Public transit, obesity, and medical costs: Assessing the magnitudes

doi:10.1016/j.ypmed.2007.10.004

Preventive Medicine

Volume 46, Issue 1, January 2008, Pages 14-21

https://doi.org/10.1016/j.ypmed.2007.10.004 Get rights and content

Abstract

Objective.

This paper assesses the potential benefits of increased walking and reduced obesity associated with taking public transit in terms of dollars of medical costs saved and disability avoided.

Methods.

I conduct a new analysis of a nationally representative U.S. transportation survey to gauge the net increase in walking associated with public transit usage. I translate minutes spent walking into energy expenditures and reductions in obesity prevalence, estimating the present value of costs and disability that may be avoided.

Results.

Taking public transit is associated with walking 8.3 more minutes per day on average, or an additional 25.7–39.0 kcal. Hill et al. [Hill, J.O., Wyatt, H.R., Reed, G.W., Peters, J.C., 2003. Obesity and the environment: Where do we go from here? Science 299 (5608), 853–855] estimate that an increase in net expenditure of 100 kcal/day can stop the increase in obesity in 90% of the population. Additional walking associated with public transit could save $5500 per person in present value by reducing obesity-related medical costs. Savings in quality-adjusted life years could be even higher.

Conclusions.

While no silver bullet, walking associated with public transit can have a substantial impact on obesity, costs, and well-being. Further research is warranted on the net impact of transit usage on all behaviors, including caloric intake and other types of exercise, and on whether policies can promote transit usage at acceptable cost.

Introduction

A topic of much recent interest is the degree to which public transportation may increase exercise through walking. Other things equal, an increase in exercise could then improve health outcomes by lowering obesity, which many view as a looming but potentially manageable threat to public health (Hill et al., 2003, Olshansky et al., 2005, Preston, 2005). The “New Urbanism” movement of the 1990s, which continues today, calls for development of denser, grid-based neighborhoods in order to increase walking, bicycling, and use of transit (Cervero and Radisch, 1996). More recently, the entire January 2007 issue of Environment and Behavior was devoted to examining how the built environment relates to diet and exercise, and thus, to obesity. A joint study by the Transportation Research Board and the Institute of Medicine (2005) surveyed the state of knowledge regarding the built environment and physical activity. Although the study showed that the built environment, including access to public transit, can help or hinder the choice to engage in physical activity, it emphasized how the lack of good data and inadequate study design have significantly hampered inference.

Because residents typically select their communities, much remains unclear about the causal influence of environment on activity (Handy and Mokhtarian, 2005, Ogilvie et al., 2006). Longitudinal panel studies of relocated families and their behavior and outcomes, such as the nascent RESIDE project in Perth, Australia, are designed to untangle this issue. Without a clear sense of how urban form and the availability of mass transit can actually produce more exercise, researchers are limited in advocating specific policy interventions. Still, it is worth assessing the potential magnitudes of the influences of public transit on health, in order to gauge the plausible scope for policy and motivate further research.

The amount of additional physical activity associated with public transportation appears potentially significant. Besser and Dannenberg (2005) report that half of the roughly 3% of adults in the 2001 U.S. National Household Travel Survey (NHTS) who walked to and from public transit spent 19 min or more in total walking time, and almost a third exceeded 30 min. Wener and Evans (2007) find that the average New York City train commuter walked about 9500 steps per day, roughly 2000 or 30% more steps than the average car commuter. Several papers associate form of transit with obesity directly. Frank et al. (2004) report that obesity around Atlanta, as measured by body mass index (BMI), is associated positively with time spent in cars and negatively with mixed land-use and with walking. Gordon-Larsen et al. (2005) reveal that non-overweight young adults in the Add Health survey were more likely to engage in active transportation like walking or bicycling, possibly in addition to taking public transit. Rundle et al. (2007) find BMI to be inversely associated with the density of bus stops, subway stops, and population around New York City.

However, is the additional walking associated with mass transit large enough to reduce obesity and associated health care costs? If yes, by how much? In this paper, I address this question by modeling daily time spent walking based on characteristics including transit use, and I then translate those differences into extra net energy expenditure and reductions in obesity.

Section snippets

Estimating additional walking associated with public transit

The quantity of interest is the additional amount of physical activity associated with taking public transit as opposed to driving. Wener and Evans (2007) measure this directly by asking a sample of car and train commuters around New York City to wear pedometers, and then comparing total steps for each group. No comparable study exists at the national level, but the 2001 National Household Travel Survey (U.S. Dept. of Transportation and Federal Highway Administration, 2001) contains similar

Additional walking through transit

Table 1 describes the characteristics of the weighted NHTS sample of adults, where the observations are person-days. Typical respondents are nearly 50 years old, roughly split between men and women, predominantly white, and typically hold only high school degrees. Average household income in the dataset is roughly twice per capita income because the data file frequently includes both adults in a typical household. Eighty percent of respondents own their own home. The average population density

Discussion

The objective of this paper was to explore the potential benefits of shifting an average U.S. citizen from driving to using public transit. Savings in avoided medical expenses through increased physical activity and decreased obesity appear to be relatively large, around a present value of $5500 per person. By comparison, a recent estimate suggests that quitting smoking could save between €7600 and 12,200 in present value per person depending on sex (Rasmussen et al., 2005), and a comparable

Conclusion

Use of public transit is associated with more walking, by about 8.3 extra minutes per day. This is not enough walking to halt the spread of obesity, but it could substantially reduce it. The present value of medical expenditure savings per person could be $5500, while the value of reduced disability could be even greater.

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^☆: All errors and opinions are those of the author alone and do not reflect the views of Queens College or the City University of New York.

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Public transit, obesity, and medical costs: Assessing the magnitudes☆

Abstract

Objective.

Methods.

Results.

Conclusions.

Introduction

Section snippets

Estimating additional walking associated with public transit

Additional walking through transit

Discussion

Conclusion

Am. J. Prev. Med.

Transp. Policy

J. Econom.

Am. J. Prev. Med.

The direct health care costs of obesity in the United States

Am. J. Publ. Health

Changes in the value of life, 1940–1980

J. Risk Uncertain.

Measuring the health of the U.S. population

Brookings Pap. Econ. Act., Microecon.

Why have Americans become more obese?

J. Econ. Perspect.

Risk–benefit analysis of cigarette smoking: public policy implications

J. Consum. Aff.

National medical spending attributable to overweight and obesity: how much, and who's paying?

Health Aff.

Prevalence and trends in obesity among U.S. adults, 1999–2000

J. Am. Med. Assoc.

Associations among active transportation, physical activity, and weight status in young adults

Obes. Res.

Which comes first? The neighborhood or the walking?

Access

Obesity and the environment: where do we go from here?

Science

The health and cost consequences of obesity among the future elderly

Health Aff.

The uses of Tobit analysis

Rev. Econ. Stat.