Circulation

AHA SCIENCE ADVISORY

Built Environment Approaches to Increase

Physical Activity
A Science Advisory From the American Heart Association

ABSTRACT: Engaging in regular physical activity is one of the most John D. Omura, MD,
important things people can do to improve their cardiovascular health; MPH, FAHA, Chair
however, population levels of physical activity remain low in the Susan A. Carlson, PhD,
United States. Effective population-based approaches implemented in MPH
communities can help increase physical activity among all Americans. David R. Brown, PhD
Evidence suggests that built environment interventions offer one such David P. Hopkins, MD,
approach. These interventions aim to create or modify community MPH
environmental characteristics to make physical activity easier or more William E. Kraus, MD,
FAHA
accessible for all people in the places where they live. In 2016, the
Beth A. Staffileno, PhD,
Community Preventive Services Task Force released a recommendation
FAHA
for built environment approaches to increase physical activity. This Randal J. Thomas, MD,
recommendation is based on a systematic review of 90 studies (search MS, FAHA
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period, 1980–June 2014) conducted using methods outlined by the Felipe Lobelo, MD, PhD,
Guide to Community Preventive Services. The Community Preventive FAHA
Services Task Force found sufficient evidence of effectiveness to Janet E. Fulton, PhD,
recommend combined built environment strategies. Specifically, FAHA, Vice Chair
these strategies combine interventions to improve pedestrian or On behalf of the American
bicycle transportation systems with interventions to improve land use Heart Association Physical
and environmental design. Components of transportation systems Activity Committee of
can include street pattern design and connectivity, pedestrian the Council on Lifestyle
and Cardiometabolic
infrastructure, bicycle infrastructure, and public transit infrastructure
Health; Council on
and access. Components of land use and environmental design can
Cardiovascular and
include mixed land use, increased residential density, proximity to Stroke Nursing; and
community or neighborhood destinations, and parks and recreational Council on Clinical
facility access. Implementing this Community Preventive Services Task Cardiology
Force recommendation in communities across the United States can
help promote healthy and active living, increase physical activity, and
ultimately improve cardiovascular health.

Key Words: AHA Scientific Statements

◼ built environment ◼ exercise

© 2020 American Heart Association, Inc.

https://www.ahajournals.org/journal/circ

e160 September 15, 2020 Circulation. 2020;142:e160–e166. DOI: 10.1161/CIR.0000000000000884

 Omura et al Built Environment Increasing Physical Activity

R
egular physical activity is associated with a wide Table 1. Recommended Interventions for Increasing Physical Activity

CLINICAL STATEMENTS
array of health benefits, from reducing feelings Recommendation Year

AND GUIDELINES
of anxiety and depression and improving sleep Digital health interventions for adults ≥55 y of age 2019
and cognition to lowering the risk of developing type
Interventions to increase active travel to school 2018
2 diabetes mellitus, some cancers, and heart disease.1
Obesity prevention and control: meal or fruit and vegetable 2018
Among its many health benefits, physical activity im- snack interventions combined with physical activity
parts significant cardiovascular health benefits by interventions in schools
reducing the risk and progression of cardiovascular Interventions including activity monitors for adults with 2017
disease and cardiovascular disease mortality.2,3 Recog- overweight or obesity
nizing the importance of physical activity for achieving Built environment approaches combining transportation 2016
ideal cardiovascular health, the American Heart As- system interventions with land use and environmental design
sociation includes physical activity as one of its Life’s Family-based interventions 2016
Simple 7 metrics.4 The Physical Activity Guidelines for Diabetes mellitus: combined diet and physical activity 2014
Americans, second edition from the US Department of promotion programs to prevent type 2 diabetes mellitus
Health and Human Services, recommends that adults among people at increased risk

should move more and sit less.1 For substantial health Enhanced school-based physical education 2013
benefits, they should do at least 150 to 300 minutes of Health communication and social marketing: campaigns that 2010
moderate-intensity aerobic physical activity, 75 to 150 include mass media and health-related product distribution

minutes of vigorous-intensity aerobic physical activity, Worksite programs 2007

or an equivalent combination per week.1 For youth, the Point-of-decision prompts to encourage use of stairs 2005
Guidelines recommend ≥60 minutes of moderate to Community-scale urban design and land use policies* 2004
vigorous physical activity daily.1 However, despite the Street-scale urban design land use policies* 2004
known health benefits of physical activity, only 26%
Creating or improving places for physical activity 2001
of adolescents and 54% of adults in the United States
Community-wide campaigns 2001
reported levels of physical activity consistent with meet-
ing the guideline for aerobic activity.5 Individually adapted health behavior change programs 2001
Effective strategies for promoting active lifestyles and Social support interventions in community settings 2001
overcoming related barriers can help increase physical College-based physical education and health education 2001
activity levels among all Americans. Population-based
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*Recommendation replaced by the updated 2016 built environment

approaches, often implemented at the community lev- recommendation.
el, are a promising way to accomplish this goal, in part Data derived from the Community Preventive Services Task Force.10
because they offer several benefits compared with ap-
proaches focused on individual behavior change.1,6 For nonfederal group of public health and disease preven-
example, population-based approaches tend to have tion experts.11 The CPSTF is supported by 32 liaison or-
greater reach and can result in longer-lasting changes. ganizations that represent federal agencies, including
Even modest improvements in health behaviors in the the Armed Forces, and national organizations invested
population can substantially improve health outcomes in America’s health. The Centers for Disease Control
and disease risk at the population level.1,6,7 These types and Prevention provides the CPSTF with scientific and
of approaches such as built environment interventions, administrative support.11 The CPSTF makes evidence-
as well as community programs (eg, social support pro- based recommendations about the effectiveness and
grams) and policies (eg, Complete Streets policies), can economics of community preventive services, pro-
help populations reduce or eliminate barriers to making grams, and other interventions. The work of the CPSTF
physical activity the easy choice.1 Population-based ap- complements that of the US Preventive Services Task
proaches to supporting physical activity in communities Force, which makes evidence-based recommendations
have been recommended in several seminal documents about clinical preventive services.12
released over the past decade, including reports from In 2016, the CPSTF recommended combined built
the American Heart Association, the Office of the US environment approaches to increase physical activity,
Surgeon General, and the Department of Health and updating its 2004 recommendations for land use and
Human Services.1,6,8,9 street-scale interventions.13 Combined built environ-
The Guide to Community Preventive Services (The ment approaches work to create or modify environ-
Community Guide) is a resource to help communities mental characteristics in a community to make physi-
select community-level intervention approaches to im- cal activity easier or more accessible. This new built
prove health, including approaches to increase physical environment recommendation provides a timely review
activity (Table 1).10 The Community Guide is a collec- of the evidence on this evolving topic; it also outlines
tion of evidence-based findings from the Community 2 specific components that built environment inter-
Preventive Services Task Force (CPSTF), an independent, ventions should include to ensure their effectiveness.

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 Omura et al Built Environment Increasing Physical Activity

Table 2. Built Environment Approaches to Increase Physical Activity in Combination by Intervention Type
CLINICAL STATEMENTS

Pedestrian and Bicycle Transportation System Intervention Component Land Use and Environment Design Intervention Component
AND GUIDELINES

Intervention Selected Examples Intervention Selected Examples

Street pattern design and Designs that increase street Mixed land use Residential, commercial, cultural,
connectivity connections and create multiple route institutional, or industrial land uses that
options, shorter block lengths are physically and functionally integrated
to provide a complementary or balanced
mix of restaurants, office buildings,
housing, and shops
Pedestrian infrastructure Sidewalks, trails, traffic calming, Increasing residential density Smart growth communities and new
intersection design, street lighting, urbanist designs, relaxed planning
and landscaping restrictions in appropriate locations to
reduce sprawl, sustainable compact
cities and communities with affordable
housing
Bicycle infrastructure Bicycle systems, protected bicycle Proximity to community or Community destinations such as stores,
lanes, trails, traffic calming, neighborhood destinations health facilities, banks, and social clubs
intersection design, street lighting, that are accessible and close to each
and landscaping other
Public transit infrastructure and Expanded transit services, times, Parks and recreational facility access Public parks, public recreational facilities,
access locations, and connections private fitness facilities

Data derived from the Community Preventive Services Task Force.13

Increased collaboration within and across sectors, in- Branch, which has been described previously.15 The
cluding health care, can help to amplify and extend review was conducted by a team of specialists in sys-
existing efforts to implement this recommendation tematic review methods and in research, practice, and
and to undertake new initiatives to support it.8 The policy related to increasing physical activity. The team
accompanying policy statement addresses upstream identified and abstracted evidence from articles pub-
interventions for cardiovascular health related to com- lished between 1980 and June 2014.13 Ultimately, 90
munity infrastructure and transportation and highlights studies that evaluated the effectiveness of built envi-
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the important intersection between the public health ronment approaches used in combination to create or
sector and the healthcare system related to this field.14 enhance opportunities for physical activity met the cri-
The purpose of this science advisory is to highlight the teria for inclusion in the systematic review. Longitudinal
recent CPSTF recommendation on built environment changes (16 studies) or cross-sectional differences (74
approaches to increase physical activity in communities studies) for a wide range of physical activity outcomes
across the United States. were evaluated.

THE COMMUNITY GUIDE SYSTEMATIC Main Findings

REVIEW The CPSTF found sufficient evidence of effectiveness to
recommend built environment strategies combining ≥1
Methods for the Systematic Review interventions to improve pedestrian or bicycle transpor-
The CPSTF defined built environment interventions to tation systems with ≥1 land use and environmental de-
increase physical activity as those creating or modifying sign interventions to increase physical activity.13 Effect
environmental characteristics in a community to make estimates for changes in the level of physical activity
physical activity easier or more accessible.13 Coordi- could not be calculated because of differences in out-
nated approaches must combine new or enhanced ele- come measures, analyses, and reporting in the included
ments of pedestrian or cycling transportation systems studies. The CPSTF based its finding on a qualitative
with the creation or enhancement of land use and en- synthesis and assessment of results for the included
vironmental design features. Intervention approaches studies.
must be designed to enhance opportunities for active The CPSTF recommendation for built environment
transportation, leisure-time physical activity, or both. approaches to increase physical activity is specific to
Active transportation encompasses all human-powered intervention approaches including ≥1 components
means of travel to reach a destination such as walking, that improve pedestrian or bicycle transportation sys-
bicycling, or wheelchair rolling. tems and ≥1 land use and environmental design com-
The systematic review was conducted with the use ponents (Table 2).13 Improving transportation systems
of a rigorous methodology developed by the Centers involves creating activity-friendly routes (ie, pedestrian,
for Disease Control and Prevention’s Community Guide bicycle, or public transit access) that are a direct and

e162 September 15, 2020 Circulation. 2020;142:e160–e166. DOI: 10.1161/CIR.0000000000000884

 Omura et al Built Environment Increasing Physical Activity

convenient connection with common or everyday des- interventions, including those from the American Heart

CLINICAL STATEMENTS
tinations. Such interventions may benefit from safety Association and the Office of the US Surgeon Gener-

AND GUIDELINES
considerations such as offering physical protection al.6,8,9 Most recently, the Physical Activity Guidelines for
from cars and making it safer and easier to cross the Americans, second edition, released in 2018, includes a
street. Specific components to consider when improv- new chapter, “Taking Action: Increasing Physical Activ-
ing transportation systems include street pattern design ity Levels of Americans,” that provides evidence-based
and connectivity, as well as supports for multimodal strategies to promote and support physical activity.1 One
transportation, including pedestrian, bicycle, and public of the community-level strategies recommended in this
transit infrastructure and access (Table 2).13 chapter pertains to community design whereby com-
Land use and environmental design involves creating munities can implement built environment interventions
and enhancing access to everyday destinations, places that make it easier for people to be active. This chapter
people can get to from where they live by walking, bicy- also provides examples of what various sectors, includ-
cling, or public transit. These can include grocery stores, ing the healthcare sector, can do in partnership with
schools, worksites, libraries, parks, restaurants, cultural other sectors to improve physical activity. Strategies such
and natural landmarks, and healthcare facilities. These as counseling, social support programs, and campaigns
places are often desirable, useful, and attractive. Specific can help promote or complement the CPSTF recommen-
components to consider in land use and environmental dation for effective built environment interventions.
design include mixed land use, increased residential den- This built environment CPSTF recommendation can
sity, proximity to community or neighborhood destina- be applicable to a wide variety of everyday destinations,
tions, and parks and recreational facility access (Table 2).13 including grocery stores, schools, worksites, libraries,
The CPSTF’s recommendation is applicable to a wide parks, restaurants, cultural and natural landmarks,
range of populations and environments, including and healthcare facilities. In August 2018, the CPSTF
adults and youth, women and men, urban and mixed released a recommendation that focuses on schools
environments (urban, suburban, rural), macrolevel in- as the destination.16,17 Specifically, the CPSTF recom-
terventions (elements of overall community design re- mended interventions to increase active travel to school
lated to walkability), and microlevel interventions (eg, such as Safe Routes to School on the basis of evidence
bike racks, street-crossing amenities).13 that they increase walking among students and reduce
risks for traffic-related injury. Active travel interventions
make it easier for children and adolescents to commute
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DISCUSSION to school actively (eg, walking or biking) by improving

Lack of physical activity is an important modifiable risk the physical or social safety of common routes to school
factor for many chronic diseases, including cardiovas- or by promoting safe pedestrian behaviors.
cular disease. Physical activity levels in the United States Implementation guides and other supportive re-
remain low. Population approaches implemented in sources and documents can help practitioners from
communities such as built environment interventions a variety of sectors (eg, public health, health care,
creating or enhancing activity-friendly environments transportation, land use, and community design) act
offer important mechanisms to promote physical activ- on the CPSTF recommendation for effective built en-
ity and to encourage active lifestyles. In 2016, the CP- vironment interventions. For example, Connecting
STF found sufficient evidence of effectiveness for built Routes to Destinations materials from the Centers for
environment interventions and released a new recom- Disease Control and Prevention can help practitioners
mendation in The Community Guide.13 This recommen- implement strategies aligned with this recommenda-
dation is for strategies combining ≥1 interventions to tion at the community level.18 These materials include
improve pedestrian or bicycle transportation systems a visual guide illustrating what a community may look
with ≥1 land use and environmental design interven- like when activity-friendly routes connect to everyday
tions to increase physical activity. destinations, a list of resources to help communities
This recommendation is based on a comprehensive implement the CPSTF built environment recommen-
systematic review and provides a valuable synthesis and dation, and real-world examples of communities that
summary of the substantial evidence that has accumu- have implemented the recommendation. For example,
lated on this evolving topic over the past decade. In opening a previously closed road in Hernando, MS, con-
addition, the recommendation adds details about spe- nected a middle school and high school. The revitalized
cific components that built environment interventions road provides opportunities for safe travel between the
should include. Such guidance will be useful for prac- schools and gives neighborhood residents access to a
titioners when implementing strategies. For these rea- newly surfaced school track. A second example is from
sons, this recommendation provides a critical addition to El Paso, TX, where a new walking route connects cul-
help support the uptake and dissemination of previous tural and economic hubs, namely the Downtown Arts
calls for community strategies using built environment District and the El Paso Union Plaza District. Previously,

Circulation. 2020;142:e160–e166. DOI: 10.1161/CIR.0000000000000884 September 15, 2020 e163

 Omura et al Built Environment Increasing Physical Activity

a locked parking lot prevented pedestrian access be- as well as intervention effectiveness among different
CLINICAL STATEMENTS

tween districts. These and other examples contained in community characteristics or demographic popula-
AND GUIDELINES

the real-world resource illustrate how the CPSTF rec- tions (eg, racial and ethnic minorities, varying socio-
ommendation can be implemented in communities. In economic statuses), would also be useful. Designing
addition, the CPSTF review includes selected examples studies that can evaluate dose-response relationships
of the different components of the recommendation, between multiple environment changes and physical
which may also help facilitate implementation at the activity, as well as longer-term clinical outcomes such
community level (eg, pedestrian infrastructure can refer as stroke, heart disease, and mortality, can help to im-
to sidewalks, trails, traffic calming, intersection design, prove our understanding of the potential impact of
street lighting, and landscaping; Table 2). built environment interventions. Finally, it would be
Surveillance of built environment supports for physi- beneficial for researchers to continue updating and
cal activity can help monitor progress in the implemen- refining summary assessment tools and measures of
tation of this CPSTF recommendation. Previous studies objective and perceived environmental characteristics
have assessed the national prevalence of such efforts in and changes.
the United States on the basis of survey respondents’ per-
ceptions. In data from the 2015 National Health Interview
Survey, an estimated 85.1% of US adults reported roads, CONCLUSIONS
sidewalks, paths, or trails on which to walk and 62.6% Strategies to improve the built environment as recom-
reported sidewalks on most streets where they live.19 The mended by the CPSTF can enhance community design
most frequently reported destination that respondents to promote physical activity in the places where people
could walk to was a place to relax (71.8%), followed by live.13 Partnerships between key sectors are important
shops (58.0%), transit stops (53.2%), and movies, librar- to help increase the planning, implementation, and
ies, or churches (47.5%). For most design elements, the evaluation of these strategies. Resources such as Con-
prevalence was similar among adults 18 to 24 and 25 to necting Routes to Destinations materials18 from the
34 years of age but decreased at >35 years of age. Adults Centers for Disease Control and Prevention can help
in the South reported a lower prevalence of all elements practitioners implement strategies aligned with the
compared with those in other Census regions. These find- CPSTF recommendation. In addition, surveillance ef-
ings provide a useful overview of the current presence of forts can help monitor progress in implementation, and
built environment supports for physical activity and high-
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future research can add to the evidence on this topic

light substantial room for improvement in activity-friendly by filling research gaps. By implementing built environ-
built environment infrastructure nationally. However, ment strategies, communities across the United States
these estimates report primarily individual components of can be designed in ways that help promote healthy and
this CPSTF recommendation (ie, activity-friendly routes or active living, increase physical activity, and ultimately
everyday destinations). Future surveillance efforts examin- improve cardiovascular health for everyone.
ing the combined components as recommended by the
CPSTF can help assess and monitor the implementation of
this recent recommendation comprehensively. In addition, ARTICLE INFORMATION
surveillance strategies may expand beyond self-reported Disclaimer: The findings and conclusions in this report are those of the authors
perceptions of the environment to include more objective and do not necessarily represent the official position of the Centers for Disease
Control and Prevention.
measures of the environment (eg, geospatial technology, The American Heart Association makes every effort to avoid any actual or
image analysis) that also capture local data.20 potential conflicts of interest that may arise as a result of an outside relationship
Additional research is needed in several areas.13 For or a personal, professional, or business interest of a member of the writing pan-
el. Specifically, all members of the writing group are required to complete and
example, longitudinal studies are needed to strength- submit a Disclosure Questionnaire showing all such relationships that might be
en the evidence base and to help identify specific com- perceived as real or potential conflicts of interest.
binations of interventions that have the greatest im- This advisory was approved by the American Heart Association Science Ad-
visory and Coordinating Committee on May 28, 2020, and the American Heart
pact on physical activity. These studies could be based Association Executive Committee on June 22, 2020. A copy of the document is
on evaluation of existing or planned interventions, in- available at https://professional.heart.org/statements by using either “Search for
cluding natural experiments.21 Such evaluation efforts Guidelines & Statements” or the “Browse by Topic” area. To purchase additional
reprints, call 215-356-2721 or email [email protected].
would be strengthened by the use of common metrics The American Heart Association requests that this document be cited as
to allow comparisons of various interventions and be- follows: Omura JD, Carlson SA, Brown DR, Hopkins DP, Kraus WE, Staffileno
tween communities.8 Studies examining the magni- BA, Thomas RJ, Lobelo F, Fulton JE; on behalf of the American Heart Association
Physical Activity Committee of the Council on Lifestyle and Cardiometabolic
tude of changes in physical activity or the proportion Health; Council on Cardiovascular and Stroke Nursing; and Council on Clinical
of the population influenced can help quantify the Cardiology. Built environment approaches to increase physical activity: a science
impact of such interventions at the population level. advisory from the American Heart Association. Circulation. 2020;142:e160–
e166. doi: 10.1161/CIR.0000000000000884.
Future research evaluating combinations of microscale The expert peer review of AHA-commissioned documents (eg, scientific
interventions in different settings and populations, statements, clinical practice guidelines, systematic reviews) is conducted by

e164 September 15, 2020 Circulation. 2020;142:e160–e166. DOI: 10.1161/CIR.0000000000000884

 Omura et al Built Environment Increasing Physical Activity

the AHA Office of Science Operations. For more on AHA statements and Permissions Request Form” appears in the second paragraph (https://www.

CLINICAL STATEMENTS
guidelines development, visit https://professional.heart.org/statements. Se- heart.org/en/about-us/statements-and-policies/copyright-request-form).

AND GUIDELINES
lect the “Guidelines & Statements” drop-down menu, then click “Publica-
tion Development.”
Permissions: Multiple copies, modification, alteration, enhancement, and/
Acknowledgment
or distribution of this document are not permitted without the express permis- The authors thank Cammie Marti, PhD, MPH, RN, Science and Medicine Advi-
sion of the American Heart Association. Instructions for obtaining permission sor, American Heart Association, for her expert assistance in the preparation of
are located at https://www.heart.org/permissions. A link to the “Copyright this manuscript.

Disclosures
Writing Group Disclosures

Other Speakers’ Consultant/

Writing Group Research Bureau/ Expert Ownership Advisory
Member Employment Research Grant Support Honoraria Witness Interest Board Other
John D. Omura Centers for Disease Control and None None None None None None None
Prevention
Janet E. Fulton Centers for Disease Control and None None None None None None None
Prevention
David R. Brown Centers for Disease Control and None None None None None None None
Prevention
Susan A. Carlson Centers for Disease Control and None None None None None None None
Prevention
David P. Hopkins Centers for Disease Control and None None None None None None None
Prevention, Community Guide Branch
William E. Kraus Duke University Medical Center, Duke None None None None None None None
Molecular Physiology Institute
Felipe Lobelo Emory University Rollins School of None None None None None None None
Public Health
Beth A. Staffileno Rush University Medical Center DSMB (NIH SIREN None None None None None None
DSMB committee
member)*
Randal J. Thomas Mayo Clinic None None None None None None None
Downloaded from http://ahajournals.org by on October 5, 2023

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on
the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if
(a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the
voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than
“significant” under the preceding definition.
*Modest.

Reviewer Disclosures

Other
Research Speakers’ Bureau/ Expert Ownership Consultant/
Reviewer Employment Research Grant Support Honoraria Witness Interest Advisory Board Other
David R. University of Tennessee None None None None None None None
Bassett
David National Cancer None None None None None None None
Berrigan Institute
Amy A. Eyler Washington University None None None None None None None
in St. Louis
Leonard A. Ball State University None None None None None None None
Kaminsky
James F. University of California Robert Wood Johnson None University None None America Walks*; None
Sallis San Diego Foundation (study of Colorado Rails to Trails
includes an assessment at Denver*; Conservancy*;
of environments where Department of Voices for Healthy
adolescents are active)†; Health, Tasmania, Kids*; University
NIDDK (coinvestigator Australia* of Tasmania,
on a study that includes Australia*
environmental measures)†

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more
during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Circulation. 2020;142:e160–e166. DOI: 10.1161/CIR.0000000000000884 September 15, 2020 e165

 Omura et al Built Environment Increasing Physical Activity

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