1. Neighbourhood Walkability and Physical Activity Levels in Canadian Communities Justin Thielman Michael Lebenbaum Laura Rosella Ray Copes Heather Manson

2. PublicHealthOntario.ca Outline of Presentation Background and Research Gaps Data Sources and Methods Results Discussion 2

3. PublicHealthOntario.ca Background and Research Gaps 3 HIGH WALKABILITY LOW WALKABILITY

4. PublicHealthOntario.ca Background and Research Gaps Recent systematic reviews show some evidence of associations between walkability and some types of physical activity, but not conclusive [12-19] Non-significant estimates of associations identified in many studies may be due to type II error [16,18] Almost all studies done in one or two large metropolitan cities, so not generalizable to smaller centres [15,16,18-20] 4

5. PublicHealthOntario.ca Background and Research Gaps Our study uses national-level data sources that cover all of Canada Large sample size Diverse range of city sizes Cross-Canada representation Research Questions: Is walkability associated with walking for transportation or total leisure and transportation physical activity among Canadians aged 12 and older? How, and to what extent are these associations affected by variables such as age of respondent and city size? 5

6. PublicHealthOntario.ca Data Sources and Methods Canadian Community Health Survey (CCHS): The CCHS is a national survey of health, health determinants, and health care utilization among Canadians aged 12 and older Primary outcomes: Walking to work or school Energy expenditure on transportation and leisure physical activity Covariates: Age, sex, race, immigration, income, education level, children in household, location, work or school attendance, population centre size class 6

7. PublicHealthOntario.ca Data Sources and Methods 7 Walkability data: Street Smart Walk Score (SSWS) (www.walkscore.com)www.walkscore.com Grocery stores For given locations, SSWS algorithm based on number and proximity of amenities Parks Schools Book stores Banks Entertainment Coffee shops Clothing/gift shops Restaurants/bars Penalties for lower intersection densities and longer block lengths

8. PublicHealthOntario.ca Data Sources and Methods 8 SSWS Latitude/longitude CCHS Postal code Postal Code Conversion File Latitude/longitude Postal code 2007-08 CCHS + 2009-10 CCHS + 2011-12 CCHS - Rural residents - Respondents missing data on SSWS, primary outcomes, key covariates = Final sample size: 240,595

9. PublicHealthOntario.ca Results 9 Forest plot based on multivariable analyses adjusting for age, sex, race, working or attending school, immigration to Canada, highest level of education, household income, number of children under 12, population centre size category Odds Ratio SSWS Quintile All Respondents: Walked to Work or School in Past 3 Months

10. PublicHealthOntario.ca 10 Each analysis adjusted for sex, race, working or attending school, immigration to Canada, highest level of education, household income, number of children under 12, population centre size category Age 12-17: Walked to Work or School in Past 3 Months Age 65+: Walked to Work or School in Past 3 MonthsAge 30-64: Walked to Work or School in Past 3 Months Age 18-29: Walked to Work or School in Past 3 Months SSWS Quintile Odds Ratio

11. PublicHealthOntario.ca 11 Each analysis adjusted for age, sex, race, working or attending school, immigration to Canada, highest level of education, household income, number of children under 12 Population 1,000-29,999: Walked to Work or School Population 100,000+ : Walked to Work or School Population 30,000-99,999: Walked to Work or School SSWS Quintile Odds Ratio

12. PublicHealthOntario.ca Results 12 Forest plot based on multivariable analyses adjusting for age, sex, race, working or attending school, immigration to Canada, highest level of education, household income, number of children under 12, population centre size category Similar results in age and population subgroups: +ve assoc. for Q4 & Q5: Age 30-64 Pop. 1,000-29,999 +ve assoc. for Q5 only: Age 18-29 Pop. 100,000+ No significant assoc. Remaining groups Difference in Energy Expenditure (kcal/kg/hr) SSWS Quintile All Respondents: Transport and Leisure Physical Activity

13. PublicHealthOntario.ca Discussion Limitations: Information bias due to self-reported outcomes Selection bias due to residential self-selection Residual confounding Cross-sectional study design precludes inference of causality 13

14. PublicHealthOntario.ca Discussion SSWS and walking to work or school: Positive associations identified for all quintile comparisons, increasing strength in each successive quintile Consistent across age groups and population centre sizes SSWS and energy expenditure on all leisure and transport activities: Compared to lowest quintile, only top quintile shows positive association Next steps: Findings can be used to justify more resource-intensive longitudinal studies in a variety of age and population groups 14

15. PublicHealthOntario.ca Thank you! Questions? justin.thielman@oahpp.ca 15

16. PublicHealthOntario.ca References [1] Chronic Diseases and Their Common Risk Factors. (n.d.). In World Health Organization. Retrieved July 8, 2011 from http://www.who.int/chp/chronic_disease_report/media/Factsheet1.pdf http://www.who.int/chp/chronic_disease_report/media/Factsheet1.pdf [2] Lynch, B.M., Neilson, H.K., Friedenreich, C.M. (2011). Physical activity and breast cancer prevention Recent Results in Cancer Research. 186:13-42. [3] Lee, L.L., Watson, M.C., Mulvaney, C.A., Tsai, C.C., Lo, S.F. (2010). The effect of walking intervention on blood pressure control: a systematic review. International Journal of Nursing Studies. 47(12):1545-1561. [4] Murtagh, E.M., Murphy, M.H., Boone-Heinonen, J. (2010). Walking: the first steps in cardiovascular disease prevention. Current Opinion in Cardiology. 25(5):490-6. [5] Halle M, Schoenberg MH. (2009). Physical activity in the prevention and treatment of colorectal carcinoma. Deutsches Aerzteblatt International. 106(44):722-7. [6] Caspersen CJ, Fulton JE. (2008). Epidemiology of walking and type 2 diabetes. Medical & Science in Sports & Exercise. 40(7 Suppl):S519-28. [7] Ferrier, S., Blanchard, C.M., Vallis, M., Giacomantonio, N. (2011). Behavioural interventions to increase the physical activity of cardiac patients: A review. European Journal of Cardiovascular Prevention and Rehabilitation. 18(1):15-32. [8] Foster, D.D., Summers, A.A. (2008). State executive/legislative and judicial activities and the strength of local regulation of residential housing. Urban Lawyer 40(1):1-16. 16

17. PublicHealthOntario.ca References [9] Hui, E.C.M., Lam, M.C.M., Ho, V.S.M. (2006). Market disequilibrium and urban land shortages: Analysis of policy and patterns in Hong Kong. Journal of Urban Planning and Development. 132(2):80-88. [10] Hiwasaki, L. (2005). Toward sustainable management of national parks in Japan: Securing local community and stakeholder participation. Environmental Management. 35(6):753-764. [11] De Vries, M.S. (2002). The changing functions of laws and its implication for government and governance. International Review of Administrative Sciences. 68(4):599-618. [12] Wendel-Vos W, Droomers M, Kremers S, Brug J, van Lenthe F. Potential environmental determinants of physical activity in adults: a systematic review. Obesity Reviews. 2007; 8(5):425-440. [13] Durand, C.P., Andalib, M., Dunton, G.F., Wolch, J., Pentz, M.A. A systematic review of built environment factors related to physical activity and obesity risk: Implications for smart growth urban planning. Obesity Reviews. 2011; 12(501):e173-e182. [14] Foster, C., Hillsdon, M. Changing the environment to promote health-enhancing physical activity. Journal of Sports Sciences. 2004; 22:755-769. [15] Saelens, B.E., Handy, S.L. Built Environment Correlates of Walking: A Review. Medicine and Science in Sports and Exercise. 2008; 40(7):S550-S566. [16] Sugiyama T, Neuhaus M, Cole R, Giles-Corti B, and Owen N. Destination and Route Attributes Associated with Adults’ Walking: A Review. Med. Sci. Sports Exerc. 2012; 44(7):1275-1286 17

18. PublicHealthOntario.ca References [17] McCormack C, and Shiell A. In search of causality: a systematic review of the relationship between the built environment and physical activity behaviour. International Journal of Behavioral Nutrition and Physical Activity. 2011; 8:125. [18] Van Cauwenberg J, De Bourdeaudhuij I, De Meester F, Van Dyck D, Salmon J, Clarys P, Deforche B. Relationship between the physical environment and physical activity in older adults: A systematic review. Health & Place. 2011; 17:458-469. [19] Frost, SS, Goins RT, Hunter RH, Hooker SP, Bryant LL, Kruger J, Pluto D. Effects of the Built Environment on Physical Activity of Adults Living in Rural Settings. American Journal of Health Promotion. 2010; 24(4):267-283. [20] Sallis JF, Floyd MF, Rodriguez DA, Saelens BE. Role of Built Environments in Physical Activity, Obesity, and Cardiovascular Disease. Circulation. 2012; 125:729-737. [21] Statistics Canada. Canadian Community Health Survey, 2009-2010: Annual component [Data file and code book]. 2011. [22] Statistics Canada. Canadian Community Health Survey, 2007-2008: Annual component [Data file and code book]. 2009. [23] Statistics Canada. Canadian Community Health Survey, 2009-2010: Annual component [User Guide]. 2011. [24] Walk Score. Walk Score Methodology. 2012. [25] Duncan DT, Aldstadt J, Whalen J, Melly SJ, Gortmaker SL. Validation of walk score for estimating neighborhood walkability: an analysis of four US metropolitan areas. Int J Environ Res Public Health. 2011 Nov;8(11):4160-79. [26] Carr LJ, Dunsiger SI, Marcus BH. Validation of Walk Score for estimating access to walkable amenities. Br J Sports Med. 2011 Nov;45(14):1144-8. 18

19. PublicHealthOntario.ca Next steps Climate covariates CHMS 19

20. PublicHealthOntario.ca Data Sources and Methods 20 QuintileSSWS Range 10 – 19 220 – 36 337 – 53 454 – 71 572 - 100 2007-08 CCHS + 2009-10 CCHS + 2011-12 CCHS =361,126 - Rural residents =262,630 - Respondents missing SSWS data =253,457 (3.5%) -Respondents missing data on key covariates: immigrant, cultural origin, education = (age, sex, children <12 missing none) 245,595 (3.1%) (6.5% overall) - Respondents missing data on primary outcomes = Final sample size: 240,595 (2.0%)

21. PublicHealthOntario.ca Appendix A: Table 1 21

22. PublicHealthOntario.ca Appendix A: Table 1 22

23. PublicHealthOntario.ca Appendix A: Table 1 23

24. PublicHealthOntario.ca Appendix A: Table 1 24

25. PublicHealthOntario.ca Appendix B: Results Tables 25 SSWS and Daily Energy Expenditure for All Resondents WS Quintile NEstimateLowerCLUpperCLP-value Q1 REF Q2 0.128869-0.034780.2925170.122729 Q3 0.024102-0.11740.1656040.738498 Q4 0.02316-0.13480.1811170.773826 Q5 0.3209690.1104060.5315320.002811

26. PublicHealthOntario.ca 26 SSWS and Daily Energy Expenditure by Age Category Age CategoryWS Quintile NEstimateLowerCLUpperCLP-value 12-17Q1 REF Q2 0.470359-0.497181.4378980.340684 Q3 0.251054-0.651641.1537510.585687 Q4 -0.25968-1.112590.5932190.550674 Q5 -0.22748-1.188260.7333070.642615 18-29Q1 REF Q2 0.041075-0.38290.4650480.849402 Q3 -0.0309-0.433890.3720830.880523 Q4 -0.08857-0.541620.3644740.701587 Q5 0.914610.2592041.5700170.006236 30-64Q1 REF Q2 0.133481-0.032220.2991780.114363 Q3 0.060961-0.07410.1960260.376361 Q4 0.2377150.0594690.4159610.008952 Q5 0.4556080.2192630.6919540.000158 65+Q1 REF Q2 -0.03701-0.225850.1518310.700881 Q3 -0.09176-0.240370.0568580.226235 Q4 -0.11545-0.256080.0251780.107603 Q5 -0.09807-0.248690.0525450.201883

27. PublicHealthOntario.ca 27 SSWS and Daily Energy Expenditure by Population Centre Size Class Population Class WS Quintile NEstimateLowerCLUpperCLP-value 1,000 – 29,999Q1 REF Q2 0.197115-0.093310.4875360.183429 Q3 0.169152-0.06810.4064030.162296 Q4 0.6782920.1798691.1767140.007647 Q5 0.4600430.1853920.7346940.001027 30,000 – 99,999 Q1 REF Q2 0.386996-0.177010.9510070.17868 Q3 -0.13839-0.462980.1861950.403351 Q4 -0.12908-0.443180.1850160.420545 Q5 -0.17223-0.530750.1863020.346446 100,000+Q1 REF Q2 0.065253-0.12890.2594020.51006 Q3 -0.00033-0.177460.1768020.997105 Q4 -0.06352-0.251740.1247050.508358 Q5 0.3177820.0681360.5674280.012599 Appendix B: Results Tables

28. PublicHealthOntario.ca 28 SSWS and Walking to Work/School for All Respondents WS Quintile NOdds RatioLowerCLUpperCLP-value Q1 REF Q2 1.381.291.48 Q3 1.641.521.76 Q4 2.061.912.21 Q5 3.543.293.81 Appendix B: Results Tables

29. PublicHealthOntario.ca 29 SSWS and Walking to Work/School by Age Category Age CategoryWS Quintile NOdds RatioLowerCLUpperCLP-value 12-17Q1 REF Q2 1.691.491.92 Q3 1.841.612.1 Q4 2.251.942.6 Q5 2.392.022.82 18-29Q1 REF Q2 1.291.131.46 Q3 1.521.331.73 Q4 1.811.62.05 Q5 3.012.643.43 30-64Q1 REF Q2 1.341.191.51 Q3 1.751.561.97 Q4 2.362.12.65 Q5 4.544.065.07 65+Q1 REF Q2 1.280.822.01 Q3 1.410.932.13 Q4 2.411.633.56 Q5 3.872.655.64

30. PublicHealthOntario.ca 30 SSWS and Walking to Work/School by Population Centre Size Class Population Class WS Quintile NOdds RatioLowerCLUpperCLP-value 1,000 – 29,999Q1 REF Q2 1.391.191.63 Q3 1.731.482.03 Q4 21.732.33 Q5 2.532.133.01 30,000 – 99,999 Q1 REF Q2 1.491.261.75 Q3 1.71.442.02 Q4 2.181.852.58 Q5 3.332.734.07 100,000+Q1 REF Q2 1.371.261.5 Q3 1.631.491.78 Q4 2.071.92.26 Q5 3.693.384.03 Appendix B: Results Tables

31. PublicHealthOntario.ca Appendix C: Unadjusted Results 31

32. PublicHealthOntario.ca 32 Appendix C: Unadjusted Results

33. PublicHealthOntario.ca 33 Appendix C: Unadjusted Results

34. PublicHealthOntario.ca 34 Appendix C: Unadjusted Results

35. PublicHealthOntario.ca 35 Appendix C: Unadjusted Results

36. PublicHealthOntario.ca 36 Appendix C: Unadjusted Results

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38. PublicHealthOntario.ca 38