Building Environments and a Public Health Workforce to Support Physical Activity Among Older Adults

  • Date: Nov 03 2015
  • Policy Number: 201514

Key Words: Public Health Workforce, Physical Activity, Geriatric Health

Abstract 

Physical inactivity is one of the leading causes of death worldwide and one of today's great public health challenges. Decades of empirical evidence demonstrate that engaging in regular physical activity (PA) at all ages, including older adulthood (65 years or above), significantly protects against cardiovascular disease, diabetes, certain cancers, and certain behavioral health disorders. Furthermore, PA is an effective method to intervene in age-associated decrements in physical functioning and disabilities. Such evidence is of paramount importance considering that projections indicate the older adult population in the United States will double by 2050. In 2008, the US Department of Health and Human Services released the Physical Activity Guidelines for Americans in an effort to promote PA among all of the country’s residents. Despite this, just under 16% of older adults meet the recommended level of PA, with time spent being inactive increasing across each decade beginning in middle life. There is a great need to prioritize specific, actionable recommendations promoting PA among older adults that take into account the unique needs of this group relative to younger adults. This policy statement includes a comprehensive approach to enhancing the environment for active aging and developing a public health workforce with competencies specific to PA among older adults.

Relationship to Existing APHA Policy Statements

Many of the existing policy statements listed below were written to support efforts aimed at increasing population levels of physical activity (PA). While these policies are indeed related to the current policy statement, the population-based nature of the policies’ recommendations lacks the level of specificity required to effectively address the needs of subpopulation groups such as older adults. Perhaps the best example of this is Policy Statement 20121, Supporting the National Physical Activity Plan. The highly comprehensive nature of the National Physical Activity Plan (NPAP) is both a strength and a weakness. With more than 250 recommendations across eight societal sectors, the plan’s breadth is a strength in that it attempts to reach every American. However, because the NPAP is organized around societal sectors (e.g., health care, education, and public health) as opposed to population subgroups (e.g., older adults), it sometimes lacks depth in providing actionable recommendations for older adults, whose needs are unique. In particular, effectively supporting physical activity among older adults requires both a public health workforce with expertise in addressing the needs of older adults and environmental changes specific to the needs of this group. The action steps offered here build from the policy statements listed below to provide actionable, evidence-based recommendations at the level of specificity required to sufficiently address the unique needs of older adults.

  • APHA Policy Statement 20121: Supporting the National Physical Activity Plan
  • APHA Policy Statement 9709: Promoting Public Health Through Physical Activity
  • APHA Policy Statement 2005-8: Supporting the WHO Global Strategy on Diet, Physical Activity and Health
  • APHA Policy Statement 20079: Building a Public Health Infrastructure for Physical Activity
  • APHA Policy Statement 201313: Advancing Efforts to Enumerate and Characterize the Nation's Public Health Workforce

Problem Statement

It is estimated that, by 2050, approximately 89 million US adults will be older than 65 years, double the 2010 figure.[1] Twenty percent of the total US population is projected to be above the age of 65 years in 2030, up 7% from 2010,[2] and the population above 85 years of age is projected to increase to 19 million by 2050 (from 5.5 million in 2010).[2] Also, it is projected that the proportion of minorities (including Hispanics, African Americans, and Asians) among the population older than 65 years will increase by 2050.[2]

Maintenance of a physically active lifestyle is especially important when considering prominent health concerns. Approximately 88% of older adults have one chronic disease, and 65% have two or more.[3] These observable trends are in concert with acute health concerns, most prominently fall risk, which is associated with an estimated 1.5 million bone fractures each year.[4] Collectively, this represents a decline in physical and cognitive functioning. Naturally, the adverse outcomes of such conditions accumulate with each successive diagnosis. Of noteworthy importance is the decline in physical[5] and cognitive[6] functioning, which decrease people’s capacity to engage in activities of daily living.[7] This cascade of events (declines in physical and cognitive functioning with subsequent decreases in capacity) contributes to the trajectory toward physical disabilities, which are linked to social isolation, a heightened reliance on others, and behavioral health concerns (e.g., depression, anxiety, and some aspects of dementia).[1] PA interventions have been effective in reducing falls[8,9] and the subsequent morbidity associated with them. In addition, PA improves cognitive functioning among older adults.[10] Therefore, PA is a powerful mitigating factor in reducing such outcomes, which have a crippling effect on our nation’s physical (noncommunicable diseases) and mental health and economic stability.

Conversely, physical inactivity is the fourth-leading cause of death worldwide[11] and is one of the great public health challenges of the 21st century.[12] Decades of empirical evidence demonstrate that engaging in regular physical activity significantly protects against cardiovascular disease, diabetes, certain cancers, depression, anxiety, and other noncommunicable diseases, for which older adults are at higher risk.[11–13] In 2000, physical inactivity was associated with $76 billion in health care costs.[14] Given the very limited impact of individual-level interventions designed to increase PA,[15] a comprehensive approach that addresses environmental and system-level factors and professional development is required. With the acknowledgment of the ever-growing number of individuals living into old age, interventions and policies must be tailored to meet the distinct differences in the older adult population.

The PA guideline for healthy older adults calls for 150 minutes a week of moderate-intensity or 75 minutes a week of vigorous-intensity aerobic PA, with two or more days a week of muscle-strengthening activities that are of moderate or high intensity and involve all of the major muscle groups.[16] Despite such recommendations, in 2011 only 52.7% of US adults older than 65 years reported meeting the aerobic activity guideline, 21.7% met the muscle-strengthening guideline, and a 15.9% met both.[17] A recent review examining the percentage of older adults meeting PA guidelines showed that, among the 53 papers reviewed, the percentage ranged from 2.4% to 83%, with the majority of papers reporting that 20% to 69% of older adults met the guidelines.[18] These ranges are due to the competing influences of different measurement methodologies (subjective versus objective), attempts to capture the various domains of PA (leisure, transportation, occupational, household, exercise), use of conflicting definitions of moderate and vigorous PA, and different PA recommendations. Accelerometer data (which are considered the most reliable method for measuring PA) from the National Health and Nutrition Examination Survey showed that 2.4% of US adults older than 60 years met the PA guidelines in 2003–2004, while 8.5% of adults 60–69 years of age and 6.3% of those 70 years or older met the guidelines in 2005–2006.[19] Although variations in PA measurement create challenges, the aforementioned trends in PA engagement have shown over time that the vast majority of US older adults are not meeting the stated guidelines.

However, there are observed disparities with regard to PA participation among specific subgroups of the older adult population. For example, PA engagement is lower among older adult members of racial/ethnic minority populations, in part owing to the varying socioeconomic status (SES) of these groups,[17,20] and older adults living in rural areas.[21] Older adults are particularly subject to the influences of low SES, including lack of resources (facilities, equipment, transportation) and general health knowledge as well as age- and culture-related misconceptions about PA.[22,23] Furthermore, older adult women are less active than men, and this gap widens with increasing age.[24] Thus, efforts aimed at enhancing social support and self-efficacy related to the benefits of exercise are warranted to ameliorate detrimental influences of SES and gender in the older adult population.

A myriad of barriers result in PA behavior adoption and maintenance being more difficult among older adults. These barriers can broadly be categorized as individual or environmental. Individual factors, such as chronic conditions, can cause mobility issues that result in increased risk or fear of falling.[25] Many chronic health problems can lead to a cycle in which symptoms of the chronic condition lead to inactivity, which further exacerbates the health problem.[26] Thus, there is not only a direct influence of the health outcome on PA engagement but also an indirect influence (such as chronic pain or sensory deficits from degenerative diseases).[27] Individual barriers to PA such as lack of interest, motivation, or enjoyment are also commonly reported by older adults,[28] and culture, gender, and generation should be considered in planning programs.[29] Beyond the evidence of correlations between individual barriers and PA,[30] interventions directed at modifiable individual barriers among older adults have shown success through a combination of self-monitoring,[31] education to reduce barriers and their associated management, and specific PA prescriptions.[32]

Environmental barriers to PA engagement are of equal importance to individual influences. For example, a critical factor in older adults not being habitually active is safety, which can be defined via intrapersonal and environmental factors.[33] Fear of crime and concerns regarding personal safety are reported barriers for older adults considering outdoor PA.[34] Other reports of safety concerns that limit outdoor PA include poorly maintained sidewalks and streets, few walking paths close to home, poor street connectivity, and concerns about heavy traffic.[29] Many older adults report that places designed for indoor PA are too far away; a lack of transportation inhibits access, or transportation systems are unreliable or too costly.[25,34] In rural communities, barriers to PA among older adults also include lack of transportation to recreational facilities, isolation, lack of safe places to be physically active, lack of sidewalks and lighting, safety fears (e.g., loose dogs, crime), and issues related to climate and terrain.[35] Accordingly, these barriers represent a dichotomy in the needs of older adults residing in urban and rural environments.[36] However, there is evidence suggesting that modifications to both urban[37] and rural[38] environments have a meaningful impact on health and physical activity.

An estimated 11.1% of US health care expenditures ($131 billion) are attributable to physical inactivity.[39] In addition, an estimated $5.6 billion in costs associated with heart disease would be saved if 10% of US adults began a regular walking program.[14] Although the United States has made strides in building the capacity to promote physical activity in public health agencies and departments, the investment in PA promotion is still inadequate to lead to significant changes in the public’s level of PA.[40] Furthermore, the current public health workforce does not have education or preparation related to working with older adults, and the field of public health does not include competencies related to the needs of this group.[41] There is a low level of interest among public health students in enrolling in aging-related courses.[41] Thus, the public health workforce needs training in healthy aging, and schools of public health need to retool and enhance their focus in this area. 

Evidence-Based Strategies to Address the Problem

Because of the broad scope of barriers to PA among older adults, promotion strategies need to consider a socioecological approach. In particular, enhancing the built environment to address the PA needs of older adults should be a priority. For example, street lighting, safe sidewalks, and benches for resting would address some of their safety concerns. Transportation options for connecting residences with community indoor and outdoor PA opportunities could also enhance PA among older adults. Beyond the built environment, there is a need for training in active aging among both public health practitioners and health care providers so that they can address social and intraindividual obstacles and advocate for, plan, and implement environmental interventions.

Public transit has been associated with greater amounts of walking and biking,[42] whereas driving has been associated with lower levels of PA.[43] Enhancing public transit systems (e.g., improving pricing and safety) has the potential to encourage wider usage[43] and, thus, increases in walking among transit users. In addition, walking is a common form of PA among older adults for both recreation and transportation, and this often occurs on streets; therefore, creating an environment that is conducive to walking through building pedestrian-friendly infrastructures (e.g., sidewalks, buffers, protected crosswalks) and establishing supportive zoning (e.g., land use diversity, interconnected street designs) can promote walking.[43] 

However, in rural communities, owing to the dispersed population, active transportation is less likely an option. As a result, increasing access to programming in multiple locations spread throughout rural communities (e.g., churches, senior centers, school buildings), developing or updating shared-use policies, and enhancing existing recreational facilities to meet older adults’ needs might reach a larger percentage of this group than built environment changes.[35] In addition, many rural communities may not have an adequate tax base to make extensive built environment changes such as widening shoulders; thus, starting with smaller changes, such as repainting crosswalks or adding pedestrian signs, might be more feasible.[35] Parks and recreation areas are another aspect of the environment that supports PA. Evidence suggests that creating and maintaining walking trails, biking trails, and sport fields and offering organized PA programming within parks can promote physical activity.[44]

As mentioned, safety is a major environmental barrier to PA within the older adult population. Environmental changes can reduce these concerns. For instance, adequate lighting could reduce fear of crime and personal safety concerns, and well-maintained walking paths could reduce the risk of falling. While environmental change is not without costs, studies have shown that building pedestrian trails reduces health care costs associated with physical inactivity. For example, every dollar invested in building trails saves nearly $3 in medical costs.[45] Also, linking different parts of the community with trails and walkways opens up the opportunity for community integration, more efficient land use, less traffic congestion, a better quality of life, and increased property values.[46] 

The mission of the US public health workforce encompasses PA promotion because it is a key strategy in preventing and controlling chronic disease. Therefore, training of the public health workforce needs to include creation of messaging aimed at promoting PA; implementation and evaluation of evidence-based programming, with attention to the diversity of environments (e.g., geography, resource base) and the racial, ethnic, and linguistic diversity of older adults; advocacy for environmental policies; and use of surveillance data (e.g., data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System) to monitor progress toward promoting PA.[47] Public health practitioners are in a key position to implement evidence-based programming, advocate for environmental changes aimed at older adults, and monitor progress toward increasing PA levels in this group. There is evidence to support the effectiveness of brief counseling by health care providers[48] and the use of exercise prescriptions[49] to promote PA among older adults. However, barriers to promoting PA frequently reported by health care providers include lack of training on counseling approaches, lack of education on PA recommendations, and lack of support, time, and resources.[48]

Promoting PA among older adults can improve quality of life, extend life expectancy, and reduce health care costs.[11,13,50] Reducing the prevalence of physical inactivity by 25% worldwide could decrease the annual number of deaths by 1.3 million.[11] It is estimated that PA can increase life expectancy by 0.4 to 6.9 years.[11,51] Higher levels of PA have also been associated with lower health care costs among older adults. One study showed that older adults who were active one to three days a week had 8%–20% lower health care costs than sedentary older adults, and costs among those who were active at least four days were an additional 8%–11% lower.[50] In addition, a recent report revealed that for every dollar spent on evidence-based community health promotion programs, including physical activity promotion, the country could receive a return of $5.60 per year; in other words, an investment of $10 per person could save $16 billion annually, and this return on investment could be realized within just five years.[52] Thus, the recommendations we are proposing could have substantial health and economic benefits.

Opposing Arguments/Evidence 

The majority of interventions designed to promote PA in older adults have focused on individual behavior change programs conducted in community settings (such as recreational facilities).[41,49] There is sufficient evidence to indicate that these programs are effective, and they are recommended by the US Preventive Services Task Force[53] and the American Geriatrics Society; however, there are gaps in evidence regarding which strategies are most effective among older adults, especially over time.[41,53] Methodology problems in ascertaining the most effective approaches include a preponderance of self-reported results versus objective measurements or observations, a lack of randomization, a lack of well-matched intervention or comparison groups, insufficient study durations (often as a result of funding limitations), an emphasis on personal-level strategies rather than a community-based or public health–based focus that recognizes socioenvironmental influences, and a focus on leisure activity rather than activities of daily living or occupational activities.[41,49]

In addition, there are issues relating to recommendations regarding the built environment. In a recent review on active aging, the authors pointed out that conclusions about characteristics (e.g., connectivity) that result in “walkable” neighborhoods often apply to people commuting to jobs and that, among older adults, a different set of characteristics (e.g., cul-de-sacs) might encourage or enable activity.[42] Much of the environmental research has involved cross-sectional designs, and thus it is difficult to make conclusions regarding causality.[54] There have been numerous attempts to create urban environments that encourage and assist healthy aging and aging in place; however, there are limited evaluations of this approach.[54] Despite this lack of sufficient evidence supporting the potential of environmental interventions to increase PA levels among older adults, the Community Guide and the National Physical Activity Plan recommend environmental-level interventions to promote PA among older adults, including community and street-scale designs and land use policies that create environments conducive to active living, creation of or enhancement of access to places designed for PA, and transportation and travel policies and practices that promote use by and support the needs of older adults.[53,55]

Action Steps

This proposal provides evidence to support a comprehensive approach to promoting PA among older adults. The action steps listed below are based on recommendations from the National Physical Activity Plan[55] and the National Standards for Culturally and Linguistically Appropriate Services (CLAS).[56] All of the recommendations listed have an evidence base supporting their efficacy in improving physical activity among older adults. Any single recommendation should be prioritized for implementation given sufficient resources and the will to do so. However, we have created two priority categories based on feasibility and the likelihood of implementation or adoption. 

Highest-Priority Recommendations:

  • Leaders in schools of nursing, medicine, and public health should expand recruitment, outreach, and training efforts (e.g., through scholarship programs sponsored by professional societies) to increase the numbers of ethnic minority students, students with disabilities, and students representing groups at particular risk of physical inactivity, thereby increasing the diversity of the nursing, public health, and medical workforce.
  • Leaders in public health departments and health care organizations (e.g., clinics, hospitals) should implement workforce CLAS training, institute polices directed toward the CLAS standards, and provide needed financial and organizational support to achieve the standards.
  • Practitioners and workers in public health departments should develop collaborative relationships with other government-sector workers (e.g., those in urban planning/design and transportation) in order to plan, design, and implement activity-friendly communities that will support PA among older adults (e.g., through improvements in street lighting and creation of open spaces).
  • Practitioners and workers in public health and transportation departments should collaborate on designing and implementing enhanced local transportation systems to better support the active transport needs of older adults, including but not limited to providing accessible and safe transit services as well as extended walk times at pedestrian crosswalks, particularly in rural and other low-resourced neighborhoods and communities.
  • Public parks and recreation departments and private recreation facilities should offer culturally, racially, and linguistically appropriate programming to meet the needs of diverse older adults (e.g., with respect to level of physical ability, language, and race/ethnicity).
  • Leaders in public health departments should develop, maintain, and leverage partnerships and coalitions with agencies and organizations that have a vested interest in healthy aging (e.g., Senior Services of America, AARP) in order to better implement effective strategies to promote physical activity among older adults.
  • Leaders in state and local health departments should create a physical activity and health unit that is part of a chronic disease prevention unit. These units should be staffed with practitioners who are specialists in public health and physical activity among diverse populations.

High-Priority Recommendations:

  • Leaders in public parks and recreational departments should prioritize and appropriate required resources for building and maintaining amenities (walking trails, shaded areas, benches) that support the health and well-being of older adults, particularly in rural and other low-resourced neighborhoods and communities.
  • Faculty in public health schools should include required curriculum training on physical activity strategies to be used in working with older adults as a means of promoting physical activity, with special training in healthy aging, active living, and culturally competent and sensitive approaches.
  • Leaders in health care systems and payers should prioritize physical activity assessments and promotion, develop reimbursement mechanisms for physical activity assessments and counseling, and develop comprehensive approaches to promoting physical activity among older adult populations.

References

1. The State of Aging and Health in America. Atlanta, GA: Centers for Disease Control and Prevention; 2013.

2. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key Indicators of Well-Being. In: Statistics FIFoA-R, ed. Washington, DC: U.S. Government Printing Office; 2012.

3. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269–2276.

4. Lehnert T, Heider D, Leicht H, et al. Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev. 2011;68:387–420.

5. Seeman T, Chen X. Risk and protective factors for physical functioning in older adults with and without chronic conditions: MacArthur Studies of Successful Aging. J Gerontol B Psychol Sci Soc Sci. 2002;57:S135–S144.

6. Chodosh J, Miller-Martinez D, Aneshensel CS, Wight RG, Karlamangla AS. Depressive symptoms, chronic diseases, and physical disabilities as predictors of cognitive functioning trajectories in older Americans. J Am Geriatr Soc. 2010;58:2350–2357.

7. Tinetti ME, McAvay G, Chang SS, et al. Effect of chronic disease-related symptoms and impairments on universal health outcomes in older adults. . J Am Geriatr Soc. 2011;59:1618–1627.

8. El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f6234.

9. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ. 2004;328:680.

10. Bherer L, Erickson KI, Liu-Ambrose T. A review of the effects of physical activity and exercise on cognitive and brain functions in older adults. J Aging Res. 2013;2013:657508.

11. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380:219–229.

12. Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med. 2009;43:1–2.

13. Danaei G, Rimm EB, Oza S, Kulkarni SC, Murray CJ, Ezzati M. The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States. PLoS Med. 2010;7:e1000248.

14. Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical Activity. Atlanta, GA: Centers for Disease Control and Prevention; 2008.

15. Alvaro C, Jackson LA, Kirk S, et al. Moving Canadian governmental policies beyond a focus on individual lifestyle: some insights from complexity and critical theories. Health Promot Int. 2011;26:91–99.

16. Physical Activity Guidelines for Americans. Washington, DC: US Department of Health and Human Services; 2008.

17. Centers for Disease Control and Prevention. Adult participation in aerobic and muscle-strengthening physical activities—United States, 2011. MMWR Morb Mortal Wkly Rep. 2013;62:326–330.

18. Sun F, Norman IJ, While AE. Physical activity in older people: a systematic review. BMC Public Health. 2013;13:449.

19. Tucker JM, Welk GJ, Beyler NK. Physical activity in U.S. adults: compliance with the Physical Activity Guidelines for Americans. Am J Prev Med. 2011;40:454–461.

20. Troiano R, Berrigan D, Dodd K, Masse L, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc. 2008;40:181–188.

21. Patterson P, Moore C, Probst J, Shinogle J. Obesity and physical inactivity in rural America. J Rural Health. 2004;20:151–159.

22. Lee A. Using self-efficacy theory to develop interventions that help older people overcome psychological barriers to physical activity: a discussion paper. Int J Nurs Stud. 2008;45:1690–1699.

23. Costello E, Kafchinski M, Vrazel J, Sullivan P. Motivators, barriers, and beliefs regarding physical activity in an older adult population. J Geriatr Phys Ther. 2011;34:138–147.

24. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key Indicators of Well-Being. Washington, DC: US Government Printing Office; 2012.

25. Newson R, Kemps E. Factors that promote and prevent exercise engagement in older adults. J Aging Health. 2007;19:470–481.

26. Egan BA, Mentes JC. Benefits of physical activity for knee osteoarthritis: a brief review. J Gerontol Nurs. 2010;36:9–14.

27. Cooper KM, Bilbrew D, Dubbert PM, Kerr K, Kirchner K. Health barriers to walking for exercise in elderly primary care. Geriatr Nurs. 2001;22:258–262.

28. Whitehead C, Wundke R, Crotty M. Attitudes to falls and injury prevention: what are the barriers to implementing falls prevention strategies? Clin Rehabil. 2006;20:536–542.

29. Hall K, McAuley E. Individual, social environmental and physical environmental barriers to achieving 10,000 steps per day among older women. Health Educ Res. 2010;25:478–488.

30. Pan SY, Cameron C, Desmeules M, Morrison H, Craig CL, Jiang X. Individual, social, environmental, and physical environmental correlates with physical activity among Canadians: a cross-sectional study. BMC Public Health. 2009;9:21.

31. Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol. 2009;28:690–701.

32. Conn VS, Hafdahl AR, Brown SA, Brown LM. Meta-analysis of patient education interventions to increase physical activity among chronically ill adults. Patient Educ Couns. 2008;70:157–172.

33. Tucker-Seeley RD, Subramanian SV, Li Y, Sorensen G. Neighborhood safety, socioeconomic status, and physical activity in older adults. Am J Prev Med. 2009;37:207–213.

34. Belza B, Walick J, Shiu-Thornton S, Schwartz S, Taylor M, LoGerfo J. Older adult perspectives on physical activity and exercise: voices from multiple cultures. Prev Chronic Dis. 2004;1:1–12.

35. Yousefian A, Hartley D. Promoting active living in rural communities. Available at: http://activelivingresearch.org/sites/default/files/ALR_Brief_RuralCommunities_Sept2015.pdf. Accessed January 18 2016.

36. Cleland V, Sodergren M, Otahal P, et al. Associations between the perceived environment and physical activity among adults aged 55–65 years: does urban-rural area of residence matter? J Aging Phys Act. 2015;23:55–63.

37. Rosso AL, Auchincloss AH, Michael YL. The urban built environment and mobility in older adults: a comprehensive review. J Aging Res. 2011;2011:816106.

38. de Koning JL, Stathi A, Fox KR. Similarities and differences in the determinants of trips outdoors performed by UK urban- and rural-living older adults. J Aging Phys Act. 2015;23:613–621.

39. Carlson SA, Fulton JE, Pratt M, Yang Z, Adams EK. Inadequate physical activity and health care expenditures in the United States. Prog Cardiovasc Dise. 2015;57:315–323.

40. Pratt M, Epping JN, Dietz WH. Putting physical activity into public health: a historical perspective from the CDC. Prev Med. 2009;49:301–302.

41. Frank JC. A missing piece in the infrastructure to promote healthy aging programs: education and work force development. Front Public Health. 2014;2:287.

42. KIng A, King D. Physical activity for an aging population. Public Health Rev. 2010;32:401–426.

43. Frank L, Kavage S. A national plan for physical activity: the enabling role of the built environment. J Phys Act Health. 2009;6(suppl 2):S186–S195.

44. Mowen AJ, Baker BL. Park, recreation, fitness, and sport sector recommendations for a more physically active America: a white paper for the United States National Physical Activity Plan. J Phys Act Health. 2009;6(suppl 2):S236–S244.

45. Wang G, Macera CA, Scudder-Soucie B, Schmid T, Pratt M, Buchner D. A cost-benefit analysis of physical activity using bike/pedestrian trails. Health Promot Pract. 2005;6:174–179.

46. Shoup L, Ewing R. The Economic Benefits of Open Space, Recreation Facilities and Walkable Community Design. Princeton, NJ: Robert Wood Johnson Foundation; 2010.

47. Heath GW. The role of the public health sector in promoting physical activity: national, state, and local applications. J Phys Act Health. 2009;6(suppl 2):S159–S167.

48. Vuori IM, Lavie CJ, Blair SN. Physical activity promotion in the health care system. Mayo Clinic Proc. 2013;88:1446–1461.

49. Renehan E, Dow B, Lin X, et al. Healthy aging literature review. Available at: https://www2.health.vic.gov.au/Api/downloadmedia/%7B33D1A7A1-08BC-4F7F-90A4-B8B7FC2BCA72%7D. Accessed January 18, 2016.

50. Wang F, McDonald T, Reffitt B, Edington D. BMI, physical activity, and health care utilization/costs among Medicare retirees. Obes Res. 2005;13:1450–1457.

51. Reimers C, Knapp G, Reimers A. Does physical activity increase life expectancy? A review of the literature. J Aging Res. 2012;2012:243958.

52. Levi J, Segal L, Juliano C. Prevention for a healthier America: investments in disease prevention yield significant savings, stronger communities. Available at: http://healthyamericans.org/reports/prevention08/. Accessed January 18, 2016.

53. US Preventive Services Task Force. The Community Guide. Available at: http://www.thecommunityguide.org. Accessed January 18, 2016.

54. Beard J, Petitot C. Ageing and urbanization: can cities be designed to foster active ageing? Public Health Rev. 2010;32:427–450.

55. National Physical Activity Plan Alliance. National Physical Activity Plan. Available at: http://physicalactivityplan.org/theplan.php. Accessed January 18, 2016.

56. Koh HK, Gracia JN, Alvarez ME. Culturally and Linguistically Appropriate Services—advancing health with CLAS. N Engl J Med. 2014;371:198–201.