The Health Economic Assessment Tool (HEAT) for walking and cycling - experiences from 10 years of application of a health impact assessment tool in policy and practice.

Introduction: In recent years, walking and cycling have moved into the focus as promising approaches to achieve public health, sustainable transport, climate goals and better urban resilience. However, they are only realistic transport and activity options for a large proportion of the population when they are safe, inclusive and convenient. One way to increase their recognition in transport policy is the inclusion of health impacts of walking and cycling into transport economic appraisals. Methods: The Health Economic Assessment Tool (HEAT) for walking and cycling calculates: if x people walk or cycle a distance of y on most days, what is the economic value of impacts on premature mortality, taking into account effects of physical activity, air pollution and road fatalities, as well as effects on carbon emissions. Different data sources were collated to examine how the HEAT in more than 10 years of existence, and to identify lessons learned and challenges. Results: Since its launch in 2009, the HEAT has gained wide recognition as a user friendly, yet robust, evidence-based tool usable by academics, policymakers, and practitioners. Originally designed for use in Europe, it has since been expanded for global use. Discussion: Challenges for a wider uptake of health-impact assessment (HIA) tools including active transport such as HEAT are the promotion and dissemination to local practitioners and policy makers also outside European and English-speaking regions and in low- and middle-income contexts, further increasing usability, and more generally the advancement of systematic data collection and impact quantification related to walking and cycling.

Non-occupational physical activity and risk of cardiovascular disease, cancer and mortality outcomes: a dose-response meta-analysis of large prospective studies.

OBJECTIVE: To estimate the dose-response associations between non-occupational physical activity and several chronic disease and mortality outcomes in the general adult population. DESIGN: Systematic review and cohort-level dose-response meta-analysis. DATA SOURCES: PubMed, Scopus, Web of Science and reference lists of published studies. ELIGIBILITY CRITERIA: Prospective cohort studies with (1) general population samples >10 000 adults, (2) ≥3 physical activity categories, and (3) risk measures and CIs for all-cause mortality or incident total cardiovascular disease, coronary heart disease, stroke, heart failure, total cancer and site-specific cancers (head and neck, myeloid leukaemia, myeloma, gastric cardia, lung, liver, endometrium, colon, breast, bladder, rectum, oesophagus, prostate, kidney). RESULTS: 196 articles were included, covering 94 cohorts with >30 million participants. The evidence base was largest for all-cause mortality (50 separate results; 163 415 543 person-years, 811 616 events), and incidence of cardiovascular disease (37 results; 28 884 209 person-years, 74 757 events) and cancer (31 results; 35 500 867 person-years, 185 870 events). In general, higher activity levels were associated with lower risk of all outcomes. Differences in risk were greater between 0 and 8.75 marginal metabolic equivalent of task-hours per week (mMET-hours/week) (equivalent to the recommended 150 min/week of moderate-to-vigorous aerobic physical activity), with smaller marginal differences in risk above this level to 17.5 mMET-hours/week, beyond which additional differences were small and uncertain. Associations were stronger for all-cause (relative risk (RR) at 8.75 mMET-hours/week: 0.69, 95% CI 0.65 to 0.73) and cardiovascular disease (RR at 8.75 mMET-hours/week: 0.71, 95% CI 0.66 to 0.77) mortality than for cancer mortality (RR at 8.75 mMET-hours/week: 0.85, 95% CI 0.81 to 0.89). If all insufficiently active individuals had achieved 8.75 mMET-hours/week, 15.7% (95% CI 13.1 to 18.2) of all premature deaths would have been averted. CONCLUSIONS: Inverse non-linear dose-response associations suggest substantial protection against a range of chronic disease outcomes from small increases in non-occupational physical activity in inactive adults. PROSPERO registration number CRD42018095481.

Towards a global framework for transport, health and health equity.

This study derives a generalised global framework for transport, health and health equity, based on a synthesis of 94 urban transport and health frameworks. The framework emphasises factors related to health equity, which are generally ignored in existing conceptual frameworks on the relationship between transport and health. While some factors such as travel behaviour were included in most reviewed frameworks, climate change and other macro-level factors were included in less than a quarter of frameworks, and health equity was included in less than 10%. We developed a framework that includes key framework components identified by a scoping review, as well as addressing important gaps. This framework can be utilized to inform work on transport, health and health equity by different agencies such as the World Health Organization. It can be used to guide health sector engagement with transport issues to lead to healthier and more equitable transport decision-making globally.

What next? Expanding our view of city planning and global health, and implementing and monitoring evidence-informed policy.

This Series on urban design, transport, and health aimed to facilitate development of a global system of health-related policy and spatial indicators to assess achievements and deficiencies in urban and transport policies and features. This final paper in the Series summarises key findings, considers what to do next, and outlines urgent key actions. Our study of 25 cities in 19 countries found that, despite many well intentioned policies, few cities had measurable standards and policy targets to achieve healthy and sustainable cities. Available standards and targets were often insufficient to promote health and wellbeing, and health-supportive urban design and transport features were often inadequate or inequitably distributed. City planning decisions affect human and planetary health and amplify city vulnerabilities, as the COVID-19 pandemic has highlighted. Hence, we offer an expanded framework of pathways through which city planning affects health, incorporating 11 integrated urban system policies and 11 integrated urban and transport interventions addressing current and emerging issues. Our call to action recommends widespread uptake and further development of our methods and open-source tools to create upstream policy and spatial indicators to benchmark and track progress; unmask spatial inequities; inform interventions and investments; and accelerate transitions to net zero, healthy, and sustainable cities.

Modelling SARS-CoV-2 disease progression in Australia and New Zealand: an account of an agent-based approach to support public health decision-making.

OBJECTIVE: In 2020, we developed a public health decision-support model for mitigating the spread of SARS-CoV-2 infections in Australia and New Zealand. Having demonstrated its capacity to describe disease progression patterns during both countries' first waves of infections, we describe its utilisation in Victoria in underpinning the State Government's then 'RoadMap to Reopening'. METHODS: Key aspects of population demographics, disease, spatial and behavioural dynamics, as well as the mechanism, timing, and effect of non-pharmaceutical public health policies responses on the transmission of SARS-CoV-2 in both countries were represented in an agent-based model. We considered scenarios related to the imposition and removal of non-pharmaceutical interventions on the estimated progression of SARS-CoV-2 infections. RESULTS: Wave 1 results suggested elimination of community transmission of SARS-CoV-2 was possible in both countries given sustained public adherence to social restrictions beyond 60 days' duration. However, under scenarios of decaying adherence to restrictions, a second wave of infections (Wave 2) was predicted in Australia. In Victoria's second wave, we estimated in early September 2020 that a rolling 14-day average of <5 new cases per day was achievable on or around 26 October. Victoria recorded a 14-day rolling average of 4.6 cases per day on 25 October. CONCLUSIONS: Elimination of SARS-CoV-2 transmission represented in faithfully constructed agent-based models can be replicated in the real world. IMPLICATIONS FOR PUBLIC HEALTH: Agent-based public health policy models can be helpful to support decision-making in novel and complex unfolding public health crises.

Supporting a Healthy Planet, Healthy People and Health Equity through Urban and Territorial Planning.

The form of human settlements impacts on planetary health, population health and health equity. Yet goals for urban and territorial planning are only tangentially linked to public health outcomes. The WHO and UN-Habitat support actions to bring health to the fore in planning and design of human settlements, recently publishing 'Integrating Health in Urban and Territorial Planning: a sourcebook' focusing on 'why' action is needed, 'how' to initiate it; and curating several existing resources on 'what' to do. Recommendations for research, policy and practice include calls for rapid development of closer relationships between public health and spatial planning.

Effect of COVID-19 response policies on walking behavior in US cities.

The COVID-19 pandemic is causing mass disruption to our daily lives. We integrate mobility data from mobile devices and area-level data to study the walking patterns of 1.62 million anonymous users in 10 metropolitan areas in the United States. The data covers the period from mid-February 2020 (pre-lockdown) to late June 2020 (easing of lockdown restrictions). We detect when users were walking, distance walked and time of the walk, and classify each walk as recreational or utilitarian. Our results reveal dramatic declines in walking, particularly utilitarian walking, while recreational walking has recovered and even surpassed pre-pandemic levels. Our findings also demonstrate important social patterns, widening existing inequalities in walking behavior. COVID-19 response measures have a larger impact on walking behavior for those from low-income areas and high use of public transportation. Provision of equal opportunities to support walking is key to opening up our society and economy.

A guide to value of information methods for prioritising research in health impact modelling.

Health impact simulation models are used to predict how a proposed policy or scenario will affect population health outcomes. These models represent the typically-complex systems that describe how the scenarios affect exposures to risk factors for disease or injury (e.g. air pollution or physical inactivity), and how these risk factors are related to measures of population health (e.g. expected survival). These models are informed by multiple sources of data, and are subject to multiple sources of uncertainty. We want to describe which sources of uncertainty contribute most to uncertainty about the estimate or decision arising from the model. Furthermore, we want to decide where further research should be focused to obtain further data to reduce this uncertainty, and what form that research might take. This article presents a tutorial in the use of Value of Information methods for uncertainty analysis and research prioritisation in health impact simulation models. These methods are based on Bayesian decision-theoretic principles, and quantify the expected benefits from further information of different kinds. The expected value of partial perfect information about a parameter measures sensitivity of a decision or estimate to uncertainty about that parameter. The expected value of sample information represents the expected benefit from a specific proposed study to get better information about the parameter. The methods are applicable both to situationswhere the model is used to make a decision between alternative policies, and situations where the model is simply used to estimate a quantity (such as expected gains in survival under a scenario). This paper explains how to calculate and interpret the expected value of information in the context of a simple model describing the health impacts of air pollution from motorised transport. We provide a general-purpose R package and full code to reproduce the example analyses.

Decline in Stroke Mortality Between 1997 and 2012 by Sex: Ecological Study in Brazilians Aged 15 to 49 Years.

This study aimed to analyse the time trends of stroke mortality between 1997 and 2012 according to sex in Brazilians aged 15 to 49 years. This ecological study used data obtained from the Mortality Information System, which is available from the National Health System Department of Informatics - DATASUS and maintained by the Brazilian Ministry of Health. Stroke definition included International Classification of Disease version 10 (ICD-10) codes I60, I61, I63, and I64. Crude and age-standardized mortality rates and respective 95% confidence intervals were estimated per 100,000 inhabitants and stratified by age, region, year, and sex. Linear regression models were used to analyse the time trends with a confidence level of 95%. The statistical program used was Stata 11.0. Between 1997 and 2012, there were 124,866 deaths due to stroke in Brazilians aged 15 to 49 years. There was a decreasing linear trend in stroke mortality among men (ß = -0.46, p < 0.001, R2 = 0.95) and women (ß = -0.40, p < 0.001, R2 = 0.98) during this period. Overall there was no significant difference in stroke mortality trends by sex, except with respect to the age group of 40 to 49 years where there was a difference in the decrease of stroke mortality between men and women (interaction sex * year: ß = 0.238, p = 0.012, R² = 0.96). Mortality rates decrease significantly over time in men and women in the age group 15 to 49 years old, but there is only significant difference in the decrease of rates by sex only in the age group from 40 to 49 years old.

Reporting bias in the literature on the associations of health-related behaviors and statins with cardiovascular disease and all-cause mortality.

Reporting bias in the literature occurs when there is selective revealing or suppression of results, influenced by the direction of findings. We assessed the risk of reporting bias in the epidemiological literature on health-related behavior (tobacco, alcohol, diet, physical activity, and sedentary behavior) and cardiovascular disease mortality and all-cause mortality and provided a comparative assessment of reporting bias between health-related behavior and statin (in primary prevention) meta-analyses. We searched Medline, Embase, Cochrane Methodology Register Database, and Web of Science for systematic reviews synthesizing the associations of health-related behavior and statins with cardiovascular disease mortality and all-cause mortality published between 2010 and 2016. Risk of bias in systematic reviews was assessed using the ROBIS tool. Reporting bias in the literature was evaluated via small-study effect and excess significance tests. We included 49 systematic reviews in our study. The majority of these reviews exhibited a high overall risk of bias, with a higher extent in health-related behavior reviews, relative to statins. We reperformed 111 meta-analyses conducted across these reviews, of which 65% had statistically significant results (P < 0.05). Around 22% of health-related behavior meta-analyses showed small-study effect, as compared to none of statin meta-analyses. Physical activity and the smoking research areas had more than 40% of meta-analyses with small-study effect. We found evidence of excess significance in 26% of health-related behavior meta-analyses, as compared to none of statin meta-analyses. Half of the meta-analyses from physical activity, 26% from diet, 18% from sedentary behavior, 14% for smoking, and 12% from alcohol showed evidence of excess significance bias. These biases may be distorting the body of evidence available by providing inaccurate estimates of preventive effects on cardiovascular and all-cause mortality.

Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis.

PURPOSE:  To estimate the strength and shape of the dose-response relationship between sedentary behaviour and all-cause, cardiovascular disease (CVD) and cancer mortality, and incident type 2 diabetes (T2D), adjusted for physical activity (PA). Data Sources: Pubmed, Web of Knowledge, Medline, Embase, Cochrane Library and Google Scholar (through September-2016); reference lists. Study Selection: Prospective studies reporting associations between total daily sedentary time or TV viewing time, and ≥ one outcome of interest. Data Extraction: Two independent reviewers extracted data, study quality was assessed; corresponding authors were approached where needed. Data Synthesis: Thirty-four studies (1,331,468 unique participants; good study quality) covering 8 exposure-outcome combinations were included. For total sedentary behaviour, the PA-adjusted relationship was non-linear for all-cause mortality (RR per 1 h/day: were 1.01 (1.00-1.01) ≤ 8 h/day; 1.04 (1.03-1.05) > 8 h/day of exposure), and for CVD mortality (1.01 (0.99-1.02) ≤ 6 h/day; 1.04 (1.03-1.04) > 6 h/day). The association was linear (1.01 (1.00-1.01)) with T2D and non-significant with cancer mortality. Stronger PA-adjusted associations were found for TV viewing (h/day); non-linear for all-cause mortality (1.03 (1.01-1.04) ≤ 3.5 h/day; 1.06 (1.05-1.08) > 3.5 h/day) and for CVD mortality (1.02 (0.99-1.04) ≤ 4 h/day; 1.08 (1.05-1.12) > 4 h/day). Associations with cancer mortality (1.03 (1.02-1.04)) and T2D were linear (1.09 (1.07-1.12)). CONCLUSIONS:  Independent of PA, total sitting and TV viewing time are associated with greater risk for several major chronic disease outcomes. For all-cause and CVD mortality, a threshold of 6-8 h/day of total sitting and 3-4 h/day of TV viewing was identified, above which the risk is increased.

Prevalence of active transportation among adults in Latin America and the Caribbean: a systematic review of population-based studies / Prevalência do deslocamento ativo em adultos na América Latina e Caribe: revisão sistemática de estudos populacionais

Objective. To describe the prevalence of “active” (self-propelled, human-powered) transportation in the Latin America and Caribbean (LAC) region over the past decade. Methods. MEDLINE, Excerpta Medica (Embase), SportDiscus, Lilacs, MediCarib, Web of Science, OVID, CINAHL, Scopus, Google Scholar, National Transportation Library, and TRIS/TRID were searched for articles on active transportation published between January 2003 and December 2014 with (at least) a title and abstract in English, Portuguese, or Spanish. Research was included in the study if the two reviewing authors agreed it 1) was conducted in an adult sample (≥ 18 years old), 2) was designed to be representative of any LAC area, and 3) reported at least one measure of active transportation. Reference lists of included papers and retrieved reviews were also checked. A total of 129 key informants (87 scientific experts and 42 government authorities) were contacted to identify additional candidate publications. Two other authors extracted the data independently. Results. A total of 10 459 unique records were found; the full texts of 143 were reviewed; and a total of 45 studies were included in the study, yielding estimates for 72 LAC settings, most of which were in Argentina, Brazil, and Colombia. No eligible studies were found for the years 2003–2004, resulting in a 10-year study time frame. Estimates were available for walking, cycling, or the combination of both, with a high degree of heterogeneity (heterogeneity index (I2) ≥ 99%). The median prevalence of active transportation (combining walking and cycling) was 12.0%, ranging from 5.1% (in Palmas, Brazil) to 58.9% (in Rio Claro, Brazil). Men cycled more than women in all regions for which information was available. The opposite was true for walking. Conclusions. Prevalence of active transportation in LAC varied widely, with great heterogeneity and uneven distribution of studies across countries, indicating the need for efforts to build comprehensive surveillance systems with standardized, timely, and detailed estimates of active transportation in order to support policy planning and evaluation.

Objetivo. Descrever a prevalência do “deslocamento ativo” (uso de modais de transporte autopropulsados e de propulsão humana) na região da América Latina e Caribe (ALC) na última década. Métodos. Foi realizada uma busca nos bancos de dados MEDLINE, Excerpta Medica (Embase), SportDiscus, Lilacs, MediCarib, Web of Science, OVID, CINAHL, Scopus, Google Scholar, National Transportation Library e TRIS/TRID por artigos sobre deslocamento ativo publicados entre janeiro de 2003 e dezembro de 2014 com (pelo menos) título e resumo em inglês, espanhol ou português. Pesquisas foram incluídas no estudo se os dois autores da revisão concordaram que a pesquisa 1) havia sido realizada em uma amostra de adultos (≥ 18 anos de idade), 2) tinha o intuito de ser representativa de uma área da ALC e 3) relatava pelo menos uma medida de deslocamento ativo. As referências bibliográficas dos artigos e revisões incluídos também foram analisadas. Foram contatados 129 informantes-chave (87 peritos científicos e 42 autoridades de governo) para identificar possíveis publicações adicionais de interesse. Outros dois autores extraíram os dados de maneira independente. Resultados. Foram encontrados 10 459 registros não duplicados; os textos completos de 143 foram examinados; e 45 foram incluídos na revisão, gerando estimativas para 72 regiões da ALC, a maioria na Argentina, Brasil e Colômbia. Não foi encontrado nenhum estudo dos anos 2003-2004 que atendesse os critérios de inclusão; portanto, o período de análise foi de 10 anos. Foram obtidas estimativas para caminhada, deslocamento com bicicleta ou a combinação de ambos os modais; con alto grau de heterogeneidade (índice de heterogeneidade (I2) ≥ 99%). A prevalência mediana de deslocamento ativo (combinação de caminhada e deslocamento com bicicleta) foi de 12,0%, variando de 5,1% (em Palmas, Brasil) a 58,9% (em Rio Claro, Brasil). Homens andaram de bicicleta mais do que as mulheres em todas as regiões para as quais havia informações disponíveis. Constatou-se o oposto em relação à caminhada. Conclusões. A prevalência de deslocamento ativo variou muito na ALC, com grande heterogeneidade e distribuição desigual de estudos entre países. Isso indica necessidade de esforços para construir sistemas de vigilância integrais que proporcionem estimativas padronizadas, oportunas e detalhadas do deslocamento ativo para subsidiar a formulação e avaliação de políticas.

Artificially Sweetened Beverages and the Response to the Global Obesity Crisis.

Christopher Millett and colleagues argue that artificially sweetened beverages should not be promoted as part of a healthy diet.

Prevalence of active transportation among adults in Latin America and the Caribbean: a systematic review of population-based studies.

OBJECTIVE: To describe the prevalence of "active" (self-propelled, human-powered) transportation in the Latin America and Caribbean (LAC) region over the past decade. METHODS: MEDLINE, Excerpta Medica (Embase), SportDiscus, Lilacs, MediCarib, Web of Science, OVID, CINAHL, Scopus, Google Scholar, National Transportation Library, and TRIS/TRID were searched for articles on active transportation published between January 2003 and December 2014 with (at least) a title and abstract in English, Portuguese, or Spanish. Research was included in the study if the two reviewing authors agreed it 1) was conducted in an adult sample (≥ 18 years old), 2) was designed to be representative of any LAC area, and 3) reported at least one measure of active transportation. Reference lists of included papers and retrieved reviews were also checked. A total of 129 key informants (87 scientific experts and 42 government authorities) were contacted to identify additional candidate publications. Two other authors extracted the data independently. RESULTS: A total of 10 459 unique records were found; the full texts of 143 were reviewed; and a total of 45 studies were included in the study, yielding estimates for 72 LAC settings, most of which were in Argentina, Brazil, and Colombia. No eligible studies were found for the years 2003-2004, resulting in a 10-year study time frame. Estimates were available for walking, cycling, or the combination of both, with a high degree of heterogeneity (heterogeneity index (I2) ≥ 99%). The median prevalence of active transportation (combining walking and cycling) was 12.0%, ranging from 5.1% (in Palmas, Brazil) to 58.9% (in Rio Claro, Brazil). Men cycled more than women in all regions for which information was available. The opposite was true for walking. CONCLUSIONS: Prevalence of active transportation in LAC varied widely, with great heterogeneity and uneven distribution of studies across countries, indicating the need for efforts to build comprehensive surveillance systems with standardized, timely, and detailed estimates of active transportation in order to support policy planning and evaluation.

Physical activity as part of daily living: Moving beyond quantitative recommendations.

The purpose of this study is to discuss a paradigm shift towards a broader understanding of physical activity (PA) as part of daily living and, therefore, a different approach for PA guidelines, research, and promotion. To this aim, we centered the discussion in two topics: 1) PA: from a restricted view to a broader phenomenon; and 2) Recommendations for PA: moving beyond minutes and dose-response. A holistic understanding of PA and its relationship with health is not possible unless it is considered values, meanings, and symbols that impregnate the human behavior linked to the modes of living of a given people. If we do believe that PA is a behavior essential to human life, we must align our actions to our speech. However, current guidelines, as well as in most policies and programs of PA is largely portrayed as a way to attain longer life expectancy and less diseases, which runs against our consolidated understanding of PA as part of our everyday life. New guidelines could focus on how, when, why, where, and with whom we include PA in our daily lives, based on a day-long approach, instead of how much we should do in order to prevent non-communicable diseases.