, there is no prior research evaluating the association between public transport and active transport,
analysed separately, with Vitamin D or hepatic inammation markers.
The evidence showing the relationship between transport modes and health outcomes in Latin American is scarce and mixed,
focusing mainly on active commuting. Ramírez-V
elez et al. (2017) found that Colombian children and adolescents who regularly
commuted to school by bicycle showed a lower incidence of metabolic syndrome and better physical tness than their non-cyclist
counterparts. Another study that analysed Colombian university students showed that those who walked to campus were less likely
to have high blood pressure, obesity and low HDL cholesterol (García-Hermoso et al., 2018). Counterintuitively, in Brazil, Treff et al.
(2017) showed a protective effect of leisure-time physical activity against hypertension amongst adult women, but not for physical
activity during transportation. To our knowledge, only two studies have explored this topic in Chile. Both of them used data from the
ENS 2010, and both found associations of travel-related physical activity and cardiometabolic markers such as triglycerides, waist
circumference, BMI as well as health outcomes such as metabolic syndrome and diabetes (Sadarangani et al., 2018; Steell et al., 2018).
However, as in the aforementioned Latin American studies, the associations of public transport and health have not been individually
examined yet, therefore, we do not know if public transport by itself may also contribute to an improved cardiometabolic prole in
Latin America.
Chile is a very centralised country, with approximately 40% of its population living in its capital city, Santiago (INE, 2018). The
country is motorising quite fast; in 2002 there were 144 cars per 1,000 inhabitants (Roque and Masoumi, 2016), while now this has
risen to around 270 (INE, 2017). The modal share has also changed quite drastically in the last decades. In the case of Santiago, the
modal share of private car use increased 12% in 1977 to 46% in 2012 (SECTRA and Universidad Alberto Hurtado, 2014), despite
massive investments in an impressive Metro network and public transport subsidies. Some Chilean cities have seen a remarkable
increment in bicycle use. In the case of Santiago, according to the citywide origin-destination survey, cyclings contribution to urban
mobility doubled between 2001 and 2012, reaching 4% of daily trips ( SECTRA and Universidad Alberto Hurtado, 2014). Since then,
most observers agree that bicycle use has kept growing in Santiago, fed by active cycling advocacy groups (Sagaris, 2015); a broader
and better bike path network; and the appearance of docked and dockless public bikes in the most afuent area of the city.
In Chile, transport investments are carefully evaluated before implementing them (OECD, 2017). This involves a quite rigorous
process, in which future ows and levels of service are predicted, to decide whether a given project should move ahead. Based on this
prediction, several direct impacts as time savings or operational costs are estimated. Although methodologies to include indirect
health-related impacts, such as pollution, crashes and injuries, have been developed, they are still waiting to be incorporated (Min-
isterio de Desarrollo Social de Chile, 2019): the impact of transport mode choice on individual health has been largely ignored.
Planners are aware that someone shifting from car to cycle for the commuting trip would receive important health benets at the
individual level. However, the current cost-benet methodology to evaluate the convenience of infrastructure projects neglects in-
dividual health impacts. Thus, if the time taken by the bike trip takes longer than by car, the methodology might treat the modal shift as
a cost, which appears as a contradiction given the personal option of the traveller and the positive health impacts. Thus, identifying an
association between mode choice and health condition is relevant to incorporate a key attribute that differentiates between different
transport modes, especially between active modes as walking and bicycling, and passive transport modes as the automobile.
There is a paucity of studies about the association between transport and objective measures of health as anthropometric and
metabolic markers using nationally representative samples worldwide, especially among Latin American countries. Given that, the
recent ENS 20162017 added a new, specic question about the main type of transport and added new metabolic markers (e.g. serum
vitamin D). It, therefore, provides an opportunity to further explore the relationship between active transportation and objective
measures of health in Chile. The primary aim of this study was to assess the association between demographic and socioeconomic
factors with transport mode. The secondary aim was to explore the association between anthropometric and metabolic markers with
transport mode.
2. Methods
2.1. Data source and sample
ENS 20162017 was a household survey with a stratied multistage probability sample of 6,233 non-institutionalised participants
aged 15 years from urban and rural Chile including the 15 Chilean geographical regions. The data collection was done between
August 2016 and March 2017. Sample size was calculated with 20% relative error for the estimation of national prevalence over 3%.
One participant per household was randomly selected using a computational Kish algorithm. Response rate was 67%; refusal rate was
9.8%, with no replacements. The study protocol and ethical consent forms were approved by the ethics committee of the Ponticia
Universidad Cat
olica de Chile (PUC) and the Ministry of Health. A team of lay interviewers and certied nurses were trained and
supervised to apply the survey using electronic devices for data capture. In the rst home visit, a lay interviewer applied health
questionnaires, including a question on the main type of transport used at least once a week. A trained nurse applied questionnaires,
measured anthropometry (waist circumference, weight and height) and performed multiple biological sampling in a second-day visit
to 89% of the sample. Excluding the missing values on mode of transport (n ¼110), the analysed sample consisted of 6,113
participants.
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
4
2.2. Variables analysed
Mode of transport: self-reported main mode of transport measured with the following question: out of the following alternatives,
what is the transportation mode you most frequently use, at least once a week?. Three categories of transport were created based on
the original response categories 1. Motor vehicle (vehicle driver or light vehicle passenger); 2. Active modes (cycling or walking) and 3.
Public transport.
Anthropometry: nurse measurement of waist circumference (WC) in cm, body mass index (BMI) in kg/m
2
and obesity (BMI30 kg/
m
2
).
Laboratory analyses: all blood samples were run at a central laboratory (UC Christus). Serum vitamin D: Serum 25-Hydroxy
Vitamin D2 and D3 (ng/mL) were measured among females 1549 years and males and females of 65 or older, using liquid
chromatography-tandem mass spectrometry (LC-MS/MS) (Q TRAP 4500/AB SCIEX). We used the sum of D2 and D3. Serum total
cholesterol (mg/dL) was measured using an enzymatic, colorimetric method (CHOD-PAP). Cholesterol samples with 9 h or more of
fasting were included in the analyses. Gamma-glutamyltransferase (GGT) (U/L) was measured using an enzymatic, colorimetric
method. Alanine transaminase (ALT) (U/L) was measured with UV test according to the IFCC method without pyridoxal-5-phosphate
activation. Total cholesterol, GGT and ALT were measured among a random subsample of 62% of the total sample, using the Cobas
8000-c702/Roche. Details of the laboratory methods and variation coefcients are described elsewhere (Ministerio de Salud de Chile,
2018).
Healthy lifestyles: Current smoker was dened as occasional or daily smoker. Water intake was measured with the following
question: How many glasses of water do you drink daily?and it was dichotomized into <6 or 6 glasses/day. Reduced-fat dairy
consumption was dened according to the question: What kind of dairy do you preferably consume?. Three categories were con-
structed: 1. dairy-free diet, 2. skimmed/low-fat and 3. Whole milk. Fruit and vegetable consumption, according to the number of days
per week and the number of portions per day in a typical week, was dichotomized into <5 or 5 portion/day. Alcohol use disorders
were assessed with the AUDIT score. Frequency of physical activity during leisure time was measured with the following question: In
the last month, did you practice sports or physical activities outside of your work schedule, for 30 min or more each time?with four
options as answers: 1. 3 times/week, 2. Once or twice/week, 3. <4 times/month and 4. No sports in the last month.
2.3. Statistical analyses
We described the sample of 6,113 participants with valid data in mode of transport, according to gender, age (mean and categories:
1524, 2544, 4564, 65 years) educational level (i.e. low:<8y, medium:8-12y, high:>12y of formal education) and urban/rural
residence.
For the rst aim we analysed mode of transport as the outcome and age, gender, educational level and urban/rural residence as the
exposure variables. First, the distribution of modes of transport was described according to the exposure variables. Secondly, separate
multinomial logit regression models were performed to determine the associations between the transport mode and age, gender,
educational level and urban/rural residence. Models were adjusted for age and gender. Age was included in the models as a continuous
variable; the other independent variables were entered as categorical. From these models, we estimated Relative Risk Ratios (RRR)
with accompanying 95% condence intervals (95% CI) for active and public transport, using motor vehicle as the reference category.
For the second aim we analysed WC, BMI and obesity as the outcomes and mode of transport as the exposure variable. First, we
described mean WC, mean BMI and obesity prevalence with 95% CI according to mode of transport and gender. Secondly, associations
between WC and BMI with mode of transport were calculated by linear regression, and associations between obesity and mode of
transport using logistic regression. Three regression models were performed for each outcome (WC, BMI and obesity) and stratied by
gender: model 1, non-adjusted; model 2, adjusted by age; model 3, adjusted by age and healthy lifestyles: current smoker, water intake
6 glasses/day, reduced-fat dairy consumption, fruit and vegetable consumption 5 portion/day, AUDIT score and frequency of
physical activity during leisure time. Age and AUDIT score were included in the models as continuous variables; the other independent
variables were entered as categorical. Thirdly, gender-specic serum vitamin D, total cholesterol, ALT and GGT levels were also
evaluated against transport mode using the three models described above. Vitamin D analyses were stratied in two age groups (15-
49y and 65y) and self-reported sunlight exposure (little or a lot in the last week) was also included in the model (3).
Analyses were based on complete-cases. We used the appropriate weights in all analyses; these account for differences in selection
probability and minimise bias from non-response. P-values <0.05 were classed as signicant (two-tailed). All analyses were conducted
in Stata V14.0 (StataCorp LP, College Station, Texas) adjusting for the complex survey design.
3. Results
3.1. Descriptive statistics of the sample
The total ENS 20162017 sample included 6,233 participants aged 15 years, of whom 6,113 had valid information on transport
modes and demographic variables, and 5,385 and 5,382 had valid measures of BMI and WC respectively. Demographic characteristics
of the sample with valid data on transport mode are presented in Table 1.
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
5
3.2. Mode of transport associated with socio-demographic variables
As seen in Fig. 1, motor vehicle was the most frequently reported transport mode (41%); followed by public transport (38%) and
active modes (21%). The use of public transport was higher among females (44% females; 31% males) while the prevalence of motor
vehicle use was lower for females (36% females; 47% males). Active travellers were: 15%, walkers (17% females; 13% males) and 6%
cyclists (3% females, 9% males). Chile, a long narrow country, has 15 geographical regions. The main type of transport varied by
geographical region, with highly populated regions (located centrally in the country) having higher rates of public transport use, as
shown in Fig. 2.
The age-adjusted multinomial regression (Fig. 3) showed that females were more likely than males to use public transport, with a
Relative Risk Ratio (RRR) of 1.90 (95% CI 1.55, 2.32, reference: motor vehicle). Active and public transport decreased with age (RRR
¼0.56 (0.380.82) and RRR ¼0.35 (0.250.49), respectively, age 65 vs 15-24y); participants with low level of education were more
likely to use active transport than were those of high education level (RRR ¼1.73 (1.282.33); while participants residing in rural
areas were more likely to use active transport (RRR ¼1.27 (0.971.67)) and less likely to use public transport than those residing in
urban areas (RRR ¼0.71 (0.520.97)).
3.3. Anthropometric and metabolic markers associated with mode of transport
Descriptive statistics for WC, BMI and obesity by transport mode are shown in Fig. 4. The regression models showed gender dif-
ferences in the associations between the anthropometric measures and transport mode (Table 2). BMI was associated with transport
mode among males and females, however, WC and obesity were associated with transport mode only among males. Among males.
these associations were signicant (p <0.001) in the crude model (1), age-adjusted model (2) and in the fully adjusted model (3). Men
using active transport showed an odds ratio (OR) estimated by model (3) of 0.53 (0.350.81) of being obese compared with motor
vehicle users. WC was 5.20 cm (3.297.11) smaller and BMI was 1.90 kg/m
2
(1.142.65) lower among male active than motor users.
Similar signicant associations were found among males when comparing public versus motor vehicle transport in the fully adjusted
model (3). Among females, active transport was associated with signicantly lower mean BMI (β ¼  0.84 (1.67 to 0.02)) than
motor vehicle transport in the fully adjusted model (3). Additional analyses pooling both genders showed similar associations to those
described among males (see Table 1, Supplemental Digital Content 1, which shows the regression coefcients with their 95% CI for all
persons).
Higher levels of vitamin D were found among females of both age groups using active transport compared with public transport
when the fully adjusted model (3) was used (β ¼2.71 mg/dL (0.744.67) for those aged <50y and β ¼2.85 mg/dL (0.565.15) for
those aged 65y). Higher levels of vitamin D were found among males and females aged 65y using active transport compared with
motor vehicle (β ¼3.98 mg/dL (1.466.50) for males; β ¼2.69 mg/dL (0.614.77) for females). Total cholesterol was lower among
Table 1
Sample characteristics. Chile, ENS 20162017.
Variable Category n
a
% or mean (95% CI)
Sociodemographic characteristics
Gender Males 2,262 48.9% (46.651.1)
Females 3,851 51.1% (48.953.4)
Age (y) x 6,113 43.0 (42.243.8)
1524 831 19.1% (17.320.9)
2544 1,794 37.4% (35.039.8)
4564 2,028 30.5% (28.532.6)
65 1,460 13.1% (11.814.5)
Zone Urban 5,136 88.8% (87.390.1)
Rural 977 11.2% (9.912.7)
Educational level (years of formal education) Low (<8) 1,425 16.3% (14.418.3)
Medium (812) 3,272 55.5% (52.658.4)
High (>12) 1,362 27.6% (24.830.7)
missing 54 0.5% (0.30.9)
Anthropometric measures
Waist (cm) x 5,382 93.2 (92.693.9)
BMI (kg/m
2
) x 5,385 28.5 (28.328.8)
Metabolic markers
Vitamin D (ng/mL, males 65y) x 447 21.3 (19.822.8)
Vitamin D (ng/mL, females <50y) x 1580 20.1 (19.320.8)
Vitamin D (ng/mL, females 65y) x 792 17.7 (16.818.6)
Total cholesterol (mg/dl) x 3,471 177.3 (175.0179.6)
ALT (U/L) x 3,619 25.6 (24.526.7)
GGT (U/L) x 3,631 30.5 (28.632.5)
a
Non-weighted sample sizes. Weighted estimation with 95% condence intervals (95% CI).
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
6
males using active and public transport than motor vehicle (β ¼  13.78 mg/dL (21.3 to 6.26) and β ¼  8.58 mg/dL (16.99 to
0.18), respectively); the opposite was seen among females when comparing active transport versus motor vehicle (β ¼8.07 mg/dL
(1.1015.04)). Among males, active and public transport users had lower levels of ALT when compared to motor vehicle users (β ¼
5.81 U/L (9.61 to 2.03) and β ¼  5.18 (9.37 to 1.00), respectively); among males, GGT showed lower levels among public
transport than motor vehicle users (β ¼  9.89 U/L (15.92 to 3.87)) (see detailed results in Table 2).
4. Discussion
This analysis from a large representative sample of the Chilean adult population indicates that around 41% were using public
transport, 38% motor vehicle and 21% active modes (cycling and walking) as the main modes of transport in Chile during 20162017.
We found higher levels of active transport among males, younger groups, less educated and rural populations. This pattern has also
been reported in other countries (Nehme et al., 2016; Reis et al., 2013; S
a et al., 2018; Titze et al., 2014). Our results on active transport
are consistent with those reported by Aguilar-Farias et al. (2019) using the Chilean National Environment Survey (CNES) 2014 and
2015, where cycling prevalence was 7%, with higher use among youth and participants of low socioeconomic status. According to the
CNES2015, females tended to walk more than males, however, the overall prevalence of active transport was similar by gender
(Ministerio del Medio Ambiente de Chile, 2018). This study broadens the evidence obtained by the transportation sector, where trips
rather than prevalence were studied. The Chilean Origin-Destination Survey (EOD) 2012 showed that around 30% of the trips in
Santiago were made by public transport, another 30% by motor vehicle and around 40% were made walking or cycling (SEC-
TRAUniversidad Alberto Hurtado, 2014). Our results showed that Santiago had higher use of public transport (around 50%) and lower
of active transport (20%). However, these differences between EOD and ENS are expected, because the questions were different. ENS
asked about the transportation mode most frequently used (at least once a week) in a sample aged 15y while EOD described total trips
in a given week-day and a weekend day with no age restrictions.
Our study showed that anthropometric benets are associated with active and public transport in males: we found lower WC, BMI
and obesity than in motor vehicle users. We also found lower BMI among females using active transport than motor vehicles, but the
magnitude of the association was 58% smaller than among males (0.9 versus 1.9 kg/m
2
for females and males, respectively). We ran
three models to analyse the associations and the effects of potential confounders. The likelihood of being obese was lower for male
active travellers compared with motor vehicle travellers. This held after adjusting for fruit-vegetable, alcohol and water consumption
as well as physical activity and smoking. Other benets were associations with decreased levels of hepatic enzymes, lower total
cholesterol and a higher level of serum vitamin D. Our study described a dose-response relationship with transport modes. Increased
health benets were seen among active transport users (cycling or walking), followed by mid benets among public transport users
when compared with motor vehicle users. According to our fully adjusted model, WC, BMI, obesity, total cholesterol and hepatic
enzymes were signicantly lower among male public transport than motor vehicle users.
Our results are in line with the benecial associations of active transport on BMI described in Chile by Steell et al. (2018) using ENS
2010. They reported that 30 min increase in active transport measured by the Global Physical Activity Questionnaire (GPAQ) was
associated with lower odds for obesity, with an OR of 0.93 (95% CI 0.88, 0.98). We found a stronger association between transport and
obesity in the fully adjusted model: OR ¼0.67 (0.520.86) for obesity when comparing active vs motor travel among males. Steel et al.
merged public and motor vehicle transport into a single category. We highlighted the importance of differentiating the analysis be-
tween public and motor vehicle users. For instance, we found an OR for obesity among males of 0.64 (0.430.96) when comparing
public with motor vehicle use. Steel et al. adjusted for gender but did not show stratied results. Our ndings showed stronger
Fig. 1. Type of transport by gender, age, educational level, urban or rural zone. Chile, ENS 20162017*.
*Educational level (years of formal education): Low (<8), Medium (812) and high (>12).
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
7
associations between transport and anthropometry in males, pointing out the relevance of gender-specic analyses. This gender
difference has been described by others (Falconer et al., 2015). Potentially, males tend to travel longer distances and perform more
vigorous physical activity than females. This may be a plausible hypothesis for Chile, given the results obtained from the analysis of the
GPAQ transport questions included in the ENS 20162017 (not shown) where males and females using active transport reported 79
and 58 min of transport-based physical activity, respectively. Associations of transport with vitamin D has been described in Chile
recently by Solis-Urra et al. (2019), using ENS 20162017 in women, but some concern arises with the absence of complex sampling
design on their variance estimation: variances are underestimated when complex sampling design is not considered. For instance,
using the complex sample design for variance estimation we did not nd a signicant association between transport and Vitamin D
among females aged 65y after adjusting for the confounding variables described by Solis-Urra (i.e. age, menopausal status, achieved
education level, geographical region, dairy consumption and sunlight exposure). According to our fully adjusted model for females
65y, we found an association between transport and vitamin D, but after region, BMI and menopause were included in this model,
signicance was lost (results available on request). According to a meta-analysis based on prospective cohorts, active commuting was
signicantly related to lower incidence of coronary events, stroke and heart failure (Dinu et al., 2019). This decrease in cardiovascular
risk could be partially explained by the improvement on the lipid prole. Aligned with our results, Zwald et al. (2018), using the U.S.
Fig. 2. Transportation modal share by each geographical region Chile, ENS 20162017*.
*The regions have been organized in the same order they are located geographically, from north to south with the densest ones located at the centre
of the territory.
Fig. 3. Multinomial regression of associations between gender, age, educational level, place of residence and transport modes. Chile, ENS
20162017*.
*RRR ¼Relative Risk Ratio. RRR were calculated using multinomial logistic regression. Models were gender and age-adjusted. The reference
category for the outcome was motor vehicle. Educational level (years of formal education): Low (<8), Medium (812) and high (>12).
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
8
National Health and Nutrition Examination Survey (NHANES) 20072016, found lower LDL cholesterol among active transport users.
Active and public modes of transport could decrease WC, BMI and obesity by mechanisms related to higher energy expenditure
(Besser and Dannenberg, 2005; Voss et al., 2016). Mechanisms by which active modes of transport could reduce hepatic inammatory
markers and improve the lipid prole are still greatly unknown, but physical activity linked to transport could decrease hepatic fat and
in this way reduce hepatic inammation (Farzanegi et al., 2019) and could also enhance the use of lipids by skeletal muscles, reducing
plasma lipid levels (Wang and Xu, 2017).
In recent decades Chile has shown a systematic drift of trips from active and public transport to the automobile. Only recently, few
cities have seen an encouraging growth of bicycle trips, most noticeably Santiago. Interventions aiming to increase more active modes
of transport are described as major opportunities for the improvement of public health (Celis-Morales et al., 2017). Our associations
suggest that incidental physical activity related to mass population transport could have a major role in public health. Our results may
contribute to the formulation of policies or investments to shift modal share towards more active modes of transport, since on the one
hand, they describe the baseline distribution of the main type of transport modes and, on the other hand, they describe the magnitude
of anthropometric and metabolic benets linked to differentiated modes of transport. This study underpins active modes promotion
policies where walking and cycling could be promoted serving as feeders for the transportation system, particularly in small and
mid-sized cities, where public transport is less available. Variations in patterns of use of active modes in Chile by geographical regions
highlight the need for appropriate local policies allowing for a range of climates and geographic features. For instance, the south-
ernmost region of Chile (XII-Magallanes) had the least use of active transportation modes, which is congruent with its cold and windy
climate and high levels of obesity compared to other Chilean regions. However, authorities from Magallanes have recently invested in
17.5 km of new bike routes and announced 60 km more to be added. In Magallanes, reinforcing public transport could also serve as a
health-enhancing local policy. Specic populations such as the less educated, females, rural and older groups would benet greatly
from cycling and pedestrian-inclusive policies which may help to tackle socioeconomic health inequalities (Gao et al., 2017). Also,
investment in infrastructure could help to increase active modes (Langlois et al., 2016).
Some of this studys strengths are the use of a big, nationally-representative sample of the adult general population, including all
socioeconomic groups from urban and rural areas; use of objective measures of health (i.e. not self-reported); analysis of public
transport as a separate transport mode (and not included with non-active modes) and adjusting for lifestyle risk factors (i.e. current
smoker, water intake, reduced-fat dairy consumption, fruit-vegetable consumption, alcohol use disorders and physical inactivity
during leisure time). However, our study has some limitations. The cross-sectional nature of the sample limits causal inferences, as
Fig. 4. Mean waist circumference, mean BMI and obesity (%) by type of transport and gender. Chile, ENS 20162017.
*BMI: Body Mass Index (kg/m
2
), Obesity: BMI30 kg/m
2
.
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
9
reverse causality and survival bias could be affecting our results. Moreover, other unobservable variables could affect our results (e.g.
motivation or availability of time), potentially introducing a bias towards rejecting the hypothesis of no association. Health status may
also inuence transport modes (healthier people choose more active modes): we did not adjust by health status, but we did adjust by
healthy lifestyles and benets were seen both in healthy and unhealthy lifestyle populations. Nevertheless, our ndings on obesity,
BMI and WC were consistent with population-based prospective longitudinal research, as reported by Flint et al. (2016) using the UK
Biobank data and by Qin et al. (2012) using the longitudinal China Health and Nutrition Survey data.
Chile has recently implemented policies for increasing the use of active transport modes, which is positive for health. The focus has
been in adding bicycle routes mostly in capital cities of each region and afuent areas of Santiago. From 2013 to 2018 the number of
bicycle lanes in Santiago increased 20-fold, from a total of 20 km of paths to 400 km, representing 10% of the cycling lanes in Latin
America (Ríos et al., 2015). Some other big cities, noticeably Rancagua, have followed this lead. Trafc calming areas, with maximum
speeds of 30 km/h, have been implemented in a few areas of Santiago (Ministerio de Transportes y Telecomunicaciones de Chile,
2014). INE, 2018, a new law regulating the ow of different modes in a road was passed. The law reduced the maximum speed of cars
from 60 to 50 km/h and ordered cyclists to use the road unless its cycling conditions were considered unsafe (Ministerio de Transportes
y Telecomunicaciones de Chile, 2018). Finally, pedestrianised streets have increased in business districts of a few Chilean cities, but
they are still quite insignicant. Including the same transport question in the next ENS will be key for surveillance of the health impacts
of transport policies and investments in transportation infrastructure. Including this question may be a low-cost surveillance method
that could be used by other countries. Future research using longitudinal data from the Chilean population would help to clarify the
causality of the associations between transport and objective measures, particularly if examined only among participants who were
Table 2
Mode of travel associations with anthropometric and metabolic markers by gender. Chile, ENS 20162017.
Males Females
Outcome Travel mode Sample
size
#
β Model 1 β Model 2 β Model 3 Sample
size
#
β Model 1 β Model 2 β Model 3
Anthropometry
Waist (cm) Active vs MV 1,958 5.76*** 5.33*** 5.20*** 3,418 1.73* 1.13 1.14
Public vs MV 5.72*** 4.02*** 3.91*** 1.41 0.79 0.96
Public vs
active
0.04 1.31 1.29 0.32 0.34 0.18
BMI (km/m
2
) Active vs MV 1,956 1.99*** 1.91*** 1.90*** 3,423 0.97** 0.82* 0.84**
Public vs MV 1.57*** 1.25*** 1.22*** 0.59 0.44 0.51
Public vs
active
0.42 0.67 0.67 0.37 0.38 0.34
Obesity (OR) Active vs MV 1,956 0.53*** 0.54*** 0.53*** 3,423 0.80 0.81 0.80
Public vs MV 0.60*** 0.64** 0.63** 0.82 0.84 0.82
Public vs
active
1.13 1.20 1.20 1.03 1.04 1.03
Metabolic markers
Vitamin D (ng/m)
[<50y]
Active vs MV N/A N/A N/A N/A 1,577 1.99** 2.00** 2.00**
Public vs MV N/A N/A N/A 0.85 0.85 0.75
Public vs
active
N/A N/A N/A 2.85*** 2.85*** 2.75**
Vitamin D (ng/m)
[65y]
Active vs MV 446 2.10 2.02 3.99*** 792 2.42** 2.33* 2.56**
Public vs MV 2.17 2.22 2.07 0.05 0.14 0.26
Public vs
active
0.07 0.20 1.92 2.46** 2.47** 2.82**
Total Cholesterol (mg/
dL)
Active vs MV 1,256 16.45*** 15.26*** 13.78*** 2,210 4.75 7.24** 8.07**
Public vs MV 13.35*** 9.44** 8.58** 1.65 0.93 1.77
Public vs
active
3.09 5.83 5.20 6.40* 6.31* 6.30*
ALT (U/L) Active vs MV 1,321 6.31*** 6.37*** 5.82*** 2,293 2.06 1.76 2.08
Public vs MV 5.33** 5.54** 5.18** 1.01 0.71 0.98
Public vs
active
0.98 0.83 0.64 1.06 1.05 1.09
GGT (U/L) Active vs MV 1,325 4.52 3.54 2.57 2,301 3.88 2.52 2.06
Public vs MV 13.63*** 10.44*** 9.89*** 4.85** 3.48 3.86*
Public vs
active
9.11** 6.90* 7.32* 0.98 0.96 1.80
Note: *p<0.1, **p<0.05, ***p<0.01. Linear regression coefcients (β) for the association between transport mode and waist circumference, Body
Mass Index (BMI), vitamin D, total cholesterol, Alanine transaminase (ALT) and Gamma-Glutamyl transferase (GGT). Logistic regression Odds Ratio
(OR) for the association between transport mode and obesity (BMI 30 kg/m
2
). Model 1: non-adjusted; Model 2 adjusted for age and gender; Model 3:
adjusted for age, gender, smoking, water intake 6 glasses/day, reduced-fat dairy consumption, fruit and vegetable consumption 5 portion/day,
alcohol (AUDIT score) and frequency of physical activity during leisure time sedentarism. Vitamin D model 3 results were also adjusted for sunlight
exposure (self-reported as littleor a lotin the last week). MV: Motor Vehicle; N/A: non-available data. #Model 1, 2 and 3 used the sample with
valid data in model 3.
A. Passi-Solar et al.
Journal of Transport & Health 17 (2020) 100819
10
healthy at baseline, and thus did not base their mode choice on pre-existing impairments, and to understand the gender inequities we
found.
The evidence to support transport planning decisions in local communities is growing in Latin America, as part of the broader
spectrum of planning decisions that lead to healthy communities. There is no doubt that health is strongly related to the built envi-
ronment people live in (Koehler et al., 2018) and transport is a very important component of this environment and vice versa.
5. Conclusions
In Chile, both active transport (cycling and walking) and public transport use were associated with multiple nutritional and
metabolic benets such as lower BMI, lower waist circumference, less obesity, higher vitamin D, lower cholesterol and lower hepatic
inammation. Stronger benets were seen in males than in females. These ndings are important evidence for transport planning
policies and a great opportunity for the local design of population-wide preventive strategies to tackle chronic diseases, decrease
gender, regional and socioeconomic inequities and to improve the quality of life of the population.
Financial disclosure
ENS 20162017 was funded by the Chilean Ministry of Health. Vitamin D laboratory analyses were funded by the Ponticia
Universidad Cat
olica de Chiles School of Medicine. The authors did not receive any specic funding for this work.
CRediT authorship contribution statement
Alvaro Passi-Solar: Methodology, Formal analysis, Investigation, Data curation, Writing - original draft. Paula Margozzini:
Methodology, Investigation, Writing - original draft, Supervision. Andrea Cortinez-ORyan: Writing - original draft, Writing - review
& editing. Juan C. Mu~
noz: Methodology, Writing - original draft. Jennifer S. Mindell: Conceptualization, Methodology, Writing -
review & editing, Supervision.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jth.2019.100819.
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... Engaging in outdoor jogging is a highly sought-after aerobic exercise that immensely benefits one's physical and mental well-being (Cook, 2021;Cook et al., 2016;Deelen et al., 2019;Pascual et al., 2009). This activity positively impacts cardiovascular endurance, reduces stress, and enhances overall mood (Bodin and Hartig, 2003;Passi-Solar et al., 2020;Pretty et al., 2005;Wolf and Wohlfart, 2014). Additionally, it is a wonderful way to inspire people to lead active lifestyles, enjoy the great outdoors, and decrease healthcare costs. ...
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Jogging, historically marginalized in the realms of urban and transportation strategy since it is not about commuting , is garnering appreciation for its health-related merits. The growing public focus on health underscores the urgent need for planning and infrastructure to support outdoor physical activities, yet current evaluations of urban environments' friendliness toward such activities are insufficient. This investigation unveils a runnability evaluation framework predicated on accessible geospatial big data. Initial steps involved delineating potential metrics from the built environment, pedestrian perceptions, and the natural setting, as informed by literature. This was followed by constructing a backward stepwise regression analysis, utilizing jogging frequency as the response variable against the identified metrics as predictors. The ensuing model retained certain variables, which were then deemed valid metrics, and their regression coefficients were appropriated as weights to compute a runnability index for individual street segments. This framework was applied in Guangzhou, affirming the mod-el's objectivity and validity. The introduced framework furnishes researchers and urban planners with an objective and reproducible tool for the evaluation of runnability and possesses the versatility for an extension to assess walkability and bikeability. This study encourages the attention and support of jogging activities.
... Evidence shows that changing from passive to active transportation increases physical activity and reduces obesity, noise and air pollution, traffic injuries and social isolation [6]. The use of these active modes not only leads to health benefits such as higher heart and breathing fitness and other improved heart health indicators but also to other benefits including better mental health [7] for both tourists and local society. ...
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The aim of this study is structural modeling of the impact of the coronavirus pandemic on active post‐pandemic transport in Dorood City, Iran, emphasising both tourism and development of a long‐term tourist market through the promotion of low‐carbon travel markets.The research tool was a researcher‐made questionnaire randomly distributed among citizens of Dorood City. The impact of various factors, including economic, social, medical, and accessibility, on active transportation during the pandemic and its impact on transportation in the post‐COVID‐19 era has been investigated.The social factor has the highest factor load with a weight of 0.94. In contrast, with the lowest factor load i.e., 0.60, the economic factor proved to have the least impact on the choice of active transportation. It was found that the variable of active transport use in the post‐pandemic era with a factor load of 0.66 is the most influential factor, while the social consequences of the pandemic in the post‐pandemic era with a factor load of 0.49 turned out to be the most significant. The least effective ariable was found to occur in the post‐pandemic era.Active transport links during the pandemic in Dorood City with a regression coefficient of 0.77 had a statistically significant impact on the use of this type of transport in the post‐pandemic period. This data can be incorporated in the transport development plan with an emphasis on active transfer as an effective option for the development of sustainable tourism.
... These measures promote transport-related physical activity, lower body mass index, and reduce obesity (Mertens et al., 2017;Smith et al., 2017;Zhang et al., 2022). Public transport, such as buses, can also increase walking time and promote active lifestyles, potentially adding 16 min of walking per day and increasing the proportion of active individuals by 6.97 % if promoted among the inactive population (Passi-Solar et al., 2020;Rissel et al., 2012). However, there is limited evidence regarding associations with lower obesity, diabetes, or hypercholesterolemia. ...
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Promoting pro-environmental mobility, such as walking, cycling, reducing car usage, and using public transport, can improve population health and create sustainable environments. However, accessibility of resources and socioeconomic status, along with environmental awareness, can affect these behaviors. To explore the impact of socioeconomic status and resident place on awareness and active mobility, we analyzed data from the Eurobarometer 2019 survey (n = 27,498 individuals aged over 14 years) using structural equation modeling. We focused on the association between socioeconomic status (subjective social class, education, economic issues) and community size (rural, small urban, large urban areas) with pro-environmental awareness and intentions in the European Union. Pro-environmental awareness partially mediated the relationship between socioeconomic status and intentions for pro-environmental mobility, such as using car alternatives, reducing unnecessary car trips, and improving public transport. Socioeconomically disadvantaged groups (with low education, social class, and economic issues) reported lower awareness and intentions, while community size had minimal influence (0 < β < 0.1). Moreover, a social gradient in pro-environmental active mobility intentions was observed across European countries. These findings highlight the need for public health policies to address social and economic inequalities and promote environmental awareness to encourage alternative active mobility options among disadvantaged individuals.
... PI as a context-dependent and cross-disciplinary behavioral health has been associated with socioeconomic and built-environment factors (Aljabri 2022;Prince et al. 2022;Rütte et al. 2013). In terms of the built environment, urban characteristics such as urban form (e.g., residential density and high connectivity street network), neighborhood safety, and green space (Xiao et al. 2022;Peng et al. 2021;Passi-Solar et al. 2020;Feng and Astell-Burt 2019;Andersen et al. 2018) have received increased attention due to their associations with PI, obesity, and cardiovascular disease (Adlakha et al. 2021;Sims et al. 2020;An et al. 2019;Lenhart et al. 2017;Xu et al. 2015;Unger et al. 2014). Evidence suggests that the built environment can positively or adversely influence health behaviors. ...
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The increase in physical inactivity prevalence in the USA has been associated with neighborhood characteristics. While several studies have found an association between neighborhood and health, the relative importance of each component related to physical inactivity or how this value varies geographically (i.e., across different neighborhoods) remains unexplored. This study ranks the contribution of seven socioecological neighborhood factors to physical inactivity prevalence in Chicago, Illinois, using machine learning models at the census tract level, and evaluates their predictive capabilities. First, we use geographical random forest (GRF), a recently proposed nonlinear machine learning regression method that assesses each predictive factor’s spatial variation and contribution to physical inactivity prevalence. Then, we compare the predictive performance of GRF to geographically weighted artificial neural networks, another recently proposed spatial machine learning algorithm. Our results suggest that poverty is the most important determinant in the Chicago tracts, while on the other hand, green space is the least important determinant in the rise of physical inactivity prevalence. As a result, interventions can be designed and implemented based on specific local circumstances rather than broad concepts that apply to Chicago and other large cities.
... There is a possible two-way association among health, functional statuses and transportation reliance. For example, older adults who are less able to travel outside their homes may be in poorer health and wellbeing (56), while older adults who are traveling outside more and who use public transportation gained multiple nutritional and health benefits (57). ...
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Introduction Aging is associated with physiological changes in multiple systems in the body and may impact the transportation choices of older adults. In this study, we examine the associations between biopsychosocial factors and the transportation choices of Malaysian older adults. Methods One hundred and nineteen (119) older adults, aged 60 and above, living in Klang Valley, Malaysia were recruited for this cross-sectional study. Participants were interviewed face-to-face to obtain sociodemographic data, health status (whether there were and, if yes, the number of comorbidities), outdoor mobility and transportation patterns, Instrumental Activity Daily Living (IADL) status and cognitive function. Participants’ physical performance (dominant handgrip strength, 10-m walk, and timed up and go tests), hearing threshold (pure tone audiometry), and vision function (visual acuity, contrast sensitivity) were measured. Transportation patterns of older adults were categorized into three groups, that is, flexible (using public transport and/or private vehicles), using only private vehicles and restricted (relying on others or walking). Results Further information is needed to enable such older adults as older women, those with comorbidities and poorer functional status to access transportation, especially to meet their health care needs. Discussion The majority (51%) of participants were in the ‘using only private vehicles’ group, followed by the ‘flexibles’ (25%) and the ‘restricted’ (24%). Factors significantly associated with the restricted transportation group were: (a) being female (AdjOR 15.39, 95% CI 0.86–23.39, p < 0.001); (b) being Malay (AdjOR 21.72, 95% CI 0.36–16.12, p < 0.001); (c) having higher number of comorbidities (AdjOR 14.01, 95% CI 0.20–13.21, p = 0.007); and (d) being dependent in IADL (AdjOR 13.48, 95% CI 0.51–1.78, p = 0.002).
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Background Previous studies have examined the impact of greenway interventions on physical activity (PA); however, the results have been inconclusive. In order to address this issue, our study conducted a systematic review with meta-analysis to thoroughly evaluate the evidence and determine the effectiveness of greenway interventions in promoting PA. Methods We conducted a comprehensive search of literature databases, such as Web of Science, EMBASE, PubMed (via Medline), Cochrane Library, and Scopus, up to June 15, 2023. To synthesize the available evidence, we performed a meta-analysis using a random effects model. The quality of the included studies was assessed using the criteria developed by the Agency for Healthcare Research and Quality and the Newcastle-Ottawa Scale. Results A total of 9 publications were identified, involving 6, 589 individuals. The overall quality of most included studies was rated as moderate to high. Our study found that the greenway was effective in promoting PA among participants. Specifically, active travel (AT) showed a standard mean difference (SMD) of 0.10 [95% confidence interval (CI): 0.04 to 0.17], moderate-to-vigorous PA had an SMD of 0.11 (95% CI: 0.02 to 0.20), and total PA had an SMD of 0.14 (95% CI: 0.06 to 0.21). We also observed significant differences in AT levels among participants based on greenway characteristics, exposure distance, exposure duration, and male-to-female ratio. Discussion Newly developed or upgraded greenways have been shown to effectively promote PA. Additionally, research suggests that the longer a greenway has been in existence, the greater the benefits it provides for PA. As a result, the construction of greenways should be recognized as an effective public health intervention.
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This study seeks to contextualize the literature related to the urban transport of people and health. The methodology consisted of a systematic literature review, considering papers published between 2016 and 2021. Some 438 articles were selected for the initial analysis. It was observed that the most recurrent themes were analyses on transportation accessibility and health, and the impacts of active transportation and the built environment on health. Some 173 articles on travel behavior impacts were thoroughly analyzed. The most commonly evaluated health determinants were level of physical activity and obesity. Some studies applied standard questionnaires for health self-assessments. The analyses showed that mental/psychological well-being can have multiple dimensions. Most studies evaluated health determinants using statistical tools, specifically regression models and structural equation models. Health impact assessment was also applied recurrently in the analyzed articles. This study presents theoretical and practical implications, contributing to the state-of-the-art by theoretically deepening understandings of the relationships between transport and health. We also highlighted health aspects, methods, and data collection instruments that could be used in future studies. A better understanding of these relationships can also aid in developing public transportation strategies and policies that help move people and promote social-economic development, while also positively affecting individual physical and mental well-being.
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Few studies have investigated the influences of the multilevel built environment (BE) factors on jogging, compared with walking or cycling. This study explored neighborhood and street-level BE factors' associations with fitness jogging via multi-source urban data. Empirical analysis of Chengdu, China showed the following: (1) BE factors, including sky view factor, bus stop density, presence of waterscapes, and geographic location significantly, impact jogging activity. (2) The significance and effect of BE factors vary across time. Jogging activities are more sensitive to BE on weekends than on weekdays. (3) Jogging trips are more closely related to BE factors in urban areas than in the suburbs. Jogging activities are mainly affected by the artificial environment in urban areas and the natural environment in suburban areas. Moreover, the effects of multiple BE factors become obvious as trip distance increases. These findings call for urban planning and infrastructure provision strategies to promote jogging activities.
Thesis
Background: Up-to-date information on hypertension prevalence and management indicators (awareness, treatment, control); measures of its socioeconomic inequalities; and their impacts are required in Chile. This PhD aims to quantify the prevalence of these indicators, the magnitude of their socioeconomic inequalities, and their association with mortality risk among adults in Chile 2003, 2010, and 2017. Methods: First, using 2003, 2010, and 2017 Chilean national health surveys (ENS) I analysed secular changes in levels of hypertension outcomes by demographic variables. Secondly, I analysed socioeconomic position (SEP) inequalities in hypertension outcomes using individual-level measures (educational level, income, and health insurance). Thirdly, using a multilevel approach, I evaluated the association between individual educational level and hypertension prevalence, before and after adjustment for socioeconomic environment measures (county-level income inequality, poverty, and unemployment). Finally, I analysed all-cause and cardiovascular mortality rates by educational level and hypertension status using ENS data linked with mortality registries. Results: Between 2003 and 2017, hypertension prevalence decreased (34%-31%), awareness increased slightly (58%-66%), whereas treatment (38%-65%) and control (13%-34%) levels increased substantially. Hypertension management levels were lower among males than females. Secondly, hypertension prevalence was higher among adults with lower levels of education. Inequalities by education in hypertension prevalence, untreated, and uncontrolled hypertension were more pronounced among females. Thirdly, multilevel analyses showed that the magnitude of inequalities by education level were minimally affected by socioeconomic environment measures. Finally, I found a higher risk of all-cause and cardiovascular mortality in participants with hypertension and at the lowest educational level. Conclusions: Despite favourable changes in hypertension outcomes over time, Chile currently needs innovative and collaborative strategies to improve hypertension management (especially among males), and simultaneously decrease SEP inequalities in hypertension outcomes (mainly among females). Interventions decreasing hypertension prevalence, improving hypertension management, and increasing educational levels could help to decrease the burden of premature mortality.
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Non-alcoholic fatty liver disease (NAFLD) is a common chronic liver disorder which is associated with accumulation of fats in the liver. It causes a wide variety of pathological effects such as non-alcoholic steatohepatitis (NASH) and cirrhosis, insulin resistance, obesity, hypertension, dyslipidaemia, diabetes and cardiovascular disease. The molecular mechanisms that cause the initiation and progression of NAFLD are not fully understood. Oxidative stress (OS) induced by reactive oxygen species (ROS) and inflammation are likely a significant mechanism which can lead to hepatic cell death and tissue injury. Mitochondrial abnormalities, down-regulation of several antioxidant enzymes, glutathione (GSH) depletion and decreased activity of GSH-dependent antioxidants, accumulation of leukocytes and hepatic inflammation are the major sources of ROS overproduction in NAFLD. Excessive production of ROS suppresses the capacity of other antioxidant defence systems in NAFLD and causes further oxidative damage. Regular exercise can be considered as an effective strategy for treatment of NAFLD. It improves NAFLD by reducing intrahepatic fat content, increasing β-oxidation of fatty acids, inducing hepato-protective autophagy, overexpressing peroxisome proliferator-activated receptor- γ (PPAR-γ), as well as attenuating hepatocyte apoptosis and increasing insulin sensitivity. Exercise training also suppresses ROS overproduction and OS in NAFLD via up-regulation of several antioxidant enzymes and anti-inflammatory mediators. Therefore, an understanding of these molecules and signalling pathways gives us valuable information about NAFLD progression and a method for developing a suitable clinical treatment. This review aimed to evaluate sources of ROS and OS in NAFLD and the molecular mechanisms involved in the beneficial effects of exercises on NAFLD.
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A shift from private motorised transport to more active transportation can, among other things, deliver significant health benefits. The main disadvantage of active transport (in particular walking) for most people compared to private motorised transport is the limited range. Public transport (PT) can complement the use of active modes and extend their range. Therefore, there might be potential to increase physical activity through an increase in PT use. This article takes a closer look at how walking relates to the use of PT by examining existing literature on the topic. It aims to study how far people walk to and from PT and what key factors influence this. Scopus, Transport Research International Documentation and Web of Science have been searched systematically for relevant articles, conference papers and books. After screening of titles and abstracts, 41 relevant publications were identified. Studies were included if they quantified the amount of walking (measured as either distance or time) that is directly related to the use of PT. Studies that quantified walking using general measures of daily physical activity or daily walking or that used stated preference designs were excluded. The PT systems considered in this paper are mass transport systems in urban areas, either road- or rail-based, with fixed schedules and stops. Demand responsive transport services, which can offer door-to-door travel, are not considered, as these systems can to a large extent eliminate the need to walk. In the identified publications, a large variety of walking distances and times have been reported, and these seem to be highly context-specific. The paper establishes the evidence for the wide range of factors that influence walking related to PT, which have been categorised as personal, PT-related, environmental, and journey-related. The different methods that have been used are discussed by critically analysing their advantages and limitations. Only a limited number of these methods used allow for an accurate assessment of the walking distances to and from PT. The paper concludes with suggestions for future research, such as a need for more accurate measurement of walking and research in different geographical areas to shed light on underlying influences of culture and climate.
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The aim was to investigate the associations between different physical activity (PA) patterns and sedentary time (ST) with vitamin D deficiency (<12 ng/mL) in a large sample of Chilean women. In this cross-sectional study, the final sample included 1245 adult and 686 older women. The PA levels, mode of commuting, ST, and leisure-time PA were self-reported. Vitamin D deficiency was defined as <12 ng/mL and insufficiency as <20 ng/mL. A higher ST was associated with vitamin D deficiency (odds ratio (OR): 2.4, 95%: 1.6–4.3) in adults, and passive commuting was associated with vitamin D deficiency in older (OR: 1.7, 95%: 1.1–2.7). Additionally, we found a joint association in the high ST/passive commuting group in adults (OR: 2.8, 95%: 1.6–4.9) and older (OR: 2.8, 95%: 1.5–5.2) with vitamin D deficiency, in respect to low ST/active commuting. The PA levels and leisure-time PA were not associated with vitamin D deficiency. In conclusion, mode of commuting and ST seems important variables related to vitamin D deficiency. Promoting a healthy lifestyle appears important also for vitamin D levels in adult and older women. Further studies are needed to establish causality of this association and the effect of vitamin D deficiency in different diseases in this population.
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Background Active commuting is associated with greater physical activity, but there is no consensus on the actual beneficial effects of this type of physical activity on health outcomes. Objective To examine the association between active commuting and risk of all-cause mortality, incidence and mortality from cardiovascular diseases, cancer and diabetes through meta-analysis. Methods A comprehensive search of MEDLINE, Embase, Google Scholar, Web of Science, The Cochrane Library, Transport Research International Documentation database, and reference lists of included articles was conducted. Only prospective cohort studies were included. Results Twenty-three prospective studies including 531,333 participants were included. Participants who engaged in active commuting had a significantly lower risk of all-cause mortality [relative risk (RR) 0.92, 95% CI 0.85–0.98] and cardiovascular disease incidence (RR 0.91; 95% CI 0.83–0.99). There was no association between active commuting and cardiovascular disease mortality and cancer. Participants who engaged in active commuting had a 30% reduced risk of diabetes (RR 0.70; 95% CI 0.61–0.80) in three studies after removal of an outlying study that affected the heterogeneity of the results. Subgroup analyses suggested a significant risk reduction (− 24%) of all-cause mortality (RR 0.76; 95% CI 0.63–0.94) and cancer mortality (− 25%; RR 0.75; 95% CI 0.59–0.895) among cycling commuters. Conclusion People who engaged in active commuting had a significantly reduced risk of all-cause mortality, cardiovascular disease incidence and diabetes.
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Background: There is limited evidence concerning how active commuting (AC) is associated with health benefits in young. The aim of the study was to analyze the relationship between AC to and from campus (walking) and obesity and metabolic syndrome (MetS) in a sample of Colombian university students. Methods: A total of 784 university students (78.6% women, mean age = 20.1±2.6 years old) participated in the study. The exposure variable was categorized into AC (active walker to campus) and non-AC (non/infrequent active walker to campus: car, motorcycle, or bus) to and from the university on a typical day. MetS was defined in accordance with the updated harmonized criteria of the International Diabetes Federation criteria. Results: The overall prevalence of MetS was 8.7%, and it was higher in non-AC than AC to campus. The percentage of AC was 65.3%. The commuting distances in this AC from/to university were 83.1%, 13.4% and 3.5% for <2km, 2-5km and >5km, respectively. Multiple logistic regressions for predicting unhealthy profile showed that male walking commuters had a lower probability of having obesity [OR=0.45 (CI 95% 0.25–0.93)], high blood pressure [OR=0.26 (CI 95% 0.13–0.55)] and low HDL cholesterol [OR=0.29 (CI 95% 0.14–0.59)] than did passive commuters. Conclusions: Our results suggest that in young adulthood, a key life-stage for the development of obesity and MetS, AC could be associated with and increasing of daily physical activity levels, thereby promoting better cardiometabolic health.
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Introduction Active travel surveillance in Latin American is scarce and concentrated in a few countries. Surveillance of transport cycling in Chile is critical to document, to serve as a baseline from which to measure future planned strategies to increase transport cycling. This study aimed to document the prevalence of transport cycling in urban-dwelling Chilean adults and to examine factors associated with transport cycling in this population. Methods Data were collected from two cross-sectional National Environmental Surveys. Surveys were administered through a computer-assisted telephone interview system to representative samples of adult residents of the 15 regional capital cities in 2014 (n = 5057) and 2015 (n = 5664). Multivariable, multi-level logistic regression modelling was used to assess correlates of bicycling as the primary transport mode (yes, no) in the total sample and separately by sex. Results Transport cycling was reported by 7% of participants in 2014 and 2015. The highest prevalence estimates were found in males (9–10%), participants aged 18–24 years (12%), participants of low socioeconomic status (7%), and participants living in cities with warm summers and mild winters (8–9%). Low socioeconomic status was associated with greater likelihood of cycling in men (OR: 1.75 (95%CI 1.35–2.28), p < 0.001) but with reduced likelihood of cycling in women (OR: 0.68 (95% CI 0.52–0.91), p = 0.009). Associations between environmental factors and transport cycling were stronger in women than in men. Conclusions Transport cycling prevalence in Chile is low compared to other Latin American countries. Associations between environmental factors and transport cycling differed by gender. City planners should consider how environmental factors influence gender inequalities in transport cycling in their cities. Free link (until 6th september) https://authors.elsevier.com/a/1ZPlu7tR-38hkx
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Environmental quality has a profound effect on health and the burden of disease. In the United States, the environment-related burden of disease is increasingly dominated by chronic diseases. At the local level, public health practitioners realize that many policy decisions affecting environmental quality and health transcend the authorities of traditional health department programs. Healthy decisions about the built environment, including housing, transportation, and energy, require broad collaborative efforts. Environmental health professionals have an opportunity to address the shift in public health burden toward chronic diseases and play an important role in the design of healthy communities by bringing data and tools to decision makers. This article provides a guide for community leaders to consider the public health effects of decisions about the built environment. We present a conceptual framework that represents a shift from compartmentalized solutions toward an inclusive systems approach that encourages partnership across disciplines and sectors. We discuss practical tools to assist with environmental decision making, such as Health Impact Assessments, environmental public health tracking, and cumulative risk assessment. We also identify priorities in research, practice, and education to advance the role of public health in decision making to improve health, such as the Health Impact Assessment, as a core competency for environmental health practitioners. We encourage cross-disciplinary communication, research, and education that bring the fields of planning, transportation, and energy in closer collaboration with public health to jointly advance the systems approach to today's environmental challenges.
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Active transportation (AT), or walking or bicycling for transportation, represents one way individuals can achieve recommended physical activity (PA) levels. This study describes AT prevalence and temporal trends, and examines associations between AT levels and measured CVD risk factors (hypertension, hypercholesterolemia, low high-density [HDL] cholesterol, diabetes, and obesity) among U.S. adults. National Health and Nutrition Examination Survey (NHANES) 2007-2016 data (analyzed in 2017) were used to conduct overall trend analyses of reported AT in a typical week [none (0-9 min/week); low (10-149 min/week); or high (≥150 min/week)]. Logistic regression was used to examine associations between AT level and each CVD risk factor from NHANES 2011-2016 (n = 13,943). Covariates included age, sex, race/Hispanic origin, education, income, smoking, survey cycle, non-transportation PA, and urbanization level. U.S. adults who engaged in high AT levels increased from 13.1% in 2007-2008 to 17.9% in 2011-2012, and then decreased to 10.6% in 2015-2016 (p for quadratic trend = 0.004). Over the same period, the quadratic trend for low AT was not significant. During 2011-2016, 14.3% of adults engaged in high AT, 11.4% in low AT, and 74.4% in no AT. High AT levels were associated with decreased odds of each CVD risk factor assessed, compared to no AT. Low AT (versus no AT) was associated with decreased odds of hypertension (aOR = 0.77, 95% CI 0.64, 0.91) and diabetes (aOR = 0.68, 95% CI 0.54, 0.85). AT prevalence among adults has fluctuated from 2007 to 2016. Despite favorable associations between AT and CVD risk factors, most U.S. adults do not engage in any AT.
Article
The objectives were to describe trends in cycling and cycle related injuries in Denmark overall and in the four largest Danish cities to see if changes in cycling trips and injuries were associated. Further, we compared number of prevented deaths, type 2 diabetes (T2D), cardiovascular diseases (CVD) and cancers with registered injuries. We analyzed cycling trends over past 17 years in Denmark based on national statistics from 56 electronic counters as an ecological study. Cycle related injuries were collected by Statistics Denmark from hospital records. We also calculated the annual prevented disease and mortality accrued from the health benefits of physical activity in cycling based on relative risk (RR) of cycling derived from population studies, number of cyclists, and number of death, T2D, CVD and cancers in Denmark. Since 1998 till 2015, cycling has increased by 10% in the whole country; the cycling related injuries however, have gradually declined and were only 45% in 2015 as compared to 1998 level. In Copenhagen specifically, cycling even increased more than 30% since 1998 while cycling related injuries decreased during the same period to one third. Diseases prevented in Denmark by cycling were annually 3328 T2D cases, 5742 CVD cases and 2076 cancer cases and prevented deaths were 6190. In comparison, in 2015, 26 cyclists were killed in the traffic, 512 were seriously injured and 297 experienced light injuries in the whole country. In conclusion, in Denmark, the number of cycling trips have steadily increased over the past 17 years while cycling related injuries show a concomitant decline. Intuitively one might expect cycle related injuries to increase with increased cycling, but a decrease was observed in injuries. Health benefits of cycling calculated from cohort studies were 21 times higher than risk of injuries and for mortality alone the ratio was 238.
Article
Background: There is limited evidence on potential health benefits of active travel, independently of leisure-time physical activity (PA), with metabolic syndrome (MetS) in Latin-America. Objective: To investigate the relationship between active travel and metabolic syndrome (MetS) and its components in a national representative sample of Chilean adults. Methods: Cross-sectional study of 2864 randomly selected adults' participants enrolled in the 2009-2010 Chilean National Health Survey (CNHS). Self-reported PA was obtained with the validated Global PA Questionnaire and classifying participants into insufficiently active (<150min/week) or active (≥150min/week). MetS was diagnosed from the modified Adult Treatment Panel (ATP) III criteria with national-specific abdominal obesity cut points. Multilevel logistic regression analysis was applied to estimate associations of travel PA with MetS and its components at a regional level, adjusted for socio-demographic characteristics and other types of PA. Results: 46.2% of the sample engaged in 150min/week of active travel and the prevalence of MetS was 33.7%. Mets was significantly lower among active travel participants. Active travel was associated with lower odds of MetS (OR 0.72; 95%CI 0.61-0.86), triglycerides (OR 0.77; 95%CI 0.64-0.92) and abdominal obesity (OR 0.82; 95%CI 0.69-0.97) after controlling for socio-demographics and other types of PA. Conclusion: Active travel was negatively associated with MetS, triglycerides and abdominal obesity. Efforts to increase regional active travel should be addressed as a measure to prevent and reduce the prevalence of MetS and disease burden in middle income countries.