Fitness A WELLography™
First Edition

Copyright

Copyright

Copyright© 2017 International WELL Building Institute PBC. All rights reserved.

International WELL Building Institute PBC authorizes personal use of this Fitness WELLography™, which includes the ability by the user to download and print a single copy of the Fitness WELLography™ for the user’s own education and reference. In exchange for this authorization, the user agrees:

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Unauthorized use of the Fitness WELLography™ violates copyright, trademark, and other laws and is prohibited.

Credits

The International WELL Building Institute also acknowledges the important work of Melcher Media in bringing this document to market in its current state.

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Design & Development by Crush + Lovely

Illustrations by Kaarina Mackenzie

Animations by Vita Newstetter

Melcher Media would like to thank Callie Barlow, Jess Bass, David Brown, Dylan Butman, Tova Carlin, Maria Gagliano, Barbara Gogan, Luke Jarvis, Weronika Jurkiewicz, David Kahn, Susan Lynch, Sami Melcher, John Morgan, Lauren Nathan, Julia Sourikoff, Tori Spencer, Saif Tase, Zoe Valella, and Megan Worman.

Acknowledgements

The International WELL Building Institute (IWBI) and Delos Living LLC (Delos) acknowledge the work of the following IWBI and Delos technical staff that developed and created the WELLographies: Oriah Abera; Niklas Garrn; Trevor Granger; Soyoung Hwang; Michelle Martin; Vienna McLeod; Anja Mikic; Renu Nadkarni; Brendan O’Grady; Chris Ramos; Eric Saunders; Sara Scheineson; Nathan Stodola; Regina Vaicekonyte; Sarah Welton; Kylie Wheelock; and Emily Winer.

IWBI also is grateful for the input and insight provided by the following Subject Matter Experts:

Air: Terry Gordon, PhD; Eric Liberda, PhD; Tim McAuley, PhD; Ellen Tohn, MCP

Water: Eric Liberda, PhD; Tim McAuley, PhD; Margret Whittaker, PhD, MPH, CBiol, FSB, ERB, DABT, ToxServices LLC

Nourishment: Sharon Akabas, PhD; Alice H. Lichtenstein, DSc; Barbara Moore, PhD

Light: Chad Groshart, LEED AP BD+C; Samer Hattar, PhD; Steven Lockley, PhD, Consultant, Delos Living LLC and Member, Well Living Lab Scientific Advisory Board, Neuroscientist, Brigham and Women’s Hospital and Associate Professor of Medicine, Harvard Medical School

Fitness: Dr. Karen Lee, MD, MHSc, FRCPC, President & CEO, Dr. Karen Lee Health + Built Environment + Social Determinants Consulting; Jordan Metzl, MD

Thermal Comfort: Alan Hedge, PhD, CPE, CErgHF; David Lehrer, MArch; Caroline Karmann, PhD, MArch

Acoustics: Arline L. Bronzaft, PhD, Professor Emerita of The City University of New York; Charles Salter, PE

Materials: Clayton Cowl, MD; Matteo Kausch, PhD, Cradle to Cradle Products Innovation Institute; Megan Schwarzman, MD, MPH; Margret Whittaker, PhD, MPH, CBiol, FSB, ERB, DABT, ToxServices LLC

Mind: Anjali Bhagra, MBBS; Lisa Cohen, PhD; Keith Roach, MD; John Salamone, PhD; Nelida Quintero, PhD

Disclaimer

None of the parties involved in the funding or creation of the WELL Building Standard™ and the WELLographies™, including Delos Living LLC, its affiliates, subsidiaries, members, employees, or contractors, assume any liability or responsibility to the user or any third parties for the accuracy, completeness, or use of or reliance on any information contained in the WELL Building Standard and the WELLographies, or for any injuries, losses, or damages (including, without limitation, equitable relief) arising from such use or reliance.

Although the information contained in the WELL Building Standard and the WELLographies is believed to be reliable and accurate, all materials set forth within are provided without warranties of any kind, either express or implied, including but not limited to warranties of the accuracy or completeness of information or the suitability of the information for any particular purpose.

The WELL Building Standard and the WELLographies are intended to educate and assist building and real estate professionals in their efforts to create healthier work and living spaces, and nothing in the WELL Building Standard and the WELLographies should be considered, or used as a substitute for, medical advice, diagnosis or treatment.

As a condition of use, the user covenants not to sue and agrees to waive and release Delos Living LLC, its affiliates, subsidiaries, members, employees, or contractors from any and all claims, demands, and causes of action for any injuries, losses, or damages (including, without limitation, equitable relief) that the user may now or hereafter have a right to assert against such parties as a result of the use of, or reliance on, the WELL Building Standard and the WELLographies.

Welcome to WELL

The buildings where we live, work, learn and relax have a profound effect on our well-being: how we feel, what we eat and how we sleep at night. By examining our surroundings and our habits, and making key optimizations and changes, we have the power to cultivate spaces that promote wellness, and support efforts to live healthier, active, mindful lives – a right for every human.

The WELL Building Standard™ (WELL) envisions this reality and opens this critical dialogue. It provides a roadmap and a comprehensive set of strategies for achieving building and communities that advance human health.

WELL consists of a comprehensive set of features across seven concepts (Air, Water, Light, Nourishment, Fitness, Comfort and Mind). Together, these components address the various individual needs of the people inside buildings, while also setting forth a common foundation for measuring wellness in buildings as a whole. The standard was developed by integrating scientific research and literature on environmental health, behavioral factors, health outcomes and demographic risk factors that affect health; with leading practices in building design and management. WELL also references existing standards and best practice guidelines set by governmental and professional organizations, where available, in order to clarify and harmonize existing thresholds and requirements.

The result is the premier building standard for advancing human health and wellness – and a blueprint for creating better buildings that can enhance productivity, health and happiness for people everywhere.

How to Use This WELLography™

WELLographies™ present research relevant to health and well-being in buildings and communities. The sources included span health, wellness, and scientific and professional literature specific to the seven concepts within WELL, and other core focus areas. WELLographies are meant to complement the WELL Building Standard™ (available at standard.wellcertified.com) and provide architects, building managers, engineers, and interior designers, among others, with health- and science-focused background to support and guide their efforts to advance the healthy buildings movement.

WELLographies have three primary goals:

1. Provide background information for key topics relevant to understanding human health as it relates to the built environment.
2. Synthesize and present the science that underpins the WELL Building Standard.
3. Outline specific, evidence-based strategies that building professionals can apply to create spaces that promote health and well-being in buildings and communities.

There are nine WELLographies:

1. Air
2. Water
3. Nourishment
4. Light
5. Fitness
6. Thermal Comfort
7. Acoustics
8. Materials
9. Mind

The Fitness WELLography™ has the following sections:

Fitness and the Built Environment, which broadly describes how Fitness relates to the human experience in buildings.

Fitness and the Human Body, which provides an explanation of the biological mechanisms relating to Fitness, describing how the body functions under normal, healthy conditions.

Elements of Fitness, which describes environmental conditions or behaviors that are linked to health, focus, or occupant comfort, and that are subject to interventions in building design or policy. Each element includes coverage of associated health effects as well as solutions, interventions that can be implemented to impact the element. Some solutions may address several different elements.

Explanations of Solutions, which provides a definition and/or more detail for each solution.

Introduction

The Centers for Disease Control and Prevention (CDC) defines fitness as “the ability to carry out daily tasks with vigor and alertness, without undue fatigue, and with ample energy to enjoy leisure-time pursuits and respond to emergencies.” ¹

Fitness is comprised of several domains including: cardiorespiratory endurance, muscle power, endurance, and strength, flexibility, balance, movement speed, reaction time, and body composition. Regular physical activity not only improves these domains of fitness but can also have a profound positive impact on health and well-being.¹ The benefits of physical activity include lower risk of chronic diseases, such as cancer, cardiovascular diseases, diabetes, and obesity, as well as improved cardiorespiratory fitness, increased muscle mass, strength, and energy levels, and reduced risk of all-cause mortality.^{2 3}

Despite the well-established benefits of regular physical activity and the concerted efforts of health and government agencies around the world, physical inactivity in adults and children (measured by self-report) is highly prevalent worldwide,^{4 5} with 23% of adults failing to meet international physical activity guidelines established by the World Health Organization (WHO).⁶ In general, more women fail to meet international activity guidelines compared to men, a gap that is more evident in low- and middle-income countries.⁶ Among adolescents (11-17 years), 78% of boys and 84% of girls fail to meet WHO physical activity recommendations.⁶ Inactivity is also a concern among older age groups.⁷ In an analysis of data from the United States (U.S.), researchers found that 25.4% of those aged 50-64 and 35.3% of those aged 75 and above, fail to meet physical activity guidelines.⁸ In addition to gender, age, and socioeconomic disparities, racial and ethnic gaps are also evident,^{9 10 11} but are less robustly documented in global literature. When examining physical activity levels using objective tools, such as accelerometers, data suggests that in the U.S. alone, fewer than 50% of elementary school students, 10% of adolescents, and 5% of adults obtain even 30 minutes of daily physical activity.¹² These data indicate that the average adult in the U.S. obtained only 6–10 minutes of moderate- to vigorous-intensity physical activity per day.¹² In addition to low physical activity levels, research shows that people also engage in a significant amount sedentary time, which poses significant health risks independent of the overall physical activity levels of an individual.^{13 14}

Increasingly, physical inactivity is recognized as one of the leading threats to modern public health. According to the WHO, physical inactivity is one of the leading risk factors for mortality worldwide,⁶ responsible for an estimated 6% of deaths and approximately five million preventable deaths in 2008.³ Inactivity also contributes to a substantial portion of global chronic diseases, including heart disease, type 2 diabetes, and breast and colon cancer.² Contrary to these findings, researchers have demonstrated a strong link between higher levels of physical activity and longevity (life expectancy). In a prospective study of over 600,000 individuals across six cohorts (1 Swedish and 5 U.S.) within the National Cancer Institute Cohort Consortium, researchers observed an increase of 1.8 and 4.5 years on average, for low levels of physical activity (0.1-3.74 MET hours per week, equivalent to 75 minutes per week of brisk walking) and high levels of physical activity (22.5+ MET hours per week, equivalent to 450+ minutes per week of brisk walking, which exceeds physical activity guidelines), respectively.¹⁵

The impact of increasing physical activity engagement is substantial. A 2012 analysis published in The Lancet of the effect of physical inactivity on disease and life expectancy estimates that if physical inactivity were reduced by just 10%—if people were slightly more active—more than a half million deaths worldwide could be averted, while over one million deaths could be averted if physical inactivity were reduced by 25%.³ In general, physically fit people of all body weights have lower rates of premature death compared to their counterparts who are less fit. The association remains significant after adjustment for baseline health and smoking and either body mass index (BMI), waist circumference, or percent body fat.¹⁶ These results emphasize that weight loss is not a prerequisite for lower mortality risk.

The harmful effects of physical inactivity translate to an enormous economic burden across the world.

The economic burden of physical inactivity can be quantified in two ways, direct and indirect costs. Direct costs, include measures of health care expenditure while indirect costs, comprise more challenging constructs to measure, such as the productivity losses and/or premature mortality that can be attributed to physical inactivity. Based on representative data from 142 countries it is estimated that health care spending and productivity losses (direct and indirect costs) attributed to physical inactivity cost the global economy $67.5 billion in 2013.¹⁷ More specifically, researchers estimate that the direct health care costs of physical inactivity reached about $0.6 billion in Africa, about $3 billion in Latin America, about $26 billion in North America, about $2.4 billion in the Eastern Mediterranean region, nearly $12 billion in Europe, nearly $1 billion in southeast Asia, and about $9 billion in the Western Pacific region.¹⁷ When isolating indirect costs, in 2013 alone, premature deaths attributed to physical inactivity resulted in nearly $14 billion in productivity losses around the world.¹⁷

Many factors that influence sedentariness and physical activity may be beyond an individual’s control. Increasingly, research shows that the constructs of our physical and social environments play an important role in determining physical activity.^{6 18 19} Therefore, the buildings and spaces in which we live, learn, work, and play should be thoughtfully designed and operated in ways that promote active lifestyles, discourage sedentariness, encourage healthy behaviors, and help individuals to maintain health across throughout their lifespan.

The solutions presented in this WELLography™ are intended to encourage physical activity and planned exercise through a range of interventions from structural adaptations to buildings, such as staircase design, to interventions, such as standing desks and activity prompts, to behavioral modification programs, like wellness competitions and reimbursements. Since not all solutions are appropriate for every environment, it is necessary to determine which can be feasibly implemented and adopted by people within each unique space.

Fitness and the Built Environment

Collectively, the design and operation of the built environments in which we live, learn, work, and play constitute powerful and sustainable interventions that promote more active ways of living across the lifespan.

On a neighborhood scale, elements such as walkability, availability of and access to mass transit, active transportation infrastructure (e.g., bike lanes), and availability of and access to fitness facilities (e.g., a gym) are associated with physical activity.^{18 20} Similarly, the design of a building’s interior is also associated with our physical activity behaviors. The ways in which our building’s circulation system is designed and planned including corridors, stairs, and lobbies, can impact opportunities for physical activity during the workday.¹⁸ In addition, building elements and amenities, such as dedicated exercise spaces, shower and locker facilities, and aesthetic staircase design can also impact our activity levels.¹⁸

Strategies to promote physical activity and reduce sedentary behavior can be implemented throughout the environment, at a single building level and on a neighborhood/community scale.

Considering that virtually all of our time is spent within or around buildings,²¹ urban planning and building design that consciously encourage physical activity and discourage sedentariness constitute powerful intervention strategies to improve health and prevent disease.^{3 20}

The Fitness WELLography™ addresses elements of physical activity as they relate to community planning, building design, and organizational policies and programs. It provides an overview of the human body as it relates to physical activity and fitness, discusses the health implications of sedentariness and insufficient physical activity, and highlights the health benefits associated with physical activity. In this WELLography, we also highlight evidence-based and expert recommendation-based solutions/interventions that can be applied within the built environment to increase physical activity and decrease sedentariness among individuals in order to promote health and well-being.

Fitness and the Human Body

Humans are designed to move and regular physical activity is a key determinant of overall health and function.

Movement

Muscles work to generate force and motion, creating movement of the body.²² Muscles also generate heat, help to maintain posture, and support the function of internal organs, such as the passage of food through the gastrointestinal tract and the contraction of the heart. Muscles are predominantly powered by the oxidation of fats and carbohydrates in the mitochondria of our cells and come in three major types: cardiac, smooth, and skeletal.²²

Cardiac Muscle

Cardiac muscle is found in the heart wall and helps to pump the blood from the heart to the rest of the body.²² Cardiac muscle cells contain a central nucleus and are composed of long, fibrous proteins, which give cardiac muscle (and skeletal muscle) their striated appearance. Cardiac muscle is partially controlled by the autonomic nervous system (ANS), which is the part of the nervous system that controls involuntary bodily functions, such as breathing and digestion. Specialized myocardial cells, called autorhythmic or pacemaker cells, allow the heart to contract without any outside signals from the ANS.²² Cardiac muscle, like skeletal muscle, adapts to different types of stimuli (e.g., physical activity) in order to meet the body’s changing oxygen demands for a given activity.²³ Importantly, the structural and functional changes that occur in response to physical activity can also help to treat or prevent adverse cardiac deficits due to hypertension (high blood pressure), advanced aging, and myocardial infarction (heart attack).²⁴

Smooth Muscle

Smooth muscle is essential for maintaining homeostasis and has diverse properties depending on the functional needs of the particular organ in which it is found.²² Smooth muscle is non-striated (unlike cardiac and skeletal muscle) and is innervated by the ANS.²² Some evidence suggests that physical activity may impart a positive effect on the functioning of smooth muscle, but these effects are not yet fully understood.²⁵

Skeletal Muscle

Skeletal muscle is striated like cardiac muscle.²² Except for reflex movements, skeletal muscle is largely under conscious control, which allows the body to move and maintain posture. Skeletal muscle comprises about 40% of total body weight,²² with sex-specific hormone profiles determining slight differences in muscle mass between the sexes (males typically have slightly higher lean mass than women.²⁶ Broadly, skeletal muscles are categorized by their fiber type.²²

Slow-twitch (Type I) muscle fibers have more powerful aerobic capacities, including cells with high numbers of mitochondria, are innervated by higher quantities of capillaries that allow for more efficient oxygen transfer, and higher levels of myoglobin (oxygen-binding proteins).²² These features allow slow-twitch fibers to utilize oxygen efficiently and minimize muscle fatigue during prolonged aerobic activities, such as endurance running. Comparatively, fast-twitch (Type IIA, IIB) fibers have higher glycolytic capacities including enzymes that allow these fibers types to produce energy directly from dietary macronutrients (primarily carbohydrates), without the use of oxygen. Fast-twitch muscles have less endurance but are more powerful than their slow-twitch counterparts and can generate more force more quickly. Differences among fiber types can also be seen in their color—slow-twitch muscle fibers are more mitochondria-rich and are thus darker in color, whereas fast-twitch fibers have few mitochondria and are thus paler in color. It is important to note that muscle groups are composed of a mixture of all muscle fiber types, although one fiber type may be more common in one muscle group or another and is highly variable among individuals.²² Figure 2 below highlights the different characteristics and properties of different skeletal muscle fiber types.

Neural Control of Movememt

Movement is a highly complex process and relies on a dense connective network between the sensory and motor systems of the central and peripheral nervous systems and the muscles of the body.²² Movement of the human body is carried out by billions of neurons that form the communicative network that relays information to and from the central and peripheral nervous systems via electrical signals.²² The human nervous system is divided into two parts—the central nervous system (CNS) and peripheral nervous system (PNS).²⁷ The CNS includes the brain and spinal cord.²⁷ Neurons, which are the functional units of the nervous system, transmit information via electrical signals that flow within (via interneurons), and to or from (via afferent neurons and efferent neurons, respectively) the CNS. In addition, the CNS plays a major role in regulating the hormonal conditions that stimulate and promote muscle growth and repair. The PNS lies outside the brain and spinal cord, and includes all the sensory receptors and sensory (afferent) and motor (efferent) neurons of the human body.²⁷

The PNS is subdivided into the somatic and autonomic nervous systems and includes both sensory and motor neurons.²⁷ The autonomic system of the PNS is further divided into the parasympathetic and sympathetic systems, which innervate internal organs, blood vessels, and glands, as well as cardiac and smooth muscles and are considered involuntary. The sympathetic division of the autonomic system initiates the “fight or flight” response including increased heart rate and pupil dilation, while the parasympathetic division initiates the “rest and digest” response including muscle relaxation and saliva production. The somatic system contains both sensory nerves and voluntary motor neurons allowing the body to consciously react to the environment and move.²⁷

THE MOTOR UNIT

When the somatic nervous system communicates an electrical signal from the CNS to a skeletal muscle, it communicates through a motor unit.²⁸ A motor unit is made up of an efferent motor neuron and all the muscle fibers that neuron innervates.²⁸ Skeletal muscles are organized in motor units, which are groups of identical-twitch fibers that are serviced by one motor neuron that communicates with that unit of fibers (Figure 3).²² Motor units vary in how many muscle fibers they contain and recruit depending on the function and purpose of that muscle. For example, the small ocular muscles that move the eye only contain a few motor units, each of which recruits three to five muscle fibers.²² Conversely, the gastrocnemius (calf) muscle contains upwards of 600 motor units that cumulatively recruit over one million muscle fibers.²⁸

When the CNS sends a command to skeletal muscle, it signals motor units to engage in a specific recruitment sequence of motor units.²⁸ Of the three fiber types, slow-twitch fibers require the least amount of stimulation and energy to engage their contractile proteins. Thus, in line with the biological imperative to save energy, the CNS first attempts to recruit only slow-twitch fibers in order to complete a voluntary action. If the force required to complete a task exceeds the slow fibers’ ability to do so, the nervous system will sequentially engage type IIA and finally type IIB muscle fibers in order to generate enough force or extend contraction for a longer duration in order to complete the task at hand (Figure 4).^{22 28}

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Energy Conversion

In order for our muscles to move the human body, they need to convert dietary energy from unusable forms like carbohydrates, lipids (fats), and proteins to a usable form called adenoside triphosphate (ATP).²⁸ ATP is a nucleotide molecule whose potential energy, stored in the chemical bonds, powers all cellular processes.²⁸ Physical activity is commonly divided into two modalities—aerobic or “with oxygen,” and anaerobic or “without oxygen,” which are linked to the two major metabolic pathways that convert unusable forms of energy (e.g., macronutrients consumed through the diet) to usable forms of energy (ATP) within our cells (Figure 5).²⁸ Aerobic metabolism takes place inside the mitochondria and requires oxygen to produce ATP.²² Anaerobic metabolism begins outside the mitochondria and does not require oxygen but yields a comparably limited amount of ATP.²²

Generally, aerobic activity includes low- to high-intensity physical activities, such as swimming, biking, walking, and jogging, while anaerobic activity involves more high-intensity and muscle-strengthening type activities, such as weight lifting, jumping, and sprinting.^{28 30} However, the convention of dividing physical activity into two distinct types (aerobic and anaerobic) that involve only one metabolic pathway is somewhat misleading. Both aerobic and anaerobic metabolism are part of a connected cellular metabolic pathway active in every cell of the body and activities overlap considerably in their use these different metabolic processes for energy conversion.²⁸ Anaerobic metabolism produces less ATP but does so fairly quickly, while aerobic metabolism yields much more ATP but involves more steps and therefore takes more time.²² Thus, endurance activities like jogging or biking rely heavily on the aerobic system and slow-twitch muscle fibers, which produce ATP with less fatigue over time, while high-intensity/muscle-strengthening activities, like jumping, weight lifting, or sprinting, rely heavily on the anaerobic system and fast-twitch muscle fibers, which generate ATP very quickly although in smaller amounts and with greater fatigue.²⁸

Metabolism

Energy conversion involves cellular metabolism (also called cellular respiration), which are complex and highly coordinated processes that are carried out within each individual cell.²² Simply summarized, cellular metabolism converts one form of energy, such as dietary macronutrients (carbohydrates, lipids, and proteins), to ATP—from an unusable to a usable form—within the cell in order to meet the cell’s functional demands.²²

Every cell in the human body requires a supply of oxygen, macro and micronutrients, and cellular substrates, such as enzymes and co-enzymes, to carry out energy conversion, stay alive, and perform its functional purpose.²²

Many body systems work together in order to produce energy, in the form of ATP, for the body.²² The respiratory and cardiovascular system function to draw in and transport oxygen from the lungs into the cells where it is needed; the gastrointestinal system digests macro- and micronutrients into compounds required to carry out these reactions; while the urinary, integumentary, respiratory, and gastrointestinal systems help remove waste products of cellular metabolism.²⁸ However, the most powerful metabolic machinery in the human body are mitochondria - powerful, specialized sub-units of a cell that are the main site of energy conversion.²²

Physical activity, whether a moderate-intensity jog or a high-intensity interval training session, sends signals to the body’s metabolic systems. In response to this stimulus, molecules within our cells trigger a cascade of events that prompt cells to make new proteins and enzymes that improve the functional capacity and quantity of the mitochondria in order to meet new demands placed on the body (Figure 6).³¹ These cellular changes (adaptations) can help explain how physical activity may help prevent many age-related and chronic diseases.³²

Adaptations to Physical Activity and Exercise

Aerobic Conditioning

When aerobic pathways are pushed to their limit, the body responds by making metabolic and cardiovascular adaptations to increase the efficiency of the delivery and consumption of oxygen.²⁸ This, in partner with other physiological adaptations, contributes to an increase in the body’s ability to perform higher levels of physical exertion and ultimately reduces the basal (or baseline) load on the cardiovascular system.²⁸

Aerobic adaptations to physical activity and exercise include improved function of the cardiovascular and respiratory systems along with improvements in aerobic metabolic and muscular machinery.²⁸ Aerobic conditioning increases the quantity and quality of mitochondira and the essential enzymes for metabolism that leads to more efficient conversion of macronutrients into ATP.²⁸ Physical activity and exercise also stimulate processes within existing skeletal muscle, leading to the activation and accumulation of new proteins, mitochondira, and enzymes that are essential for efficient aerobic metabolism.³² This process, called mitochondrial biogenesis, has important consequences for metabolic health, fitness levels, longevity, and disease-prevention.³²

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Cardiorespiratory System and Oxygen Uptake

In response to repeated and sustained aerobic demands, the body also makes several adaptations that increase the efficiency with which it can transport and convert oxygen into cellular energy.²⁸ In general, more efficient oxygen use means less strain on the cardiovascular system. Maximum oxygen uptake (VO2max) is the most widely accepted, direct measure of aerobic fitness. VO2max represents the body’s maximum capacity for transporting and using oxygen during physical activity and exercise, and is typically assessed by collecting exhaled gases to measure oxygen uptake and carbon dioxide output during a progressive exercise test to exhaustion. VO2max is reached when activity intensity increases and the rate of oxygen intake plateaus along with other important clinical, physical, and psychological indicators. However, true VO2max is rarely measured in clinical practice because it is extremely challenging to push an individual to their true limit during a clinical test.²⁸ Instead, practitioners use other methods and equations to estimate VO2max based on various parameters, without actually requiring individuals to achieve true VO2max during a fitness test.³³

Cardiorespiratory fitness encompasses a variety of functional components of the cardiovascular and respiratory body systems. Cardiac output (CO), a term used to define cardiorespiratory capacity, is a function of heart rate and stroke volume and equates to the volume of blood pumped from the heart’s left ventricle (left chamber of the heart) into systemic circulation (carries blood away from the heart to the body) per minute.²⁸ A component of CO, stroke volume, defined as the volume of blood ejected from the heart’s left ventricle per beat, is dependent respiratory systems ability to fill the ventricle with oxygenated blood and the contractile strength of the heart muscle to pump blood out of left ventricle and into systemic circulation. More distally, stroke volume is a function of other circulatory system conditions, such as venous return and blood pressure.²⁸

One of the ways practitioners can easily measure cardiorespiratory adaptations to physical activity and exercise, as compared to VO2max testing, is via CO.²⁸ As the body becomes more efficient at delivering more oxygenated blood to the left ventricle of the heart, and the heart muscle increases in strength (ejecting more blood per beat) our heart rate decreases, as a result of a more efficient oxygen delivery mechanism.²⁸

Muscle Growth

The cardiorespiratory system services the mechanical function of the muscle by delivering oxygen to the working muscle.²⁸ The higher the intensity of muscular work demanded by the body, typical of higher-intensity activities, the higher the degree of cardiorespiratory involvement needed to deliver oxygen. In addition to cardiorespiratory adaptations in response to increasing demands explained above, these stressors on the working muscle trigger proteins to activate and accelerate protein synthesis leading to development of the muscle fibers. Some amount of microscopic, cell-level damage is necessary for initiating adaptations that lead to increases in muscle fiber size, also called hypertrophy.²⁸ When muscles are forced to contract with enough intensity to cause trauma (microscopic tears) within the muscle cells, specialized stem cells called satellite cells (located on the outer surface of the muscle fibers) proliferate, fuse to the fiber, and donate their nuclei to it, promoting repair and enabling an increase in fiber size.³⁴

Insulin Sensitivity

Insulin is a hormone that is responsible for helping cells take up blood sugar, in the form of glucose from the bloodstream, which our cells can use for immediate energy or metabolize and store for later use in the form of glycogen or triglycerides (the main component of body fat).²² The main tissue that takes up glucose in response to insulin release is skeletal muscle, which uses insulin to transport glucose into the cell in order to produce ATP.²⁸ When muscle cells fail to adequately respond to circulating insulin, blood glucose levels rise.

Excessive and sustained rise in blood glucose levels due to insensitivity to insulin is a precursor for type 2 diabetes and other adverse health outcomes.^{35 36}

Excess glucose in the bloodstream is converted to triglycerides by the liver and deposited into adipose tissue, contributing to metabolic dysfunction and increased fat accumulation in the body.²⁸

The causes of insulin resistance and insulin sensitivity are largely unknown, but many potential determinants have been explored. Physical inactivity and obesity are two common posited causes of insulin resistance/sensitivities, leading to elevated blood glucose and fatty acid levels, hallmarks of metabolic syndrome and precursors to both type 2 diabetes and heart disease.³⁷

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In contrast, some recent scientific findings suggest that decreased insulin sensitivity may precede obesity, rather than be a result of it.³⁹ The CDC notes that the rise in obesity over the past 30 years mirrors a rise in diabetes, both of which follow similar geographical and demographic patterns. While this observation does not determine causality, or ascertain the temporal relationship between obesity and diabetes, it highlights that these two clinical outcomes are associated and that further research is needed to understand the relationship between them.⁴⁰

Moderate-intensity physical activity is known to be effective at improving insulin sensitivity, although more time in moderate-intensity physical activity is required to achieve the same health benefits as compared to higher-intensity activities.⁴¹ In addition, studies show that exercise and physical activity are effective at reducing type 2 diabetes risk.^{41 42} However, evidence also suggests that these benefits are diminished when controlling for sedentary behavior in statistical analyses.⁴³ This indicates that meeting physical activity requirements or thresholds shown to be beneficial at reducing type 2 diabetes may be negated by significant time spent in sedentary activities.⁴³ Similar findings are emerging for a wide array of health outcomes.

A 2015 meta-analysis showed that sedentary behaviors are associated with cardiovascular disease, cancer mortality and incidence, and type 2 diabetes incidence, independent of physical activity levels.⁴⁴

These emerging findings emphasize that in addition to strategies that aim to increase physical activity, targeted strategies to reduce sedentary behavior may also have important impacts for public health.

Elements of Fitness

The elements of Fitness described below include sedentary behaviors, moderate- to vigorous-intensity physical activity, and incidental activities such as walking and biking for transportation.

The World Health Organization (WHO) recommends that adults (ages 18-64) and older adults (ages 65 and above) engage in at least 150 minutes per week of moderate intensity physical activity, or 75 minutes per week of vigorous intensity activity (or an equivalent combination), plus muscle strengthening activities (i.e., resistance exercises) on two or more days per week.⁶

Strength training should include one to three sets per exercise, incorporate all major muscle groups, and should consist of 8-12 repetitions.³⁰ Children (ages 6-17) are encouraged to engage in at least 60 minutes per day of age-appropriate moderate-to-vigorous intensity activities, muscle strengthening activities on at least three days per week, and bone strengthening activities (i.e., weight bearing activities, such as jumping, stair climbing, and weight-lifting) on at least three days per week.⁶ The U.S. Department of Health and Human Services (USDHHS) also recommends that older adults participate in neuromuscular training activities (i.e., balance and coordination activities) to mitigate fall risk and age-related functional declines.³⁰

There are many ways individuals can achieve these recommendations. For example, 30 minutes of cycling or brisk walking (moderate-intensity activities) can be accumulated over five days of the week (to equal 150 minutes). Similarly, activities like jogging, running, and aerobics (vigorous-intensity activities) can be performed for 25 minutes three times per the week (to equal 75 minutes).

A person’s physical activity status is typically characterized into three categories: 1) physically inactive - failing to achieve even one 10-minute bout of moderate- to vigorous-intensity physical activity per week; 2) insufficient physical activity - failing to meet the recommended level of physical activity per week; or 3) meeting physical activity recommendations. Notably, evidence is also emerging that an additional risk factor, sedentary behavior, plays a critical and independent role for chronic disease risk and health outcomes.^{13 14}

The section below describes the health benefits of physical activity, risks associated with sedentary behavior, and evidence-based solutions that can be implemented throughout the environment to promote physical activity and reduce sedentariness.

Sedentary Behavior

The environment in which modern humans live, work, learn, and play has rapidly evolved into one that not only reduces demands for physical activity, but also perpetuates a new category of health-related behavior – sedentariness.⁴⁵ Sedentary behavior is defined as “any waking behavior characterized by an energy expenditure ≤1.5 METs while in a sitting or reclining posture.”⁴⁶ Briefly defined, a MET (metabolic equivalent) is a physiological measure used to quantify the caloric cost of various physical activity types.²⁸ Epidemiological evidence consistently suggests that the health risks posed by sedentary behavior are distinct and independent from too little physical activity.^{13 14 45}

1. Prolonged Sitting

Prolonged sitting includes any extended period of sitting in a seated and/or reclined position without intermitted bouts of activity (e.g., sitting at work, in front of the TV, or while commuting). Compared to standing, sitting burns about 50 fewer calories per hour (note that exact caloric expenditure is dependent on body size, weight, and other individual factors).⁴⁷ Therefore, standing in lieu of sitting for three hours per day, five days per week will burn approximately 750 additional calories. Over the course of one year, this adjustment can add up to more than 39,000 calories.

Prolonged sitting has been shown to increase the risk of several adverse health outcomes including premature⁴⁸ and all-cause mortality.⁴⁹

More specifically, research among U.S. populations has shown that sitting for more than three hours a day is associated with a two-year lower life expectancy.⁵⁰ As mentioned above, the health risks associated with sedentariness appear to act independent of an individual’s physical activity levels.^{45 13 14} It is therefore possible to meet recommended physical activity levels and still remain vulnerable to the adverse effects of prolonged sitting, making reduced sedentary time an imperative chronic disease prevention strategy.

Health Effects

Cardiovascular System

Cardiovascular events. In a systematic review of 18 studies, increased sedentary time was associated with a higher risk of cardiovascular events and mortality.⁴⁹ Individuals in the highest category of sedentary time had a 147% and 90% higher risk of cardiovascular events and mortality, respectively, compared to those in the lowest category.⁴⁹

Endocrine System

Diabetes. In a systematic review of 18 studies, increased sedentary time was associated with a higher risk of type 2 diabetes, with a 112% increase in relative risk between the highest and lowest amounts of sedentary time.⁴⁹

Glucose metabolism. In randomized trial of blood glucose and sedentary behavior among 70 normal- and overweight-adults, researchers categorized participants into three intervention groups: 1) the prolonged sitting intervention (nine hours of sedentary time); 2) the physical activity intervention (30 minutes of activity followed by sitting); and 3) the regular-activity break intervention (100-second activity breaks every 30 minutes).⁵¹ Results showed that those sitting for nine hours had higher post-meal blood glucose and insulin levels compared to the activity groups.⁵¹

More recently, a randomized crossover trial with 19 overweight and obese adults, those sitting for prolonged periods of time (five hours) without any interruption (only moving to use the bathroom) had higher post-meal blood glucose and insulin levels compared to those who broke up their sitting time with two-minute bouts of light- or moderate-intensity walking every 20 minutes.⁵²

Weight gain and obesity. In a systematic review of 46 studies, increased sedentary time was associated with an increased risk for weight gain in adults.¹⁴ In addition, sedentary behavior during childhood and adolescence was found to be a strong predictor of obesity in adulthood.¹⁴

Metabolic risk factors. Metabolic risk factors encompass several health conditions including excess body fat around the waist, high triglycerides, low HDL (good cholesterol), high blood pressure, high fasting blood sugar.⁵³

Studies suggest that decreasing sitting time may be as important as engaging in exercise and/or regular moderate-to-vigorous physical activity in reducing an individual’s risk for metabolic syndrome.^{54 55}

In a cross-sectional study of 168 adults, those sitting for prolonged, uninterrupted periods of time had a larger waist circumference, higher BMI, and higher triglyceride levels compared to those who took activity breaks.⁵⁶ These findings were independent of total sitting time and time spent in moderate-to-vigorous physical activities.⁵⁶

Another cross-sectional study of almost 1,000 adults found that metabolic syndrome risk was positively associated with sedentary activities, such as time spent sitting in front of the TV or computer, and these results were significant even after adjusting for physical activity levels.⁵⁷

Digestive System

Constipation. In a study using survey data of over 33,0000 adolescents, excessive sedentary behavior was associated with reported episodes of constipation.⁵⁸ In the study children who spent more than four hours watching TV, using the Internet, or playing video games had a 25% higher adjusted odds ratio for constipation, compared to adolescents who engaged in these behaviors for four hours per day or less.⁵⁸

Colon cancer. A meta-analysis demonstrated prolonged sitting and TV viewing were associated with a higher risk of colon cancer.⁵⁹ In the study, each two-hour increase in sitting time per day was associated with an 8% increase in colon cancer risk, and adjusting for physical activity did not affect the association.⁵⁹

Reproductive System

Endometrial cancer. Results from a meta-analysis found that prolonged sitting and TV viewing were associated with a higher risk of endometrial cancer.⁵⁹ In the study, each two-hour increase in sitting time per day was associated with a 10% increase in endometrial cancer risk, and adjusting for physical activity did not affect the association.⁵⁹

Ovarian cancer. In the American Cancer Society’s Cancer Prevention Study II Nutrition Cohort involving nearly 60,000 women with 314 incident cases of ovarian cancer, those who reported spending six or more hours per day in sedentary activities had a 55% higher risk of ovarian cancer than women who spent fewer than three hours in sedentary activities.⁶⁰ In addition, the risk was unchanged after accounting for recreational physical activity levels among the participants.⁶⁰

A review of 11 studies examining the relationship between sedentary behavior and cancer found a statistically significant association between sedentary behavior and several cancers, including ovarian cancer in two of the 11 studies.⁶¹

However, a larger meta-analysis of 43 studies examining the relationship between sedentary behavior and cancer, of which five studies examined ovarian cancer specifically, found no relationship between sedentary behavior and risk of ovarian cancer.⁵⁹ Given these mixed findings, more research is needed to ascertain the relationship between physical inactivity and ovarian cancer.

Respiratory System

Lung cancer. A meta-analysis found prolonged sitting and TV viewing were associated with a 21% higher relative risk of lung cancer when comparing the highest versus lowest categories of sedentariness.⁵⁹ Researchers also observed a 6% increase in lung cancer risk with each 2-hour per day increase in total sitting time. Their findings held after adjusting for covariates, such as age, current BMI, education, alcohol consumption, total calorie intake, smoking, and socioeconomic status, among others.⁵⁹

Nervous System

Psychological well-being. In a study with over 4,300 adults, individuals engaging in about 10 hours of sedentary behavior per day were 29% more likely to report psychological distress, regardless of their general physical activity levels.⁶² Active individuals, on the other hand, who participated in five or fewer hours of sedentary behavior per day, and also met the recommended guidelines for physical activity (at least 150 minutes of moderate-intensity physical activity per week), were 40% less likely to report psychological distress.⁶² In addition, findings from a cross sectional study of 3,290 men and women in Scotland showed that sedentary behavior was associated with poorer mental health scores.⁶³

Solutions

1. Passive Activity Prompts

In an office intervention comprised of 60 workers that focused on disrupting sitting time using passive and active prompts (hourly pop-up computer screen alerts and wrist-worn reminders) found a decrease in:⁶⁴

• The duration of average sitting bouts;
• The number of sitting bouts of 60 minutes or more;
• Total sitting time;
• The duration of the longest sitting bout;
• The number of sitting bouts of 30 minutes or more.

The activity reminders also led to an increase in standing and walking time.⁶⁴

In addition, passive activity prompts when paired with education, have been shown to be more effective at decreasing workplace sitting time than education alone.⁶⁵

A study with 34 employees conducted over the course of 13-weeks, testing the effectiveness of passive e-health prompts (computer screen prompts to engage in short bursts of activity), found a 22% increase in energy expenditure (i.e., calories burned) post intervention compared to before the intervention period began.⁶⁶

Based on these findings, programmatic strategies that passively prompt building occupants to engage in short bouts of physical activity throughout the workday may reduce sedentariness and encourage physical activity throughout the day.

2. Interactive Activity Prompts

A seven-day smartphone-based intervention with 30 overweight/obese individuals was associated with a 39-minute reduction in sedentary time, on average.⁶⁷ The smartphone application tracked participants’ activity throughout the day and included three different physical activity prompts—a prompt for three, six, or 12 minutes of walking after an inactivity period of 30, 60, or 120 minutes had been detected, respectively. The smartphone application also assessed participants’ responses to the physical activity prompts (they had the option to comply, silence, or delay the prompt, which comprised the interactive nature of the intervention).⁶⁷

Based on these findings, programmatic strategies that actively prompt building occupants to engage in short bouts of physical activity throughout the workday may reduce sedentariness and encourage physical activity throughout the day.

3. Sit-Stand Desks

A seven-week study that included a four-week intervention period, introduced sit-stand desks to 24 office workers, found a 224% (66-minute) increase in non-sedentary time (standing or walking) time following the intervention period.⁶⁸ Researchers continued to collect data from study participants for two weeks post intervention and found that most of the positive health effects, including reduced pain and improved mood, were largely gone within two weeks of removing the sit-stand desks. In addition, sitting time, upper back and neck pain, vigor, and total mood disturbance all returned to about baseline levels within two weeks of removing the sit-stand desks.⁶⁸

In another four-week intervention study of 42 office employees, sit-stand desks were associated with a 73-minute per day decrease and a 65-minute per day increase in time spent sitting and standing at work, respectively.⁶⁹

In a study among Australian workers, sit-stand desks were associated with a 143-minute reduction in sitting time at one week of follow-up.⁷⁰ These effects were maintained at three months with continued use of sit-stand desks with an average reduction in sitting time of 137-minutes per day.⁷⁰

The Physical Activity Design Guidelines for School Architecture support the use of sit-stand desks as a tool to increase physical activity among school children.⁷¹ Results from one of the studies highlighted in the Guidelines showed that sit-stand desks in schools significantly increased students’ standing time compared to control classrooms.⁷¹ Additional survey data from 4th grade classrooms that examined the impact of sit-stand-desks found that students in the intervention group burned about 17% more calories compared to students whose classrooms did not receive sit-stand-desks.⁷² Secondary results from this school-based intervention showed that teachers and parents reported increased focus and attention in their students and children. Notably, the implementation of sit-to-stand desks in classrooms cost about 20% more than traditional desks.⁷²

In one sit-stand desk intervention study among 24 office workers, lasting 4-weeks, those who used a sit-stand desk reported improvements in self-reported mood states, such as fatigue, vigor, tension, confusion, and total mood disturbance, compared to workers who sat at a desk throughout the day.⁶⁸ In addition, the intervention group reported feeling more comfortable, energized, healthy, focused, productive, happy, and less stressed. Researchers noted that most of the positive health outcomes observed at the end of the intervention were largely gone within two weeks after removing the sit-stand desks.⁶⁸ These findings emphasize the need for long-term opportunities to utilize strategies like sit-stand desks for health benefits. In addition, further research is still needed to establish a clear link between reduced sitting time and many of these health outcomes.

Based on these findings, implementing sit-stand desks in the workplace and in educational facilities may be an effective strategy to reduce the total amount of sitting time, as well as break up prolonged periods of sitting. Active furnishings, such as sit-stand desks, complement other design strategies, which collectively aim to promote activity and create a workplace culture of health and wellness.

4. Treadmill Desks

A 12-month treadmill desk intervention study with 40 volunteers in an office setting allowed the participants to use the treadmill desk at will and operate it at speeds from 0-1.2 km/hr (0-2 miles mph), and found:⁷³

• A reduction in sedentary time by an average of 77 minutes per day;
• An increase in daily energy expenditure by an average of 74 calories per day.

Another 12-month treadmill desk intervention study with 36 employees found similar results, with a 42-minute decrease in daily sedentary time at 12 months compared to baseline, without affecting work performance.⁷⁴

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Based on these findings, implementing treadmill desks in the workplace may be an effective strategy to reduce the total amount of sitting time, as well as to break up prolonged periods of sitting. Active furnishings complement other design and programmatic strategies, which aim to promote activity and create a workplace culture of health and wellness.

5. Cycling Workstations

In a study of 10 individuals examining the effect of a cycling workstation intervention, participants burned 2.5 times as many calories while cycling at their desk compared to sitting.⁷⁶ In addition, using the cycling workstation did not have an impact on typing errors or typing time compared to sitting. However, the study was done in a laboratory setting, not in an office environment, and each assessment session lasted only 10 minutes.⁷⁶ Therefore, long-term studies with larger sample sizes are needed to evaluate the effects of implementing cycling desks in workplaces.

Another study with 12 participants evaluated a cycling workstation and found slightly increased physical activity and energy expenditure with the use of the active workstation compared to sitting at a regular desk.⁷⁷

However, one study found slightly decreased computer-task performance (mouse performance was affected more than typing) with the use of cycling workstations compared to sitting in a chair, although the authors of the study concluded that they may still be feasible solutions to reduce workplace inactivity.⁷⁸

Based on these findings, cycling workstations may be consider as a potential strategy to reduce sedentary time and increase physical activity during the workday. However, more research is needed to better understand the potential effects that cycling workstations may have on workers’ performance and other outcomes.

6. Portable Pedal Machines

A small study using a pedal machine in the office resulted in a 289 calorie increase in energy expenditure among participants using the machines.⁷⁹ Another 4-week pilot study on 18 sedentary office workers found that participants used the pedal machine on approximately 12 out of 20 days for about 23 minutes per day, on average.⁸⁰

Although there is limited research on their effectiveness, pedal machines may be an attractive option to reduce sedentary behavior in spaces where larger, active workstations (e.g., treadmill desks) are not feasible due to space constraints or other limitations.

7. Active Meetings

In order to increase physical activity levels and decrease sedentary behaviors in the workplace, the CDC Steps to Wellness Guide suggests implementing “Walk-and-Talk” meetings instead of traditional, seated meetings in order to increase physical activity levels in the workplace.⁸¹ The Guide also suggests starting meetings with a 5-10 minutes stretching or an activity or intermixing these activities throughout longer duration meetings.⁸¹

8. Walking Programs

In order to increase physical activity levels and decrease sedentary behaviors in the workplace, the CDC Steps to Wellness Guide suggests organizing 10-minute group walks around the building (which may include taking the stairs).⁸¹ The Guide also suggests creating a walking club with a small group or groups of employees that walk together throughout the workday.⁸¹

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Based on these findings, walking programs may effectively reduce sedentary behavior during the workday. Programmatic strategies enhance a workplace culture of health and wellness, and are an important complement to other building level interventions.

9. Counseling Support (Motivational Counseling/Interviewing)

A study of 149 adults randomized into either motivational counseling sessions lasting 30–45 minutes over a six-month period, or a control group, found a small decrease in total sitting time among the intervention group, while those in the control group actually increased sitting time slightly.⁸³ Although the difference in sitting time between groups (19 minutes) was not statistically significant, fasting blood insulin, insulin resistance, and waist circumference improved for the intervention group (and were statistically significant) at the six-month study point.⁸³

Based on the findings of this study, providing individuals with counseling support may be an effective strategy to reduce total sitting time. However, more research is needed to determine the effectiveness of counseling interventions alone and in conjunction with other strategies. Programmatic strategies are an important complement to other environmental design interventions, which together, aim to improve health and wellness of occupants.

10. Active Learning Environments

The Physical Activity Design Guidelines for School Architecture provide a review of evidence-based design strategies for promoting physical activity in children, including open interior spaces that allow students to be physically active during lessons and throughout the day.⁸⁴ One study of activity-oriented classroom spaces on 40 Minnesota students found that students exposed to open classroom designs were more physically active during the day than students exposed to either standing desk classrooms or traditional classrooms with rows of chairs and desks.⁸⁴ Other studies on activity-oriented classroom spaces showed that classrooms with easily movable furniture and features led to students being more physically active during the school day and also had a positive impact on students’ posture and resulted in lower rates of low back pain.⁸⁴

The CDC published a review in 2010 on the association between classroom-based activity and academic performance.⁸⁵ Some studies show that physical activity is positively associated with performance while others show no observed effect on academic performance. Notably, this review notes that no studies showed a detrimental effect of activity on academic performance.⁸⁵

Other research on active design and learning have posited that dynamic features and furniture that promote postural shifts such as swivel chairs and seats that move in three dimensions engage the body’s proprioceptive systems, which in turn increases circulation and raises the body’s temperature and has been found to have a positive effect on learning.⁸⁴

Preliminary evidence suggests that active learning environments that promote physical activity through design may improve activity levels, physical health, and academic performance in students.

Physical Activity and Exercise

The terms physical activity and exercise are often used synonymously; yet, they mean different things. The CDC defines physical activity as “any bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a basal level.”¹ Exercise, on the other hand, is defined as a “subcategory of physical activity that is planned, structured, repetitive, and purposive in the sense that the improvement or maintenance of one or more components of physical fitness is the objective.”¹ Note that research looking specifically at physical activity acquired via active commuting or through activities associated with daily living are excluded from this section, and are covered in the Incidental Physical Activity section.

The health benefits of physical activity are numerous, from reduced risk of chronic diseases such as cancer, cardiovascular disease (CVD), and diabetes, to better mental health and reduced risk of all-cause mortality, as well as other positive health outcomes, including a better quality of life.^{6 86} Figure 7 below highlights some of the most widely recognized health benefits associated with physical activity.

The American College of Sports Medicine and the American Heart Association note that due to the dose-response relationship between physical activity and health, people who want to further improve their health and fitness and further reduce their risk of disease and premature mortality, should accumulate more than the minimum recommended amount of physical activity.⁸⁸ There is currently no known upper limit to how much physical activity should be accumulated per week, as increased health benefits are found at even the highest measured categories of physical activity.^{30 88} These added benefits are observed for both cardiovascular and muscle-strengthening activities. For example, increasing weekly aerobic activities to at least 300-minutes of moderate-intensity activity, or 150-minutes of vigorous-intensity activity (or getting an equivalent combination of moderate- and vigorous-intensity physical activity) is associated with even greater health benefits than the minimum recommendations.³⁰ In addition, engaging in progressive muscle- and bone-strengthening exercise more than the recommended two non-consecutive days per week, adding more weights, performing more repetitions, and engaging in higher impact activities (e.g., stair climbing) leads to stronger muscles and bones, and greater cardiovascular endurance.^{30 88}

1. Moderate- to-Vigorous Intensity Physical Activity (MVPA)

The WHO defines activity intensity as “the rate at which the activity is being performed or the magnitude of the effort required to perform an activity or exercise.”⁸⁹ Physical activity can be classified as low-, moderate-, or high-intensity, and can be measured in two ways: relative intensity or absolute intensity. Relative intensity is the amount of individual effort that is needed to perform an activity, which can vary between people depending on their level of fitness and previous exercise experience.⁸⁹ Relative intensity physical activity can be measured on a scale from zero to 10, where zero equals sitting and 10 equals the highest possible level of effort based on increases in heart and respiratory rate.³⁰

A second way to measure activity intensity is absolute intensity, which is the amount of energy expended per minute of activity.³⁰ A common way to express absolute intensity is Metabolic Equivalents (METs), which is the ratio of an individual’s working metabolic rate relative to their resting metabolic rate, where one MET is roughly equivalent to a caloric consumption of one kcal/kg/hr.⁸⁹

Light-intensity activities include physical activities that are less than three METs but above the MET equivalent defined as sedentary. The distinction for sedentary METs varies slightly in the literature with some sources defining sedentary as activities that are less than or equal to 1.5 METs,⁴⁴ where other studies use less than two METs as a cutoff point.⁹⁰ Light-intensity activity includes countless activities that sufficiently engage metabolic processes such as slow walking and light housework (but lower than three METs).⁸⁸ However, time spent in light-intensity physical activity does not count toward accumulating the recommended amount of moderate- to vigorous-intensity physical activity.⁸⁸

Moderate-intensity physical activity leads to increased heart rate and breathing rates and includes activities that are from three to 5.9 METs, equivalent to roughly 3.5-7 kcal per minute (the exact caloric expenditure varies per individual).⁸⁸ Moderate-intensity physical activities include brisk walking, light hiking or jogging, easy biking, and even some types of yoga.⁹¹ A good way to determine whether the activity being performed is of moderate-intensity is to perform a “talk test”—an individual should be able to carry on a conversation (but not sing).³⁰ If the conversation is only possible in a few words before pausing to take a breath, the exercise is of vigorous intensity.

Vigorous-intensity physical activity includes activities greater than or equal to six METs, equivalent to seven or more kcal per minute (the exact caloric expenditure varies per individual).⁹¹ Heart and breathing rates are substantially increased during vigorous-intensity activity, so that a continuous conversation is not possible while the activity is being performed.³⁰ Vigorous-intensity physical activities include things like fast running and biking, stair climbing, and swimming.⁹¹ One form of high-intensity physical activity- interval training- involves repeated “bursts” of vigorous activity (typically 80-90% of VO2max).⁹²

Examples of moderate- and vigorous-intensity physical activities:

A. Moderate-intensity physical activities (3.5-7 kcal/min):⁹²

• Walking at a moderate or brisk pace (3-4.5 mph) on a level surface
• Walking down the stairs or down a hill
• Hiking
• Bicycling at the speed of 5 to 9 mph on a level terrain (can include a few hills)
• Stationary bicycling (moderate effort)
• Moderate housework
• Water aerobics
• Aerobic dancing
• Light calisthenics
• Yoga (athletic-style)
• Softball (fast or slow pitch)
• Competitive volleyball
• Frisbee
• Badminton
• Golfing (walking and pulling clubs)
• Stair-climbing
• Weight training or bodybuilding
• Rowing machine
• Ballroom dancing
• Tennis (doubles) or table tennis
• Recreational swimming
• Canoeing or rowing (<4 mph)
• Gardening and yard work, walking a power lawn mower

B. Vigorous-intensity physical activities (> 7 kcal/min):⁹²

• Walking at a highly brisk pace (>5 mph)
• Stair climbing
• Walking or hiking briskly up a hill or backpacking
• Jogging/running (>5 mph)
• Roller skating
• Shoveling heavy snow
• Carrying heavy loads
• Bicycling (>10mph), biking up a steep terrain, or stationary cycling (vigorous effort)
• Vigorous calisthenics (e.g., push-ups, pull-ups, jumping jacks)
• Karate, judo, tae kwon do, jujitsu, boxing, competitive wrestling, squash
• Football
• Basketball
• Soccer
• Lacrosse
• Cross country skiing or downhill skiing
• Swimming (steady paced laps or synchronized swimming)
• Tennis (singles)
• Heavy housework
• Heavy yardwork (e.g., splitting wood, pushing a non-motorized mower)

As the previous list shows, physical activity does not have to be done in a gym setting and individuals can engage in many different types of activities in order to meet activity guidelines.

International physical activity guidelines for adults recommend 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous-intensity physical activity per week, or a combination of both. Generally, regular physical activity helps to prevent obesity, decrease risk of chronic disease such as hypertension, diabetes, breast and colon cancers, coronary heart diseases, and stroke, reduce the risk of falls and fall related injuries, improve muscular and cardiorespiratory fitness, and improve bone and overall functional health.⁶

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In addition to the health benefits mentioned above, physical activity is a robust predictor of premature mortality (Figure 8).^{30 95} A systematic review and meta-analysis of 22 studies involving nearly a million individuals found a 19% reduction in overall mortality risk when people accumulated 2.5 hours of moderate-intensity physical activity per week compared to those with no activity. The study also found that more activity was associated with even greater benefits for mortality reduction; individuals accumulating seven hours of moderate-intensity physical activity had a 24% lower mortality risk compared to those with no activity.⁹⁵

The largest health benefits occur when transitioning from inactivity to low levels of physical activity, with additional health gains beyond the current recommendations.³⁰

Health Effects

Cardiovascular and Respiratory Systems

Cardiovascular disease (CVD). Globally, CVD remains one of the leading causes of death.⁹⁶ The risk of developing CVD can be reduced with regular, moderate-intensity aerobic physical activity (at least 150 minutes per week) and is reduced even further with higher amounts of physical activity, or with vigorous-intensity physical activity (at least 75 minutes per week).³⁰ Research on nearly 8,000 men from the Harvard Alumni Health Study and over 38,600 women from the Women’s Health Study found that those who met or exceeded the physical activity recommendations had a significantly lower rate of cardiovascular disease-related mortality (31–34% lower rates in men and 22–44% lower rates in women).⁹⁷

Higher volume and/or intensity of physical activity may have some additional benefits, particularly in men. In the Health Professionals Follow-Up Study of over 44,500 men (with a 22-year follow-up period), vigorous-intensity physical activity was associated with a slightly lower risk of CVD compared to moderate-intensity physical activity.⁹⁸ When 10 MET hours of moderate-intensity physical activity were replaced with vigorous physical activity that expended the same amount of energy, CVD risk was reduced by an additional 4%. In the same study, research also examined the impact of specific activity types where running five or more hours per week was associated with a 46% lower risk for CVD, tennis with a 28% lower risk, and brisk walking with a 23% lower risk of CVD when compared to men who did not participate in these physical activities.⁹⁸

A meta-analysis of 18 studies involving nearly half a million participants from seven countries showed that participants in the highest category of walking had a 31% lower risk of cardiovascular disease compared to those in the lowest category.⁹⁹

Hypertension. In one study using a prominent study cohort, The National Runners’ and Walkers’ Health Study cohort that included nearly 50,000 participants (about 16,000 walkers and 33,000 runners), researchers examined the differences between mode of activity and intensity on the risk of hypertension.¹⁰⁰ Their study found similar effects on risk of hypertension from walking and running when participants expended equivalent amounts of energy. In addition, both runners and walkers whose physical activity dose exceeded the current recommendations had a continued reduction in new onset hypertension. Further, faster pace activity (walking or running at a higher intensity) was associated with a lower risk of hypertension in both groups.¹⁰⁰ Contrary to findings for reduced CVD risk found in the Health Professionals Follow-Up Study (discussed above),⁹⁸ researchers in this study noted that hypertension was improved only when more energy was expended (the same energy expended at a faster pace did not result in a greater risk reduction).¹⁰⁰ The results of the National Runners’ and Walkers’ Health Study suggest that similar reductions in hypertension can be achieved through both moderate- and vigorous-intensity physical activity when the same amount of energy is expended with additional reductions in risk with increasing energy expenditure.¹⁰⁰

Stroke. The Harvard Alumni Health Study (over 11,000 men, mean age 58) found that walking 20 or more km (12.4 mi) per week was associated with a significantly lower risk of stroke, independent of other physical activity.¹⁰¹ Similarly, the Nurses’ Health Study, a prospective cohort of over 70,000 female nurses ages 40-65, found that the adjusted risk of total stroke and ischemic stroke decreased with increasing levels of walking and that higher intensities of walking were generally associated with lower risk of stroke (ischemic only) compared to lower intensities.¹⁰²

Cardiometabolic risk factors. The CDC states that regular physical activity can help to lower blood pressure and improve cardiometabolic risk factors such as low density lipoprotein (LDL) and high density lipoproteins (HDL) cholesterol levels, more commonly known as “bad” and “good” cholesterol, respectively.⁸⁶

Cardiorespiratory fitness. Research shows that regular moderate-intensity physical activity is associated with increased cardiorespiratory fitness in both children and adults. In a study of 310 children and adolescents, participation in at least 60 minutes per day of activity or group sports resulted in a higher odds of being fit (measured by clinical fitness tests) compared to those who had less than 60 minutes of activity or did not participate in group sports.¹⁰³ In a randomized controlled trial among adults, both lifestyle physical activity and structured exercise arms showed significant improvements in cardiorespiratory fitness from baseline to 24 months of follow-up.¹⁰⁴

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Cardiorespiratory fitness is an important health metric where higher cardiorespiratory fitness is associated with a lower risk of CVD mortality and improved insulin sensitivity, inflammatory makers, blood lipid and lipoprotein profiles, body composition, and blood pressure.¹⁰⁶ Lower cardiorespiratory fitness is associated with an increased mortality risk, regardless of other risk factors.¹⁰⁶

Endocrine System

Type 2 diabetes prevention. Regular physical activity is essential for preventing the incidence of type 2 diabetes.⁴¹ The National Runners’ and Walkers’ Health Study (50,000 participants) found similar risk reductions resulting from the equivalent energy spent during both walking (moderate-intensity physical activity) and running (vigorous-intensity physical activity) for new onset diabetes.¹⁰⁰ Both runners and walkers whose dose exceeded the currently recommended physical activity levels had a continued reduction in risk for new onset diabetes.¹⁰⁰

In the Nurses’ Health Study (over 70,000 female nurses), greater amounts of walking (moderate-intensity physical activity) and greater amounts of vigorous-intensity physical activity were associated with a lower risk of developing type 2 diabetes.^{41 107} Women in the highest quintile of vigorous activity, and in the highest quintile of MET score for walking (both adjusted for BMI).⁴¹ had a 26% and 42% lower risk of developing type 2 diabetes.⁴¹ compared to those in the lowest quintiles, respectively. Greater walking pace was also independently associated with a lower diabetes risk.¹⁰⁷

Furthermore, the CDC notes that lower rates of diabetes are seen in individuals performing at least 120 to 150 minutes of at least moderate-intensity physical activity, and the risk can be lowered further with more physical activity.⁸⁶

There is also evidence to suggest that type 2 diabetes.⁴¹ can be better prevented and managed by lifestyle modifications, which include regular physical activity, rather than medication.^{108 109} In the Diabetes Prevention Program, over 3,000 participants were randomized to either a lifestyle, pharmacological, or placebo intervention group and were followed for a baseline of 3-years (a smaller study group continued on for additional follow-up).¹⁰⁸ Researchers found that diabetes incidence was reduced by about 34% in the group randomized to a lifestyle intervention program compared to only an 18% reduction in the group randomized to a pharmacological intervention.¹⁰⁸ In addition, evidence suggests that regular physical activity helps to increase the uptake of glucose by working muscles (via GLUT4 receptors).¹⁰⁹

Hypercholesterolemia. The National Runners’ and Walkers’ Health Study with 50,000 participants examined the differences between the effects of exercise mode and intensity on the risk of hypercholesterolemia (elevated blood cholesterol levels), and found similar risk reductions resulting from the equivalent energy spent during both walking (moderate-intensity physical activity) and running (vigorous-intensity physical activity).¹⁰⁰ Both runners and walkers whose exercise dose exceeded 450–750 MET minutes per week (the currently recommended physical activity level) had a continued reduction in new onset hypercholesterolemia. Faster pace (walking and running) was associated with a lower risk (dose response of exercise), but only when more energy was expended (the same energy expended at a faster pace did not result in a greater risk reduction).¹⁰⁰

Visceral adipose tissue. Beyond the deleterious health effects associated with obesity, special attention is given to visceral adipose tissue (abdominal fat) as research suggests it is linked to adverse health outcomes such as CVD, type 2 diabetes, and non-alcoholic fatty liver disease and risk factors including, metabolic syndrome.¹¹⁰ A systematic review and meta-analysis of 15 studies on the effect of exercise on visceral adipose tissue (VAT) found that moderate- to vigorous-intensity aerobic exercise is the most effective in reducing VAT in overweight and obese adults, without adopting a calorically restricted diet.¹¹⁰

Digestive System

Gastroesophageal cancer. A systematic review and meta-analysis of 24 studies including nearly 16,000 cases of gastroesophageal cancer found that individuals engaging in moderate- to vigorous-intensity physical activity five times per week had a 33% lower risk of gastroesophageal cancer.¹¹¹

Colon cancer. A systematic review and meta-analysis of 21 studies suggests that physical activity is associated with a lower risk of colon cancer, a leading cause of cancer deaths in the U.S. Individuals who were the most physically active had a 27% lower risk of colon cancer compared to those who were the least active.¹¹²

Digestion and gastrointestinal disorders. A review on the positive and negative effects on the gastrointestinal (GI) system associated with physical activity reports that regular physical activity may decrease the risk of severe gastrointestinal bleeding, inflammatory bowel disease, diverticular disease, constipation, and gallstones.¹¹³ However, strenuous exercise may contribute to certain GI symptoms, such as diarrhea or heartburn, although such symptoms are likely to be acute and typically cease after the vigorous exercise is discontinued, thus not having a negative impact on overall health.¹¹³ In addition, the Nurses’ Health Study I and II (nearly 195,000 women) found that physical activity was inversely associated with the risk of Crohn’s disease. Women who engaged in the highest amount of physical activity had a 36% lower risk for Crohn’s disease compared to women who engaged in the lowest amount of physical activity, and those who accumulated at least 27 MET hours per week had a 44% lower risk compared to women who were sedentary and accumulated fewer than three MET hours per week.¹¹⁴

Skeletal System

Skeletal and joint health. In children, adults and even older adults, weight-bearing exercise has been shown to be important for bone growth and development (specifically for adolescents and children) and general bone health across the lifespan.³⁰ In addition, a meta-analysis of 10 studies including 330 postmenopausal women found that those who engaged in aerobic exercise had higher lumbar spine bone mineral density compared to women who did not exercise.¹¹⁵

Regular moderate- to vigorous-intensity physical activity is also associated with lower risk of wrist or hip fracture (two very common injuries among individuals with diminished bone strength).¹¹⁶ A meta-analysis of 22 cohort studies with over 1.2 million individuals followed over time showed that there is an inverse association between physical activity and total fracture risk.¹¹⁷ More specifically, the analysis showed a 39% and 28% reduction in risk of hip and wrist fracture, respectively, among people who were accumulating the highest compared to lowest amounts of physical activity.¹¹⁷

The CDC notes that 130 to 150 minutes per week of moderate-intensity, low-impact aerobic physical activity can also improve pain management and the ability to perform everyday activities, as well as improve quality of life in people with arthritis.⁸⁶

Muscular System

Muscle Health. Regular moderate-intensity aerobic physical activity can help to maintain muscle mass, strength, and endurance in children, adults, and older adults.³⁰

Particularly for aging individuals, physical activity is considered an important countermeasure to sarcopenia.¹¹⁸ Unique to aging women, a study of more than 400 overweight and obese postmenopausal women showed that when aerobic exercise is included along with dietary approaches for weight loss, lean body mass is preserved, while still producing significant overall weight loss.¹¹⁹ Therefore, adding aerobic exercise to dietary weight loss approaches may be effective for preventing or treating sarcopenia in this population.¹¹⁹

Nervous System

Depression. In a meta-analysis of 37 studies on physical exercise and depression, exercise was moderately more effective in reducing depression compared to a control intervention.¹²⁰ A systematic review of five randomized controlled trials on exercise in the treatment of depression found evidence for using supervised, moderate-intensity exercise three times per week (for at least nine weeks) in treating depression.¹²¹ In addition, a study on nearly 200 older adults showed that higher frequency, longer duration, and greater amount of low-intensity activity were associated with better quality of life and fewer depressive symptoms.¹²² For a more comprehensive overview of mental well-being and strategies to improve it, refer to the Mind WELLography™.

Memory and cognitive function. A randomized controlled trial of 170 participants with memory problems who had completed a 24-week physical activity intervention of moderate-intensity aerobic physical activity found that there were modest improvements in cognition, even over an 18-month follow-up period.¹²³ In addition, a meta-analysis of 29 studies with more than 2,000 participants concluded that aerobic exercise is associated with “modest improvements in attention and processing speed, executive function, and memory, although the effects of exercise on working memory are less consistent.”¹²⁴

Additional research is emerging that shows physical activity has a positive impact on slowing the progression of Alzheimer’s symptoms although more rigorous clinical trials are still needed.¹²⁵

Immune System

Immunity and anti-inflammation. Moderate levels of exercise have been associated with long-term strengthening of the immune system; however, chronic overtraining can depress it and increase infection rates.¹²⁶ During and immediately after exercise, there is a decrease in white blood cells (related to the duration and intensity of the exercise), returning to normal levels within 24 hours.¹²⁶ A systematic review of 17 studies investigating the effects of an exercise intervention on immune outcomes in healthy older adults demonstrated that regular aerobic exercise may be associated with reduced chronic inflammation.¹²⁷

A single bout of moderate-intensity exercise is thought to produce an overall anti-inflammatory response while long-term exercise is thought to reduce overall inflammation.¹²⁶

Reproductive System

Breast cancer. A review of 19 cohort and 29 case-control studies found a significant inverse relationship between physical activity and breast cancer in post-menopausal women (risk reductions of 20% to 80%) and also a relationship, though weaker, among pre-menopausal women (risk reduction of 15–20%).¹²⁸

Urinary System

Urinary health. Regular physical activity may contribute to better urinary health. In a study of nearly 1,700 older men (mean age 72), those in the highest quartile of physical activity and those who walked on a daily basis were 29% and 20% less likely, respectively, to develop lower urinary tract symptoms compared to their sedentary counterparts.¹²⁹

Bladder cancer. In a systematic review and meta-analysis of 15 studies involving nearly 5.5 million people, physical activity was associated with a lower risk of bladder cancer. Higher levels of physical activity were found to be more protective than lower levels of physical activity.¹³⁰

Comfort and Focus

Productivity. In general, health programs implemented through the workplace are associated with benefits to employee health and wellness and have shown an overall positive effect on productivity and various mental and physical health outcomes.¹³¹

The Walking Resource Guide, developed in a joint initiative between the British Columbia Recreation and Parks Association, the Heart and Stroke Foundation of British Columbia and Yukon, and the British Columbia Recreation and Parks Association, suggests that active and healthy workplaces can lead to improved employee productivity, reduced absence and staff turnover, less accidents, fewer insurance and worker compensation claims, as well as lower costs related to retirement, training, and orientation.¹³² In addition, the CDC notes that worksite wellness program that include physical activity elements may increase productivity, decrease absenteeism, and increase staff attitude/morale.¹³³ Physical activity may also be associated with improved staff morale and attitudes toward their organization, the ability to cope with changes in the workplace, and improved business reputation, and company morale.^{132 134 135}

Among adolescent populations more evidence is emerging that higher physical activity levels are linked to improved grades, better test scores, and higher educational attainment.⁸⁷ However, some studies have found this trend only among school-aged girls with a limited effect among boys.¹³⁶

Solutions

1. Access to Places for Physical Activity

The Community Preventive Services Task Force recommends “the creation of or enhanced access to places for physical activity based on strong evidence of their effectiveness in increasing physical activity and improving physical fitness.”¹³⁷ Strategies might include the creation of walking paths, providing access to exercise facilities, or building new spaces physical activity, like parks and playgrounds. In the 10 studies reviewed by the Task Force, researchers found that enhanced access to places for physical activity was effective in increasing activity levels, in general. Specifically, researchers noted median increases of 5.1%, 8.2%, 2.9%, and 13.7% for aerobic capacity, energy expenditure, in participants reporting “some” leisure-time physical activity, and exercise score, respectively, in a range of study settings (e.g., industrial plants, federal agencies, low-income communities, and universities) for both men and women. In addition, many studies also noted weight loss and/or reduction in body fat among study subjects.¹³⁷

Specific to adolescent populations, an analysis of nearly 43,000 census-block groups showed that the presence of even one physical activity facility or space within a census-block group (the smallest geographic unit used by the U.S. Census Bureau) is associated with an increased likelihood of performing five or more bouts of moderate- to vigorous-intensity physical activity per week in U.S. adolescents.¹³⁸

2. Physical Activity Opportunities and Spaces in the Workplace

The Community Preventive Services Task Force has evaluated evidence from 11 interventions and grouped them into 3 large umbrellas: informational, behavioral, and social approaches that aim to increase physical activity.¹³⁹ Interventions conducted in the workplace are strongly recommended by the task force as literature shows they are effective at increasing physical activity and improving physical fitness among adults.¹³⁹

The Working Healthy Project employed several interventions in order to promote physical activity in the workplace. Some of the interventions included providing spaces for fitness equipment in the workplace, buying new equipment for existing physical activity spaces, and providing training on how to use fitness equipment.¹⁴⁰ The study found that workers in the intervention worksites were “significantly more likely to report engaging in regular exercise at the time of the interim assessment,” relative to the employees in control worksites, with a total of a 30% increase in the intervention employees’ self-reported physical activity (versus 4.3% increase in the control worksites).¹⁴⁰

The CDC Steps to Wellness Guide notes that one way to promote physical activity in the workplace is by implementing subsidized (set up as a payroll deduction) or free fitness classes in the workplace (which can take place in dedicated spaces or conference rooms), such as aerobics, Pilates, Tai Chi, and yoga, to facilitate easy participation.⁸¹ The guide reports on a worksite wellness program that utilized this approach (in addition to making other changes) and found that since fitness classes for the employees of a large medical center were implemented, the employees have been “moving more, no matter what shift they may work.”⁸¹

Based on these findings, spaces and opportunities for moderate-to-vigorous physical activity should be provided in workplaces in order to encourage and promote physical activity among employees.

3. Creative Physical Activity Spaces for Children

The Active Design Guidelines recommend designing a building’s indoor and outdoor spaces so that they may be used for active play by children.¹⁸

One of the supplements to the Active Design Guidelines titled Active Design: Affordable Design for Affordable Housing, quantifies some of the costs associated with integrating strategies for improving physical activity, including adding spaces and opportunities for children’s play and activity into buildings with very tight cost margins, such as affordable housing.¹⁴¹ They found that many of their proposed strategies, such as painted markings on playgrounds or walkways, to be low-cost or cost-neutral.¹⁴¹

The Physical Activity Design Guidelines for School Architecture provide a review of evidence-based design strategies for promoting physical activity in children including open interior spaces that allow students to be physically active during lessons and throughout the day.⁸⁴ In the review, one study of activity-oriented classroom spaces on 40 Minnesotan students found that students exposed to open classroom designs were more physically active during the day than students exposed to either standing-desk classrooms or traditional classrooms with rows of chairs and desks. Other studies in the review showed that classrooms with easily movable furniture and features led to students being more physically active during the school day and also had a positive impact on students’ postures and resulted in lower rates of low back pain.⁸⁴ Additionally, the CDC suggests that classroom-based physical activity is associated with better academic and behavioral outcomes and is an emerging area of research.⁸⁵

Based on these guidelines, design strategies should provide activity opportunities in both indoor and outdoor spaces for children. Incorporating dynamic furnishings in interior and exterior activity spaces provides fun and creative opportunities for play and active learning, which increase physical activity levels throughout the day.

4. Workplace Walking Programs

The CDC Steps to Wellness Guide suggests organizing 10-minute group walks (that could include taking the stairs) and implementing “Walk-and-Talk” meetings instead of sedentary meetings in order to increase physical activity levels in the workplace.⁸¹ The guide also suggests creating a walking club with a small group or groups of employees who walk together during lunch breaks or at other times.⁸¹

A two-month randomized controlled trial with 94 office workers looked at the effectiveness of worksite walking programs and had workers take two 30-minute lunchtime walks per week either in a nature-based route (with trees, maintained lawns and public footpaths) or building-based route (pavement routes through housing estates and industrial areas).⁸² Physical activity levels increased in both groups at the intervention mid-point, but the overall adherence was only about 40%. The mean daily step count had increased in both groups at four weeks (intervention midpoint), compared to baseline and at eight weeks (end of intervention), and the walking environment did not seem to influence activity levels. The authors concluded that intermittent motivation might improve adherence.⁸²

Based on these findings, walking programs may effectively increased physical activity engagement during the workday. Programmatic strategies are an important complement to other environmental interventions, which together aim to enhance a workplace culture of health and wellness.

5. Walking Routes

The Working Healthy Project employed several interventions, such as painting walking distance lines around the building exterior, in order to promote physical activity during the work day.¹⁴⁰ The study found that workers in the intervention worksites were “significantly more likely to report engaging in regular exercise at the time of interim assessment” (relative to employees at control worksites), with a total of a 30% increase in employees’ self-reported physical activity (versus a 4.3% increase in the control worksites).¹⁴⁰

The Active Design Guidelines recommend providing exercise facilities and walking paths when designing offices and commercial spaces as an evidence-based strategy for increasing physical activity.¹⁸ In addition, marked and measured paths on larger building sites (e.g., corporate campuses) have also been shown to encourage exercise among employees.¹⁸

The Active Design Guidelines also recommend supportive infrastructure be included along walking routes.¹⁸ Benches, drinking fountains, restrooms, and water bottle refilling stations provide added support for pedestrian activity. Additionally, access to daylighting along walking routes implemented inside buildings can also encourage pedestrian activity.¹⁸

Based on these findings and recommendations, projects should consider integration of marked walking paths that include pedestrian-friendly amenities as a strategy to promote physical activity among employees.^{18 140}

6. Financial Incentives

The CDC Steps to Wellness Guide notes that one way to promote physical activity in the workplace is through the implementation of a “Wellness Bucks” program, in which every physical activity or wellness program that an employee completes or enrolls in is worth a certain amount of “Wellness Bucks”, which can later be redeemed for monetary value.⁸¹ The Guide highlights a workplace wellness program that utilized this approach and notes that after implementing the program, ”participation in the company’s wellness programs has increased dramatically.”⁸¹

A systematic review and meta-analysis of 11 studies on nearly 1,500 adults aged 18–85 showed financial incentives (ranging from $2.79 to $46.82 per week) to be effective in increasing exercise session attendance and exercise adherence for up to six months.¹⁴² Most of the incentives were dispensed at the end of the intervention, suggesting that the immediacy of receiving an incentive may not be a crucial factor. Most of the studies were relatively short-term (4–12 weeks), and therefore may not be indicative of the effectiveness of financial incentives for promoting physical activity in the long term. However, one study showed sustained adherence for more than a year, and two studies showed sustained adherence even after withdrawing the incentive, thus indicating that there may be some potential for financial incentives to promote exercise in the long term.¹⁴²

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Based on these findings, financial incentives provided by the employer to promote physical activity may be an effective strategy for increasing the levels of moderate-to-vigorous intensity physical activity in employees.

7. Gym Membership Subsidies

The CDC Steps to Wellness Guide notes that one way to promote physical activity in the workplace is through the implementation of subsidies.⁸¹ However, the Guide reports that fully subsidizing gym memberships for every employee may not the best approach to increase physical activity engagement and gym attendance, suggesting a sliding scale approach instead, whereby the gym reimbursement is based on the number of visits to the gym within a period of time. The more visits accumulated, the higher the reimbursement percentage, up to 100%.⁸¹

Based on these findings, subsidizing employees’ gym memberships on a sliding scale may be an effective way to increase employee levels of physical activity. However, projects should be mindful to ensure that the membership subsidies they approve give employees access to both aerobic and muscle-strengthening activities and/or equipment.

8. Interactive Activity Prompts

A seven-day smartphone-based intervention with 30 overweight/obese individuals was associated with a 39-minute reduction in sedentary time, on average.⁶⁷ The smartphone application tracked participants’ activity throughout the day and included three different physical activity prompts—a prompt for three, six, or 12 minutes of walking after an inactivity period of 30, 60, or 120 minutes had been detected, respectively. The smartphone application also assessed participants’ responses to the physical activity prompts (they had the option to comply, silence, or delay the prompt, which comprised the interactive nature of the intervention).⁶⁷

Based on these findings, programmatic strategies that actively prompt building occupants to engage in short bouts of physical activity throughout the workday may encourage physical activity throughout the day.

9. Physical Activity Breaks

Incorporating physical activity into daily routines has been successful at increasing physical activity engagement along with other psychosocial and other clinical improvements.¹⁴⁴

Pausa para tu Salud, an uncontrolled pretest-post-test study, examined the effects of incorporating daily 10-minute physical activity breaks during paid work time in 335 Mexican Ministry of Health office workers.¹⁴⁵ All employees were strongly encouraged to participate in the breaks conducted each morning, which entailed varying types of music broadcasted over the building’s intercom system. Employees had the option to exercise either with the group or individually at their own workstation, and both exercise options were supervised. The breaks began as light stretching and dancing activities, gradually increasing in intensity as the workers’ fitness improved. The break routines varied, exposing the workers to different kinds of aerobic, strength, and flexibility exercises. At the end of the 12-month intervention the study participants had decreases in BMI (significant only for men), waist circumference (both genders), and diastolic blood pressure (significant only for women). However, because baseline physical activity levels were not measured, it is unclear if the effects of the intervention were exclusively due to the 10 minutes of daily office exercise, or increased physical activity outside of office.¹⁴⁵

Based on these findings, implementing programmatic strategies such as short, physical activity breaks could be implemented at the workplace throughout the day in order to increase occupants’ physical activity levels.

10. Wellness Teams and Competitions at the Workplace

The CDC Steps to Wellness Guide suggests creating employee teams that could train together and participate in planned competitions in order to increase physical activity in the workplace.⁸¹

Another suggestion from the Task Force on Community Preventative Services is a workplace buddy system, which may increase participation in planned physical activity.¹³⁹

Based on these findings, wellness teams and competitions could be implemented at the workplace in order to increase occupants’ physical activity levels.

11. School-based Physical Activity

School-based physical education (PE) classes are organized, supervised ways to ensure children engage in the recommended 60 minutes of physical activity, or more. The Task Force on Community Preventative Services found that PE can help improve children’s knowledge about physical activity.¹³⁹

Education facilities face many challenges in providing ample opportunities for physical activity to their students. However, many steps can be taken towards achieving school-based physical activity goals including exterior and interior active design and programming around physical activity.¹⁴⁶ For example, the Active Design Guidelines recommend several creative strategies for child play spaces such as playgrounds, including ground markings and natural elements, that aim to invite more physical activity.¹⁷

Design strategies can be implemented to provide adequate activity spaces that allow for diverse learning and play opportunities in both indoor and outdoor environments. In addition, these spaces provide additional opportunities for active learning experiences outside the classroom for lessons that might require more space or unique features.

2. Muscle-Strengthening Activity

Muscle-strengthening activities include resistance exercises such as push-ups, pull-ups, and sit-ups, stair climbing, weight lifting, and other similar activities.^{30 88} U.S. federal guidelines recommend that muscle-strengthening activities that work all major muscle groups should be performed at a moderate- to high-intensity on at least two non-consecutive days per week and should include at least one set of 8-12 repetitions of each exercises in order to maximize fitness gains.³⁰ Adding more weights, performing more repetitions, and engaging in muscle-strengthening exercise more than twice per week can lead to stronger muscles and higher endurance.^{30 88}

Muscle-strengthening activities provide a variety of health benefits across several body systems, beyond those conferred by aerobic exercise alone. For example, strength-training exercise is linked to increases in and preservation of muscle mass, as well as improved functional strength.¹⁴⁷

In addition, muscle mass and strength aid in the prevention of injuries—the stronger the musculoskeletal system, the lower the chance that an individual will encounter a situation where a force exceeds the muscle, tendon, and/or bone’s ability to withstand that force.³⁸ Research also shows that more lean muscle mass has been associated with lower all-cause mortality.¹⁴⁸

Health Effects

Endocrine System

Weight maintenance and metabolism. Strength training is thought to be an important factor in weight control as having more muscle mass increases an individual’s resting metabolism and helps to maintain resting metabolic rate as we age. A 16-week strength training intervention study in healthy men (50–65 years old) found a 40% increase in strength, decrease in body fat, increase in fat-free mass, and a 7.7% increase in resting metabolic rate.¹⁴⁹

Improved glucose control. Strength-training exercise can have a significant impact on diabetes management. A review of studies examining the effects of physical activity on type 2 diabetes notes that resistance training can lead to decreased HbA1c levels and increased insulin sensitivity.¹⁵⁰

Improved insulin action. In a study of 11 healthy men ages 50-63, researchers examined the impact of a 16-week strength training program and found that fasting plasma insulin and overall insulin levels decreased significantly after completing the strength training program.¹⁵¹ These changes were accompanied by increased glucose infusion rates and a 40% increase in non-oxidative glucose metabolism.¹⁵¹

Muscular System

Leg strength and walking endurance. Progressive resistance training can lead to significant increases in muscle size and strength, especially among older adults. A study of 24 elderly subjects who underwent a three-month weight-training program found a 38% increase in walking endurance as well as improved leg strength, both of which are beneficial for independent living.¹⁵²

Among trained individuals, weight training also has important implications for muscular adaptations. In a study of 18 males who were grouped into a low-load or high-load weight training group, study subjects performed three sets of seven exercises on three non-consecutive days for eight weeks.¹⁵³ Researchers found that for both study conditions (high- and low-load) the thickness of elbow flexors and extensors and quadriceps femora were significantly increased.¹⁵³

Arthritis. In a 2-year prospective study of 70 individuals recently diagnosed with rheumatoid arthritis, researchers randomized participants to either strength training or range of motion exercises (both in conjunction with recreational activities and medication to manage and treat disease).¹⁵⁴ Researchers observed significant improvements in muscle strength and disease activity markers in the strength training group compared to the control group.¹⁵⁴

Sarcopenia. Muscle-strength-training programs in older adults are likely the most effective preventive measure to delay the onset of sarcopenia (loss of muscle mass associated with aging) as they stimulate hypertrophy and increase strength.¹⁵⁵ Evidence from an early review showed that “exercise programs designed to improve muscle strength should be recommended for older individuals as an effective countermeasure to the sarcopenia of old age.”¹⁵⁶

Skeletal System

Bone strength and fracture risk. Research shows that age-related declines in bone mineral density can be attenuated with regular physical activity, including strength training.³⁰ However, some research suggests that among the elderly, weight-bearing exercises may only be effective in conjunction with calcium supplementation, which may have important implications for fracture risk.¹⁵⁷

There is limited data on the effects of strength training on bone mineral content in youth, but it is generally understood that regular physical activity can help maximize peak bone mass in early years of life.¹⁵⁷

Nervous System

Depression. Resistance training has been shown to be effective at treating symptoms of depression.^{158 159} A randomized study of 32 elderly participants with depression found that individuals who participated in a supervised, progressive resistance-training program three days per week for 10 weeks had significantly reduced depression measures compared to the participants in the control group. In addition, training intensity was a significant predictor of a decrease in depression score.¹⁵⁸ This evidence was supported in a more recent review, which found that exercise has led to a reduction in depressive symptoms in older adults.¹⁵⁹

Solutions

1. Physical Activity Opportunities and Spaces in the Workplace

The Community Preventive Services Task Force evaluated 11 types of interventions aimed at increasing physical activity grouped by informational, behavioral and social, and environmental and policy approaches. Among the interventions evaluated, several are strongly recommended and could be implemented as workplace programs, including creating and enhancing access to physical activity spaces, such as onsite fitness centers,¹³⁷ which could include muscle-strengthening equipment.

The Working Healthy Project employed several interventions in order to promote physical activity in the workplace.¹⁴⁰ Some of the interventions included providing spaces for fitness equipment in the workplace, buying new equipment for existing physical activity spaces, and providing training on how to use fitness equipment. The study found that workers in the intervention worksites were “significantly more likely to report engaging in regular exercise at the time of the interim assessment,” relative to the employees in control worksites, with a total of a 30% increase in the intervention employees’ self-reported physical activity (versus 4.3% increase in the control worksites).¹⁴⁰

2. Gym Membership Subsidies

The CDC Steps to Wellness Guide notes that one way to promote physical activity in the workplace is through the implementation of subsidies.⁸¹ However, the guide reports that fully subsidizing gym memberships for every employee may not the best approach to increase physical activity engagement and gym attendance, suggesting a sliding scale approach instead, whereby the gym reimbursement is based on the number of visits to the gym within a period of time. The more visits accumulated, the higher the reimbursement percentage, up to 100%.⁸¹

Based on these findings, subsidizing employees’ gym memberships on a sliding scale may be an effective way to increase employee levels of physical activity. However, projects should be mindful to ensure that the membership subsidies they approve give employees access to both aerobic and muscle-strengthening activities and/or equipment.

Incidental Physical Activity

Incidental physical activities are activities that are part of everyday life and can include everything from walking to and from a public transportation station, taking the stairs up to your company’s floor in the morning, bicycling to school, house and yard work, and many other types of activities.¹⁶⁰

Creating better opportunities for individuals to engage in incidental activities, such as walking, stair climbing, and active commuting (e.g., by foot or bike), through active design strategies and/or policies/programs are practical and feasible ways to promote incidental physical activity, reduce sedentariness, and increase overall levels of physical activity.

Encouraging and facilitating opportunities for incidental physical activity through active design and other programmatic strategies implemented in the workplace could help increase physical activity levels and promote health.

1. Walking

Walking is one of the most common physical activities, with six out of 10 adults reporting at least 10 minutes of walking in the previous week and 145 million adults engaging in walking for active lifestyles in the U.S. alone. ^{161 162} Walking is a versatile activity type, it can be done for leisure activity or exercise and is also part of many everyday activities, such as walking to and from work, school, or public transportation, errands, walking across the floor of your office building or between classrooms in a school, walking your dog, and many others.

Walking at a pace of about 4.8 km/hr (3 mph) is considered moderate-intensity activity.¹⁶³ Walking is beneficial for maintaining and improving health and can reduce the risk of all-cause mortality.^{99 164} A meta-analysis of 18 studies involving nearly half a million participants from seven countries showed that participants in the highest category of walking had a 32% lower risk (hazard ratio 0.68) of all-cause mortality compared to those in the lowest category.⁹⁹ In addition, a systematic review and meta-analysis of about 280,000 participants showed an 11% reduction in all-cause mortality with a standardized dose of 11.25 MET hours of walking per week.¹⁶⁴ The greatest effects were observed in the lowest exposure interval, meaning that increasing walking in individuals who walk the least may lead to the greatest health benefits.¹⁶⁴

Health Effects

Cardiovascular System

Hypertension. In a cross-sectional study of nearly 4,000 participants, those traveling to work by foot had a 9.8% prevalence of hypertension compared to a 17.7% prevalence in those who traveled to work by car or motorbike.¹⁶⁵ In another study conducted in the United Kingdom (U.K.), researchers found that walking for transportation was associated with a 17% lower odds of having hypertension compared to individuals who use private transportation modes (e.g., personal automobile).¹⁶⁶

Coronary heart disease (CHD). The Nurses’ Health Study, which included a U.S. sample of over 120,000 female nurses, ages 30-55, showed that women who achieved 1-3 hours of brisk walking per week had a 30% lower risk of coronary events.¹⁶⁷ Researchers also found that walking pace was an important negative predictor of coronary events in the cohort where a faster pace was associated with lower risk.¹⁶⁷ Similarly, the Health Professionals’ Follow-up Study, a cohort of over 44,000 U.S. men, found that 30-minutes per day of brisk walking was associated with an 18% reduced risk of CHD and that walking pace was associated with CHD risk independent of total walking time.¹⁶⁸

Cardiovascular and Respiratory Systems

Cardiorespiratory fitness. A randomized controlled trial with 38 men and 30 women investigated the effects of 10-week active transportation intervention.¹⁶⁹ The study found that the mean walking distance was 3.5 km (2.2 mi) (mean cycling distance was 10 km (6.2 mi)) among the intervention group. Compared to controls, those randomized to the active transportation intervention had a statistically significant improvement in cardiorespiratory response to submaximal and maximal fitness testing.¹⁶⁹

Comfort and Focus

Well-being. In a study of nearly 18,000 adult commuters in the U.K., walking to work was associated with a positive effect on well-being when compared to commuting by car.¹⁷⁰ In addition, researchers observed a positive association between time spent walking and well-being, compared to commuting by car, with higher amounts of walking associated with greater well-being scores. In addition, switching transportation modes, from commuting by car to walking, was associated with improved well-being scores.¹⁷⁰

Solutions

1. Active Urban Design

Active urban design includes a variety of design and policy strategies that can be implemented throughout neighborhoods, communities, and even across larger geographic areas like counties and cities.¹⁸

One element of active urban design, pedestrian-scale design, includes a host of design strategies that consider the pedestrian perspective and experience by designing the transportation network to invite pedestrian activity and ensure safety.^{18 171} Pedestrian-scale design can positively impact the user experience, increase pedestrian activity,^{18 172 173} and can address important community elements such as street connectivity, accessibility, comfort, safety, and contextual factors.¹⁷¹ Furthermore, interventions that consider the pedestrian experience can also contribute to a sense of place, especially when embedded with the cultural and historical values of each unique community.¹⁷¹

Broader aspects of active urban design, including land-use mix, walkability, and access to parks and open spaces, can have a significant effect on individuals’ levels of physical activity.¹³⁷ In addition, having retail shops, bus stops, and offices within a walking distance from home is linked to a higher likelihood of walking and public transit use.¹⁷⁴ Furthermore, greater land-use mix has been linked to lower rates of obesity.¹⁷⁵

The Community Preventive Services Task Force recommends urban design that supports “physical activity in small geographic areas (generally a few blocks) based on sufficient evidence of their effectiveness in increasing physical activity.”¹⁷⁶ A review of six studies examining the relationship between physical activity levels and pro-physical activity urban design policies found a 35% median improvement in some aspect of physical activity following an improvement in policy or design.¹⁷⁶ In addition, a review of policies promoting active design notes that “more and better-quality sidewalks are associated with adults having a higher likelihood of walking, using transit, and driving less.”¹⁷⁷

A review of policies that promote active travel notes that living in a more “walkable” neighborhood (that includes factors like high population density, parks, sidewalks, and stores within walking distance, as well as bike paths) was associated with better mental health and a healthier weight status.¹⁷⁷

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Based on the available studies, stakeholders should consider active design factors when deciding where to site their building location(s).

2. On-Site Parking Considerations

Emerging research suggests that increased parking supply may be associated with lower walking and transit use, as it promotes more opportunity for automobile use.¹⁸ Therefore, car parking should be designed to reduce unnecessary car use when walking, bicycling, and public transit are available alternatives.¹⁸ Additional strategies might be implemented to encourage active commuting that complement on-site parking considerations, such as repurposing parking spaces with bike racks or providing bike storage/bike parking elsewhere within the project boundary or close by.¹⁸

On-site parking should be thoroughly vetted, in order to ensure that it does not discourage active transportation options that promote physical activity.

3. Mass-Transit Commuter Benefits

Research shows that people who use mass transit spend, on average, 19 minutes per day walking to and from their public transit stop, and 29% of individuals walk to and from transit for 30 or more minutes every day, which is sufficient to meet the aerobic physical recommendations set by the USDHHS.¹⁷⁹ Some studies have shown even higher increases in walking (up to 33 minutes) for those who use public transit compared to those who do not.¹⁸⁰ Individuals in New York City who use mass transit spend at least eight more minutes walking and take 30% more steps per day compared to those who use cars.¹⁸¹

The Transit Cooperative Research Program Report 107, Analyzing the Effectiveness of Commuter Benefits Programs, reports increased transit use in virtually all cases when transit benefits were implemented.¹⁸² The results did vary, from minor increases to more than doubling in mass transit use. More than half of the surveys reported a 10–40% increase in transit riders and about a quarter noted a greater than 60% increase.¹⁸²

For projects where public transportation is available and accessible to employees, employer-sponsored and/or pre-tax commuter benefit programs could be implemented to encourage transit use and increase walking.

4. Pedometers

A systematic review of 26 studies with nearly 2,800 participants found significant increases in physical activity with pedometer use (in conjunction with stepping goals), as well as reductions in BMI and blood pressure.¹⁸³ The mean intervention period was 18 weeks, and there was an average increase of 27% in daily physical activity in the participants who used pedometers (compared to baseline). However, given the short duration of the study, it could not be determined whether these changes were sustained long-term.¹⁸³

A study with 390 university employees from Australia, Canada, Northern Ireland, and the U.S. found a 25% increase in workday walking at the end of a six-week intervention, where the employees were provided with a pedometer and access to an online program that instructed them to increase their daily worksite walking by 1,000 steps above baseline every two weeks.¹⁸⁴

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The effectiveness of pedometers among adolescent populations also remains unclear.¹⁸⁶ While they are still useful for tracking the number of steps taken per day, there seem to be sex-specific differences in the association between pedometer use and subsequent changes in physical activity levels, with some studies only showing a positive benefit among adolescent girls.¹⁸⁶

Based on the mixed-findings of these studies, self-monitoring tools, such as pedometers, coupled with a step goal and other activity incentive programs, could be provided to employees in order to promote walking. In an effort to increase adherence, pedometer use combined with various support strategies, such as newsletters, telephone/in-person consultations or group support, as well as financial incentives may be beneficial in sustaining the increased walking with pedometer use in the long-term.

6. Passive Activity Prompts

An office intervention involving 60 randomized workers that gave participants either hourly pop-up computer screen and wrist-worn reminders to stand-up (stand group), or reminders to prompt participants to stand and take at least 100 steps (step group).⁶⁴ The intervention intended to both disrupt sitting time and increase physical activity, and led to an increase in walking time for both study groups, as well as an increase in the number of total steps per workday (step group only).⁶⁴

Another study with 34 employees tested the effectiveness of passive e-health prompts (delivered via computer screen and prompting workers to engage in short bursts of physical activity) over the course of 13-weeks, and found a 21% increase in energy expenditure (i.e., calories burned) in the intervention group after the prompting intervention compared to before the intervention period.⁶⁶

Based on these findings, incorporating programmatic strategies that passively prompt building occupants to engage in short bouts of physical activity throughout the workday may complement physical design strategies, which together aim to reduce periods of prolonged sedentary time and contribute to an overall workplace culture that promotes health and wellness.

7. Walking Routes

The Active Design Guidelines recommend providing walking paths nearby when designing offices and commercial spaces as an evidence-based strategy for increasing physical activity.¹⁸ Alternatively, marked, measured paths on larger building sites (e.g., campuses) have also been shown to encourage exercise in employees.¹⁸

Supportive infrastructure should also be included along walking routes.¹⁸ Benches, drinking, restrooms and water bottle refilling stations provide refreshment and support during the times of walking and encourage/provide a reason for people to walk more while indoors.¹⁸ Additionally, daylighting along walking routes inside buildings can provide a more satisfying sensory experience.¹⁸

Based on these findings and recommendations, marked walking paths could be implemented on larger building sites in order to encourage and increase incidental physical activity in employees.

8. Aesthetically-Pleasing Views

The Active Design Guidelines recommend providing visually appealing environments along the travel routes inside the building.¹⁸ Some of the suggested views to potentially increase walking include “natural and designed landscapes, interior views of people-oriented activities, and visually appealing interior finishes.”¹⁸

Based on these recommendations, aesthetically pleasing views may be an effective way to encourage increased incidental physical activity during the day.

2. Stair Use

Stair use is linked to a variety of health outcomes. In general, evidence suggests that adults who climbed six or more floors of stairs per day are more likely to report “very good” or “excellent” general health compared with those who climb fewer stairs.¹⁸⁷

Stair climbing (depending on intensity) can be defined as moderate- to vigorous-intensity cardiovascular exercise, which meets the minimum intensity requirements for cardiorespiratory benefits.¹⁸⁸

One easy way to accumulate stair-climbing in the workplace is to take the stairs instead of the elevator or escalator. Employees often need to travel from one floor to another throughout their day and choosing to take the stairs is not only beneficial for your health but also leads to reduced elevator and escalator use, lowering the use of these electricity-consuming devices within the building.

Stair climbing is also an effective way to exert a high amount of energy in a short period of time.¹⁸⁹ A study examining the energy expenditure of ascending and descending stairs found that 11 flights climbed (~180 steps) resulted in an energy expenditure of approximately 19.7 kcals, or 9.6 METs (vigorous-intensity activity), and about 9 kcals, or 4.9 METs (moderate-intensity activity) while descending.¹⁸⁹ Exact caloric expenditure across all types of physical activity is dependent on body size, weight and other individual factors.²⁸

Health Effects

Cardiovascular System

Stroke. The Harvard Alumni Health Study of more than 11,000 men observed a U-shaped relationship between stair climbing and the risk of stroke.¹⁰¹ Climbing 20 to fewer than 35 flights per week was linked to a 29% lower risk of stroke, while the lowest and highest categories (<10 and > 35 flights per week) were associated with a smaller reduction in risk of stroke. The authors note that the lack of an observed linear relationship could have been affected by the small number of participants in the highest categories of stair climbing.¹⁰¹

Cardiovascular and Respiratory Systems

Cardiorespiratory fitness. In three studies, individuals performing three to six two-minute bouts of stair climbing (145–199 steps per ascent) over the course of the day showed improved cardiorespiratory fitness (increased VO2max) compared to those who did not climb stairs.^{190 191 192}

A single blind randomized controlled trial of 125 women and 35 men showed that email prompts encouraging employees to participate in a group stair-walking were effective at improving aerobic fitness among a sub-sample of 56 employees who had low baseline aerobic fitness.¹⁹³ In addition, researchers noted high overall engagement and participation during study with nearly 83% of study participants performing at least three, 10-minute stair-walking session per week.¹⁹³

Cholesterol. In a seven-week study with 22 women ages 18 to 22, those performing one to six ascents of 199 steps per day (with a gradual increase from one to six assents over the course of the study) had increased HDL (good) cholesterol and a reduced total/HDL cholesterol ratio throughout the program.¹⁹⁰ In a similar eight-week study with 15 young women, those performing one to five ascents of 199 steps per day (with a gradual increase from one to five assents over the course of the study) had a reduction in LDL (bad) cholesterol.¹⁹¹ Stair climbing was not, however, found to modify blood lipids in a third stair-climbing study with 45 participants who performed one to three ascents of 145 steps per day (with a gradual increase from one to three ascents over the course of the study).¹⁹²

Skeletal System

Bone density. The skeletal system is a dynamic body system like our muscular system that responds to daily demands, such as exercise, by becoming stronger.²² Weight-bearing and muscle-strengthening exercises are two types of exercise considered to be important for building and maintaining bone density across the life span.³⁰

According to the American College of Sports Medicine, weight-bearing activities, including stair climbing, have beneficial effects on bone health across the life span.¹⁹⁵ The position stand further notes that physical activity appears to play a critical role in the accumulation of bone mass during childhood, attenuating bone mineral losses during adulthood and subsequently reduces risk of injury from falls among the elderly.¹⁹⁵

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Solutions

1. Lock Elimination

Stair access is the most fundamental and basic requirement for stair use within buildings.¹⁸ The Active Design Guidelines recommend eliminating locks between staircases and floor areas when possible as research suggests that stairs are less likely to be regularly used if they require keys or access cards compared to stairs that are openly accessible.¹⁸

Based on this recommendation, stairs should remain unlocked and accessible to encourage increased physical activity during the day.

2. Staircases for Interior Circulation

The Active Design Guidelines recommend providing stairs for everyday use, whether as a grand stair or an open interconnecting stair where that’s possible, or as a visible, conveniently accessible and aesthetically pleasant fire stair opened up for daily use by building occupants and where possible, visitors too.¹⁸ They recommend locating stairs near the building’s entrance (within 25 feet) and before the elevator, based on evidence suggesting this will encourage increased stair use for everyday travel.¹⁸ Furthermore, the Active Design Guidelines note that locating stairs near, or directly accessible from, the elevator area are more likely to be used for routine, daily travel.¹⁸ In addition, people may consider taking the stairs that are visible from the elevator waiting area as a faster traveling option compared to waiting for the elevator.^{198 199}

Based on these recommendations, stairs should be intentionally located near a building’s entrance, and before or close to the elevators, to encourage increased physical activity during the day.

3. Comfortable and Safe Staircases

The Active Design Guidelines recommend making the stairs wide enough to accommodate multiple people traveling in both directions and people of all abilities, as research suggests that wider stairs are associated with greater stair use.¹⁸ The Active Design Guidelines also recommend designing stairs that are comfortable and safe to use, and note that stairs with 7-inch risers and 11-inch treads are comfortable for most people.^{18 198} Experts also recommend that to reduce the risk of falls among older or less active individuals, slip-resistant flooring and/or color or textural contrasts at tread nosings should also be included.^{18 200} In addition, there should be no more than 11 risers between landings, and at least one intermittent landing between floors should be provided to allow individuals to take an intermittent break from stair climbing.¹⁸

Based on these recommendations, stairs should be designed to be accommodating for both directions of travel and safe to all users to encourage increased physical activity during the day.

4. Aesthetically-Pleasing Views

The Active Design Guidelines recommend providing visually appealing environments along travel routes inside the building, including stairwells.¹⁸ Some elements consider include “natural and designed landscapes, interior views of people-oriented activities, and visually appealing interior finishes.”¹⁸ They also recommend bright and inviting colors and adding music and/or artwork to stairwells to encourage use.¹⁸

The Active Design Guidelines also recommend providing well-lit stairwells that incorporate natural daylight and that are at least 75% as bright as adjacent corridors (at least 10 foot-candles).¹⁸ Brightness of the stairwell is one of the factors found to impact the choice of stair use, with the highest stair use occurring in bright stairwells.²⁰¹ Another study has shown that natural lighting in stairwells is also associated with increased use.²⁰²

A systematic review of 26 studies focused on promoting stair use reports that implementing music and artwork in stairwells is associated with more stair use.²⁰³ In addition, an intervention study of 200 office workers found after stairwells were decorated with interactive aesthetics, such as maps, storyboards, and wish lists, employees more than doubled stair use. These results were sustained over a six-week period.²⁰⁴

Based on these recommendations, stairs should be attractively designed to encourage increased physical activity during the day.

5. Point-of-Decision Signage to Encourage Stair Use

The Active Design Guidelines recommend placing signage (point-of-decision prompts) at elevators and escalators to encourage stair use, as research shows that on average, point-of-decision prompts can increase stair use by 50%.^{18 205} The Physical Activity Design Guidelines for School Architecture also recommend adding signage to encourage increased stair use in schools.⁸⁴ A systematic review of 26 studies focused on promoting stair use reports that interventions, such as promotional messaging, aimed at encouraging the use of stairs rather than using elevators or escalators are effective at increasing the proportion of people who take the stairs.²⁰³

The use of informational and motivational messages posted at key points-of-decision should be culturally, linguistically, and age appropriate.¹⁸ Messaging that was clearly visible, targeting specific populations, and adapted from social psychology theory were found to have the greatest impact on stair use.^{206 207} For example, in one study, different sign content (health messages versus weight control messages) did not lead to any significant differences in stair use among normal-weight individuals; however, weight-control signs were shown to increase stair use over general health signs in overweight individuals.²⁰⁸ In another study, multi-message banners placed on alternate stair risers were also more effective in increasing stair use compared to single-message posters.²⁰⁹ In another study, the same signage posted in English and Spanish across multiple settings was associated with increased stair use across all settings assessed and results were sustained over nine months.²¹⁰

Based on these recommendations, point-of-decision signage should be included to promote stair use to increased physical activity during the day.

6. Financial Incentives

In a six-month intervention study with over 200 employees, an employer incentivized stair use so that employees taking the stairs accumulated points that could be redeemed for merchandise.²¹¹ The overall stair transactions per day increased from 39 to 301 (a 600% increase), with a total cost of $3,739 USD ($17.55 USD per employee) for the incentives.²¹¹

Based on this finding, programmatic strategies that promote stair use may be encouraged through incentive programs in order to increased physical activity during the day and work synergistically with other environmental design strategies.

3. Biycling

Bicycling to and/or from work can be considered a form of incidental physical activity that is associated with numerous health benefits including, lower all-cause mortality.^{212 213}

Engaging in bicycling as part of a daily commute can help achieve physical activity recommendations, thus increasing overall physical activity and fitness levels and improving health.¹⁸

Cycling at a speed of 15 km/hr (9.3 mph), or four METs (considered moderate-intensity physical activity), for 4 km (2.5 mi) (approximately 15 minutes), twice per day can lead to an energy expenditure equal to about 10 pounds per year.¹⁶³

In a prospective study in Denmark of over 2,800 women and 5,600 men, bicycling to work was associated with a 40% reduction in risk of mortality after adjusting for leisure time activity and participation in sports.²¹³ In addition to mortality, cycling as transportation is also associated with lower rates of overweight and obesity.^{165 214 215} A cross-sectional study of nearly 4,000 participants showed that those who bicycled to work were significantly (44%) less likely to be overweight or obese compared to workers who traveled to work via private transport, and the study found a dose-response relationship between the duration of biking to work and being overweight.¹⁶⁵ A nationally representative sample of nearly 7,000 Australians found that cycling to work was associated with a 34% lower risk of being overweight or obese compared to private transit modes.²¹⁴ Another study with over 1,000 Canadian adolescents found that those who cycled as a means of transportation for one or more hours per week had lower BMI and waist circumference compared to those who reported no cycling.²¹⁵

Furthermore, a pooled analysis examining the relationship between the percent of workers commuting by bicycle or foot and obesity levels demonstrated that approximately 30% of the variance in obesity per state could be explained by rates of active commuting to work.²¹⁶ A study conducted in Europe, North America, and Australia using national surveys also found that rates of active transport were inversely associated with obesity prevalence, with Europe surpassing the U.S. in active transport via bicycle by over 140 km (87 mi) per year.²¹⁷

Health Effects

Cardiovascular System

Hypertension. A cross-sectional study of nearly 4,000 participants found a 6.5% prevalence of hypertension among those who bicycled to work compared to a prevalence of 17.7% in those who traveled to work by private transport. There was a dose-response relationship between the duration of biking to work and having hypertension.¹⁶⁵

Cardiovascular and Respiratory Systems

Improved cardiorespiratory fitness. A randomized controlled trial involving 68 healthy, middle-aged adults with low to moderate physical fitness levels found that regularly walking or cycling to work for 30 minutes (one way) led to improved aerobic fitness and decreased cardiovascular strain.¹⁶⁹ A review found similar results in that cardiorespiratory fitness improved slightly more for cyclists compared to walkers.²¹⁸

A study with over 1,000 Canadian adolescents found that those who cycled as a means of transportation for one or more hours per week had higher levels of light- and moderate-to-vigorous-intensity physical activity, and greater aerobic fitness compared to those who reported no cycling.²¹⁵

Endocrine System

Diabetes. A cross-sectional study of nearly 4,000 participants showed that those who bicycled to work were significantly less likely to have diabetes compared to workers who traveled to work via less active options, such as private cars.¹⁶⁵ The prevalence of diabetes in workers commuting by bike was 3.8% compared to 10.8% in those who traveled to work by private automobile and there was an inverse, dose-response relationship between the duration of biking to work and having diabetes.¹⁶⁵ Furthermore, a nationally representative survey in the U.K. found that cycling to work was also associated with a lower risk of diabetes.²¹⁹

Cholesterol. A randomized controlled trial involving 68 healthy, middle-aged adults with low to moderate physical fitness levels found that regularly walking or cycling for at least 30 minutes led to favorable changes in HDL (good) cholesterol.¹⁶⁹ However, these changes were not significant.¹⁶⁹ A review supported these results and also concluded that cycling was found to be more effective in producing these outcomes as compared to walking.²¹⁸

A study with over 1,000 Canadian adolescents found that those who cycled as a means of transportation for one or more hours per week had lower ratio total cholesterol to HDL cholesterol compared to those who reported no cycling.²¹⁵

Solutions

1. Infrastructure for Safe Bicycling

Research shows that people bike more in countries with better cyclist infrastructure.²²⁰ A cross-sectional study looking at data from 33 U.S. cities found that each 1.6-km (1-mi) increase in the length of on-street bike lanes (per square kilometer/mile) is associated with a 1% increase in the proportion of workers commuting by bike, which researchers note could reduce both car traffic and air pollution.²²¹ In addition, a study in New Orleans found that the number of people cycling on a street with a new, two-way, 1.6-km (1-mi) bike lane increased from an average of 79 cyclists per day at baseline to 257 per day at follow-up.²²² There was an increase in both male and female cyclists, but the increase was greater among females on some streets.²²² Furthermore, a study of nearly 6,600 cyclists in Australia showed that female commuter cyclists prefer routes that are maximally separated from motorized traffic.²²³

Based on this research, creating and/or improving bicycle paths and separating them from motor traffic may be an effective way to increase the proportion of individuals who bike as a means of active transport. Workplaces could consider these factors when deciding where to site their locations and what community initiatives they can support or advocate for within their neighborhoods and cities.

2. Bike Rails and Indoor Storage

The Active Design Guidelines recommend constructing bike rails and racks along outdoor stairways (as and easy space to lock bikes), providing facilities for bicyclists both along their route and at their final destination, and providing secure and accessible bicycle storage in buildings, ideally on the ground floor, to alleviates some of the logistical challenges of biking to work.¹⁸

A variety of cyclist amenities should be provided to encourage biking to work. Organizations should consider the availability of bike amenities and storage facilities/options for their employees and clients in the buildings they build, purchase, and lease. It should be noted, in some cities, new legislation and regulations have been introduced to increase access to bicycle parking. For example, in New York City, new commercial and multifamily buildings are required to provide secure bicycle parking, and existing buildings with freight elevators are required to provide bicycle access via those elevators when tenant organizations make those requests to building management for their employees.²²⁴

3. Showers and Locker Rooms

The Active Design Guidelines note that showers and locker room facilities in buildings can be included as an on-site fitness amenity and can alleviate some of the logistical challenges of biking to work.¹⁸ A survey of 111 employees from 55 organizations in Australia showed that showers and changing rooms at work were supported by 90.1% of employees and were considered enabling factors for more physical activity engagement.²²⁵

Based on this recommendation, buildings should provide showers and locker rooms for occupants to encourage active transportation and increased physical activity during.

4. Incentives to Promote Biking

The CDC Steps to Wellness Guide reports on one successful worksite wellness program, which encouraged biking to work by awarding employees who bike to work $20 per month to spend on cycling gear and/or bike maintenance.⁸¹

Employers can also provide employees with access to free bicycles (or reimburse the purchase of a bicycle) for active commuting. A study in Sweden, which provided access to a free bicycle and accessories to obese women, found that after 18 months, women who were given bicycles were much more likely to report biking for more than two km (1.2 mi) (38% v 9%) and four kilometers (2.5 mi) (25% and 5%) per day.²²⁶

Based on these guidelines, companies should provide incentives to encourage biking to work to increase physical activity levels.

Explanations of Solutions

Passive Activity Prompts

Passive activity prompts are aimed to interrupt extended sitting periods and reduce the total amount of sitting time. They are designed to alert users independently of their activity (as opposed to interactive activity prompts, which track how long a person has been sitting or how many steps they have taken), and simply prompt the individual to stand up, stand up and stretch, or stand up and move around at set time intervals, which can be configured by the user. Two examples of these types of prompts are a computer screen-based prompt, which pops up on the user’s computer screen, or a wrist-worn prompt, which vibrates or beeps.

Interactive Activity Prompts

Interactive activity prompts are aimed to interrupt extended sitting periods and reduce the total amount of sitting time. They are designed to monitor the user’s physical activity and send prompts to stand up or move around when a set period of inactivity has been detected, which can be configured by the user. Interactive prompts exist as smartphone applications, wristbands, accelerometers, and other devices. Interactive activity prompts are also available with accessories to monitor the type of movement and vigor of activity (e.g., arm or torso bands).

Active Work Stations

Sit-stand Desks. Sit-stand desks are a way to break up sitting time and reduce the total amount of time spent sitting per day. They are adjustable-height desks, whereby the height of the desk can be raised to a higher level for use while standing and moved to a lower level for use while seated. The desk adjustments are quick and easy to perform, taking only seconds to either raise or lower the height of the desk.

Treadmill Desks. Treadmill desks are an effective way to both reduce the time spent sitting and increase physical activity in individuals that normally spend most of their day sitting at a desk. Treadmill desks, also known as walking desks, are desks positioned above and over a treadmill, allowing a person to walk at a selected pace (usually at two mph or slower) while performing regular office work.

Cycling Workstations. Cycling workstations are designed to decrease sedentary time (even if performed while sitting) and increase daily physical activity. A cycling workstation involves a stationary bike (with the handle bars and front wheel removed) positioned in front of an adjustable-height desk.

Portable Pedal Machines. Office-place stepping devices are small, easily movable devices used for stepping either while seated at a desk, or in a standing position using a height-adjustable desk. They are compact, occupying less space than treadmill, elliptical or cycling workstations, and can be placed under a desk when not in use. In addition, they can be plugged into a work computer for self-monitoring. Stepping devices are a way of reducing sedentary time (even if performed while sitting) and increasing physical activity.

Motivational Counseling / Interviewing

Motivational counseling/interviewing is a person-centered counseling style that involves a collaborative conversation between a counselor and a client, aimed at addressing ambivalence and strengthening a person’s own motivation and commitment to change. It explores the individual’s reasons for wanting to change in a compassionate, understanding, and accepting environment. This type of support could also include goal setting, which when paired with solutions, such as activity prompts applied throughout the building, could help increase adherence.²²⁷

Access to Neighborhood Places for Physical Activity

Access to places for physical activity in the neighborhood involves the presence of, and public access to, physical activity opportunities and facilities where people can engage in physical activity. Physical activity facilities include elementary and secondary schools, colleges, universities, beaches, pools, tennis courts, recreation centers, youth organizations, parks, walking, and cycling paths, YMCAs, physical fitness facilities, bicycle rentals, golf courses, dance studios, basketball instruction, martial arts, sporting and recreational camps, swimming pools, athletic clubs, gymnasiums, tennis and basketball clubs, and many more.¹³⁸

Physical Activity Opportunities and Spaces in the Workplace

Physical activity opportunities and spaces in the workplace include the presence of walking paths outside and inside the building, and/or spaces inside the building and/or within the building site boundary that include fitness equipment, and/or offer fitness classes (e.g., yoga, Pilates, Zumba, other). Rooms that are always used for work activities, such as conference or meeting rooms, can be used for fitness classes when not in use for work purposes, thus maximizing square footage. Furniture considerations, such as foldable and rolling furniture, can assist with making spaces multiuse and multipurpose.

Activity Incentives

Financial Incentives. Monetary incentives are considered external motivators of behavior and can take on a positive or negative form. We focus on models such as reimbursements, subsidies, and reward payments that can be offered to incentivize physical activity and other health related behaviors. Monetary incentives can take on a variety of forms related to their economic value including cash payments, coupons, goods, services and the like. Projects stakeholders and leaders play an integral role in defining what incentive payments and programs will be meaningful to their occupants.

Gym Membership Subsidies. Providing gym membership subsidies is a strategy to promote employee physical activity whereby the employer subsidizes the partial or full price of the total cost of an employee’s gym membership. Gym subsidies can be applied on a fixed scale, where an employee is required to accumulate a set minimum number of visits in a given time period in order to receive the subsidy. The CDC also recommends that the subsidy be applied on a sliding scale, where the proportion of subsidy increases with a greater number of gym visits.⁸⁴ For example, 25% of the membership price is covered if the gym is attended twice per month, and 100% of the price is covered if eight monthly visits are accumulated.

Creative Physical Activity Spaces for Children

Creative physical spaces for children can include spaces, such as courtyards, gardens, roofs, and terraces, which can be used when conventional physical activity spaces (e.g., parks and schoolyards) are unavailable.¹⁸ These spaces should be designed with active children’s play in mind, making any necessary adjustments or taking security precautions to ensure safe physical activity.⁷¹

Marked Walking Routes

Marked walking paths include wayfinding signs at points of decision near building entrances. These signs can provide information about the available indoor and/or walking routes, nearby public transit stops, amenities and other places of interest. They should include maps, distances, routes, and amounts of time needed to reach them by foot.¹⁸ In addition, informational signs can include motivational information, such as the number of calories that would be burned by walking to one of the nearby public transit stops or points of interest, as it may encourage people to use public transportation and/or walk to other destinations more often.¹⁸

Marked walking paths can include supportive infrastructure, such as benches, drinking fountains, restrooms, and water bottle refilling stations, in order to provide refreshment and support during the times of walking and encourage/provide a reason for people to walk more while indoors. Additionally, daylighting along walking routes inside buildings can provide a more satisfying sensory experience.¹⁸

Physical Activity Breaks

Integrating short bouts of physical activity into an organizational routine is a great strategy to increase physical activity levels. Activities that can be incorporated into the work day include walk-and-talk meetings, short group walks around the block (including stair use), lunchtime walks, or short, structured, group exercises performed as part of the workday. These programmatic strategies work synergistically with design strategies, which together aim to promote a culture of health and wellness and provide opportunities for physical activity.

Wellness Teams and Competitions in the Workplace

Wellness teams and competitions in the workplace is a strategy to increase employees’ physical activity levels. The CDC Steps to Wellness Guide suggests creating employee teams that could train together and participate in organized races and competitions in order to increase physical activity in the workplace. Some of the competitions could include a walk challenge, stairwell challenge, office Olympics, or fitness field day.⁸¹ These programmatic strategies work synergistically with design strategies, which together aim to promote a culture of health and wellness and provide opportunities for physical activity.

Street-Scale Urban Design and Land-Use Policies

Street-scale urban design and land-use policies include elements such as land-use mix, walkability, creating and/or renovating playgrounds, parks and open spaces, pedestrian squares or plazas, and bicycle lanes, pedestrian-scale lighting, and pedestrian-friendly aesthetics¹⁷² as well as creating more and better-quality sidewalks.¹⁷⁷

On-Site Parking Considerations

On-site parking provision may negatively influence use of more active modes, such as walking, bicycling, and public transit, according to the Active Design Guidelines.¹⁸ Parking restrictions can effectively deter use of more sedentary forms of transportation and encourage building occupants to engage in more daily physical activity.

Mass-Transit Commuter Benefits

Employer-sponsored commuter benefits include subsidizing public transit passes for company employees in order to promote mass-transit use, which is correlated with increased time spent walking. For example, U.S. federal tax code (Internal Revenue Code Section 132(f)—Qualified Transportation Fringe) allows individuals to use their pre-taxable income in order to pay for public transit passes via employer-sponsored pre-tax commuter benefit programs.²²⁸

Pedometers

Pedometers are portable devices that at a basic level, track the number of steps taken over a period of time (usually per day). More advanced devices can also measure distance and activity intensity. They are usually worn on the belt or kept in a pocket but can also be worn on an individual’s wrist.

Walking Programs

Walking programs are a type of planned group activity, which can occur during lunch breaks or as active meetings and are a way to break up extended sitting periods and increase physical activity during the day. These programmatic strategies work synergistically with design strategies, which together aim to promote a culture of health and wellness and provide opportunities for physical activity.

Staircase Design

Staircases for Interior Circulation. The Active Design Guidelines recommend providing stairs for everyday use as an effective strategy to increase physical activity. They recommend that stairs be position within 25 feet of the building entrance and that people encounter stairs prior to an elevator or escalator.¹⁸ The visual and physical proximity of the stairs can be complemented by informational signage (point-of-decision prompts) that encourages people to take the stairs instead of waiting for an elevator.¹⁸

Comfortable and Safe Staircases. The Active Design Guidelines recommend that stairs that are wider than the traditional 44-inch minimum requirements. Stairs that are at least 56-inches wide accommodate people walking together or in opposite directions more comfortably than narrower stairs, and are associated with increased stair use.¹⁸

The Active Design Guidelines define comfortable and safe stair risers and treads as seven-inches tall and 11-inches deep, respectively. They also suggest there should be no more than 11 stair risers between landings, and at least one intermittent landing between floors.¹⁸

Aesthetically Pleasing Views. Aesthetically pleasing views in stairways and walking routes within buildings are strategies that can increase employees’ physical activity levels throughout the workday. The Active Design Guidelines define aesthetically pleasing views as those that include nature views, designed landscapes, indoor areas of gathering, and visually appealing interior finishes.¹⁸

The Active Design Guidelines define well-lit stairwells as those that “provide illumination levels of 75 percent to equal that of adjacent corridors, with a minimum of 10 foot-candles illumination within the stair.”¹⁸ In addition, natural lighting has been shown to increase stair use.^{201 202}

Music and artwork in the stairwell includes playing music and providing artwork in the stairwell, and is a strategy to encourage stair use.^{18 228} The Active Design Guidelines note that all artwork in egress stairs should be non-combustible.¹⁸

Lock Elimination. Lock elimination entails removing locks and/or key card requirements within staircases. Lock elimination between staircases and floor areas makes stairs more accessible and makes stairs more likely to be used on a regular basis compared to stairs that require keys or access cards. Stair access is a fundamental and basic requirement for stair use within buildings and can enhance physical activity engagement in the work place if made readily available to employees.¹⁸

Point-of-Decision Signage to Encourage Stair Use. The Active Design Guidelines recommend using signage at elevators and escalators that have motivational messages aimed at promoting stair use.¹⁸ Research shows that these motivational messages are quite effective.¹⁸ Messages to encourage stair use include visible motivational messages, messages adapted from psychology theory,²⁰⁷ and/or target population-based messages that are culturally, linguistically, and age-appropriate.¹⁸ Weight messages appear to be more effective than general health messages in motivating stair use among those who are overweight or obese.²⁰⁸ The message placement includes stair-riser banners, posters, and point-of-decision prompts located at elevator and escalator areas.¹⁸

Active meetings

Active meetings are a way to interrupt extended sitting periods, reduce the total amount of sitting time, and engage employees in physical activity. They can be implemented as walking meetings or on treadmills, which could be installed inside the facility to be used when the space or weather makes active meetings less feasible.

Infrastructure for Cyclists

Building or improving infrastructure for safe bicycling includes strategies, such as building designated bicycle lanes, creating a physical buffer to separate biking, pedestrian, and car traffic lanes, and/or adding high visibility paint and surface materials to planned or existing bicycle lanes to increase the visibility of the bicycle lanes.¹⁸ Companies can also advocate locally for better bicycle infrastructure within their respective neighborhoods and cities.

Bike Rails and Indoor Storage. Bicycle rails and indoor bicycle storage include constructing bicycle rails along outdoor stairways (to lock up bikes), facilities for bicyclists to park both along their route and at their final destination, and providing “secure, sheltered, and accessible bicycle storage, preferably on the ground floor.”¹⁸

Incentives to Promote Biking. Incentives to promote biking can range from cash rewards for biking to work, reimbursement for bicycle-sharing program fees, or free bicycles for interested individuals. These programmatic strategies work synergistically with design strategies, which together aim to promote a culture of health and wellness and provide opportunities for physical activity.

Showers and Locker Rooms. Providing showers and locker room facilities are strategies that can promote active commuting. The Active Design Guidelines note that “shower and locker rooms can be integrated as part of on-site exercise facilities or provided adjacent to ground-floor restrooms.¹⁸

School-based physical education

School-based physical education (PE) classes are an organized, supervised way to help adolescents and children engage in the recommended 60 minutes of physical activity per day. The Task Force on Community Preventative Services found that PE can help increase muscular endurance and improve children’s knowledge about physical activity.¹³⁹

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