Publications and Reports

See Archived Publications from 2011 or Earlier


As the incidence of pediatric obesity and sedentary lifestyle increases, more children are being diagnosed with Type 2 diabetes, formerly a chronic disease primarily of adults who were overweight and had a sedentary lifestyle.  In March 2013, the American Diabetes Association issued the Economic Cost of Diabetes in the U.S. in 2012, part of a series of reports updated every 5 years.

  • This study updates previous estimates of the economic burden of diagnosed diabetes and quantifies the increased health resource use and lost productivity associated with diabetes in 2012.
  • The study uses a prevalence-based approach that combines the demographics of the U.S. population in 2012 with diabetes prevalence, epidemiological data, health care cost, and economic data into a Cost of Diabetes Model.
  • The total estimated cost of diagnosed diabetes in 2012 is $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity. People with diagnosed diabetes incur average medical expenditures of about $13,700 per year, of which about $7,900 is attributed to diabetes. People with diagnosed diabetes, on average, have medical expenditures approximately 2.3 times higher than what expenditures would be in the absence of diabetes. For the cost categories analyzed, care for people with diagnosed diabetes accounts for more than 1 in 5 health care dollars in the U.S., and more than half of that expenditure is directly attributable to diabetes.
  • Indirect costs include increased absenteeism ($5 billion) and reduced productivity while at work ($20.8 billion) for the employed population, reduced productivity for those not in the labor force ($2.7 billion), inability to work as a result of disease- related disability ($21.6 billion), and lost productive capacity due to early mortality ($18.5 billion).
  • The estimated total economic cost of diagnosed diabetes in 2012 is $245 billion, a 41% increase from our previous estimate of $174 billion (in 2007 dollars). This estimate highlights the substantial burden that diabetes imposes on society. 

In December 2012, the U.S. Department of Health and Human Services (HHS) released  The Physical Activity Guidelines for Americans Midcourse Report: Strategies to Increase Physical Activity Among Youth.

This mid-course report examines the research literature and provides recommendations for increasing physical activity levels of American youth across five key settings:  Schools, Preschool and Childcare, Community, Home, and Healthcare.

 Key findings from the midcourse report include:

  • School settings hold a realistic and evidence‐based opportunity to increase physical activity among youth and should be a key part of a national strategy to increase physical activity.
  • Preschool and childcare centers that serve young children are an important setting in which to enhance physical activity.
  • Changes involving the built environment and multiple sectors are promising.
  • To advance efforts to increase physical activity among youth, key research gaps should be addressed.
  • Children need 60 or more minutes of physical activity per day where they live, learn and play.

Specific to Safe Routes to School, researchers found that evidence supported three different strategies:

  • Multi-component school-based physical activity programs, including active transport to school along with additional PE, activity breaks in classes, and more;
  • Active transportation to and from schools; and
  • Making the built environment conducive to more active transportation, including mixed land use, population density, traffic calming and walking/bicycling infrastructure.

The report also calls out the “triple benefits” possible from active transportation to school by increasing the health of children, improving air quality and addressing environmental sustainability. 


In a February 2013 policy brief entitled Travel to School in California: Key Findings from the National House hold Travel Survey, the Safe Routes to School National Partnership reveals new trends regarding travel to school.  The brief reveals that between 26 and 31 percent of children in California walk or bicycle to school, more than twice the national average and that children who walk to school also walk more overall compared to other children. Another important statistic from the brief is that African-American and Latino children and children from lower-income households are more likely to walk or bicycle to school. The policy brief is an excerpt from a larger study that also shows that safety for children walking and bicycling to school is increasing along with increasing rates of walking—showing the impact of Safe Routes to School in California.


In an October 2012 report titled, Years of Potential Life Lost from Unintentional Injuries among Persons Aged 0–19 Years — United States, 2000–2009, the Centers for Disease Control and Prevention (CDC), determine that the burden of unintentional injuries was higher among males compared with females, among persons less than one year old and those aged 15–19 years compared with the other 5-year age groups, among American Indian/Alaska Native (AI/AN) compared with those of any other race/ethnicity, and among those residing in two clusters of adjacent states (the South Central states of Arkansas, Louisiana, Mississippi, and Alabama, and the Mountain states of Montana, Wyoming, and South Dakota) compared with any other region. These estimates can be used to target injury prevention strategies to young persons most at risk.


On May 8, 2012, the Institute of Medicine (IOM) released a consensus report funded by the Robert Wood Johnson Foundation Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Two-thirds of adults and one-third of children are overweight or obese. If left unchecked, obesity’s effects on health, healthcare costs, and productivity as a nation could become catastrophic. The staggering human toll of obesity-related chronic disease and disability, and an annual cost of $190.2 billion for treating obesity-related illness, underscore the urgent need to strengthen prevention efforts in the United States. The IOM evaluated prior obesity prevention strategies and identified five recommendations to meet the following goals:

  • Integrate physical activity every day in every way
  • Market what matters for a healthy life
  • Make healthy foods and beverages available everywhere
  • Activate employers and health care professionals
  • Strengthen schools as the heart of health

According to the Physical Activity Guidelines for Americans, children should get at least 60 minutes of physical activity per day, and one way for children to meet this goal is through brisk walking or bicycling to school. Yet, active commuting to school has declined over the past four decades. In a March 2012 research brief, Impact of State Laws on Walking and Bicycling to School, Active Living Research was the first to examine the impact of state laws on walking and bicycling to school among a national sample of elementary schools in the United States. The key findings and recommendations of this study are:

  • Some types of state laws, such as those requiring crossing guards, speed zones and traffic calming around schools, were linked with more principals reporting that more students were allowed to walk/bike to school and fewer principals reporting that no students walked/bicycled to school.
  • State policymakers should consider adopting laws that are associated with increased walking and bicycling to school among students, such as those requiring crossing guards, speed zones and traffic calming around schools.
  • There is a need for school and community leaders to ensure that the areas around schools are designed to make walking and bicycling to school safe and easy. When routes are safe, bussing distance policies should make active commuting the default option for students living closest to school.

The federal Safe Routes to School program provides funds to support programs in each state to ensure that it is safe and easy for children to walk and bicycle to school. Walking and bicycling to school can help children be more active, and active children are less likely to be obese. The Federal Highway Administration (FHWA) oversees the Safe Routes to School program and provides states with program goals, but states choose how to run their programs. Congress sets aside money for Safe Routes to School programs in every state, but there is significant variation in the amount of available federal Safe Routes to School funding that states actually spend. A March 2012 research brief by Active Living Research, States Vary in Safe Routes to School Spending, assessed how states spent these funds between 2005 and 2009, as well as how effective states were at meeting FHWA’s goals for the state-run programs. The key findings and recommendations of this study are:

  • Many states are using the SRTS program to make important changes that support safe, physically active trips to school.
  • However, the program is not likely to impact active commuting to school if the funds do not reach the local level.
  • Areas with high rates of child poverty or little history with walking and bicycling projects spent less of the available funding.
  • National and state leaders can help states track their SRTS spending and identify local areas that could benefit from SRTS programs.
  • State program staff can actively solicit applications for funding from local areas each year and link local groups, which may not have the resources to apply for funds or plan projects, with regional partners who can help schools or communities with the application and planning processes.
  • To make the best use of the funds available through the federal SRTS program, states should work to ensure that the money benefits the communities that need it most, such as those with high rates of poverty or obesity among children. 

Walking to school is recommended by many health authorities, because it gives children the opportunity to be active and may lower their risk of obesity. However, walking to school also could increase children’s risk of injury, especially when crossing a street. A March 2012 research brief by Active Living Research, Impact of the Walking School Bus Program on Children’s Pedestrian Safety Behaviors, reported that parents listed their children’s safety as one of the top concerns regarding walking to school, and that improving safety may lead more parents to allow their children to walk to school. Walk-to-school programs have not been studied for their impact on children’s safety. This study tested a way to evaluate children’s safety at the school level as part of a pilot Walking School Bus program for fourth graders. The key findings and recommendations of this study are:

  • Children at the schools participating in the Walking School Bus program were five times more likely to cross the street in a safe location—at the corner or crosswalk— than they were before their schools started the program.
  • Children’s safety behaviors were more strongly related to whether their school participated in the Walking School Bus than to the number of traffic lanes or parents’ perceptions of neighborhood safety.
  • Traffic lanes and perceived neighborhood safety may have less of an effect on children’s behavior than the influence of peers, adults or crossing guards.
  • Because walking to school may increase children’s risk of pedestrian injury, walk-to-school programs, such as the Walking School Bus, should be designed to make this activity as safe as possible.

With support provided by the Barr Foundation, WalkBoston and the Metropolitan Area Planning Council (MAPC) developed a spatial framework for assessing district- and school-level walkability; new methods for collecting student commute data; and a formula for estimating the GHG footprint of student auto commutes and the reductions that might be achieved by successful SRTS programs. WalkBoston and MAPC recorded their findings and recommendations in the recently released report Kids are Commuters Too: Assessing the Mode Shift Potential of Walk to School Programs. Some key findings from this study are:

  • 79% of the school-age children in the study area live within a mile of at least one school.
  • 54% of students living in the one mile walk-shed of a surveyed school are currently being driven to school.
  • Most districts use proximity as one factor among many when assigning students to schools.
  • High student proximity is a prerequisite to having a high walk/bike share, but not a guarantee.
  • More than one-eighth of auto emissions at the surveyed schools result from auto commutes that could be shifted to walking or biking.

Safe Kids Worldwide released a report Walking Safely, A Report to the Nation that examines 15-year trends in child pedestrian injuries and deaths in the U.S. The report reveals that while walking safety has improved overall for children since 1995, there are still a staggering number of children hit by cars. More than 61 children are injured every day severely enough to seek medical attention. More than 500 children are killed every year. Interestingly, the most at-risk age group has shifted since 1995 when 5-9 year olds sustained the most injuries, to today when teens are at greatest risk. The death rate among older teens is now twice that of younger children. These findings indicate that while the increased focus on younger kids has made a difference, stakeholders must cast a new focus on education and behavior change about pedestrian safety for kids 14 to 19, while continuing education and programs that have been effective for younger kids. Other recommendations include:

  • Research must be conducted to determine the causes of the negative trends and uncover effective means to reverse them.
  • Government at all levels must invest in infrastructure to make walking safer for kids of all ages, especially in and around school zones.
  • All people must commit to walking and driving without distraction. Distraction due to mobile technologies is an epidemic resulting in both deaths and injuries and must end.

Washington State Department of Transportation released a report Moving Forward: Safe Routes to School Progress in Five States that assessed the Safe Routes to School program in five states: Florida, Mississippi, Texas, Washington, and Wisconsin. A database of all SRTS projects announced for funding and all schools affected by these projects were developed. The database was analyzed to (1) quantify the SRTS programs’ impact in the five states and compare them to SRTS programs nationally, (2) assess the SRTS programs’ effectiveness in increasing rates of walking and bicycling to school, and (3) identify characteristics of SRTS projects associated with greater increases in walking and bicycling to school. The results of this study offer preliminary evidence that the SRTS program is achieving one of its primary goals of increasing rates of walking and bicycling to school and that SRTS funds are delivering a return on investment. It identified some trends of more successful projects, which warrant further investigation. As more projects end, the research framework established in this study can be used to further explore these findings and refine programs that help children safely walk or bicycle to school. Some key findings from this study are:

  • In the five states, more than 1400 schools and 781,000 children have been reached as a result of Safe Routes to School funding; this is roughly 11 percent of the pre-kindergarten through eighth grade public school population in the five states.
  • Engineering projects made up about 72 percent of the funding in the five states, with sidewalk projects featured in about 69 percent of these projects. Interestingly, the engineering projects that were on smaller scales (affected fewer schools and students) and included encouragement and education components tended to perform better.
  • Rates of walking increased by 45 percent, bicycling increased by 24 percent, and all active travel to school increased by 37 percent in these five states.
  • The study findings suggested that Safe Routes to School projects may be more effective at encouraging bicycling to school where few children already do so.

Regular physical activity can reduce children’s risk of obesity and improve their classroom performance, but many schools provide few opportunities for students to be active. Schools can provide excellent opportunities for children to be physically active through regular recess. The research report Increasing Physical Activity Through Recess summarizes the growing body of research examining recess, which shows that providing recess during the school day is an effective and efficient way to increase physical activity and improve academic performance among children.  Key findings and recommendations include:

  • Providing recess breaks throughout the day can improve students’ classroom behavior and attentiveness.
  • Children can accumulate up to 40 percent of their total daily physical activity during recess.
  • There are many effective strategies for increasing children’s levels of physical activity during recess, including inexpensive playground equipment, interactive games with recess supervisors, painted playground surfaces, and designating space for “activity zones”.
  • The number of school districts that require or recommend daily recess may be decreasing.
  • Children at high risk for obesity are least likely to have recess.

A new research brief from Active Living Research, Promoting Physical Activity through the Shared Use of School and Community Recreational Resources, summarizes research on community access to school sport and recreation facilities outside of school hours, as well as studies that examine the shared use of school facilities and programs with other community groups or agencies. It also describes challenges commonly associated with the shared use of recreational facilities, and opportunities for policy-makers at the state and local level. Some key findings and recommendations from this study are: 

  • Children who have access to existing and renovated school recreational facilities outside of regular school hours are more likely to be active.
  • Progress toward opening school facilities for recreational use outside of school hours is slow and some evidence suggests that lower-income communities are less likely than higher-income communities to offer shared use of school facilities.
  • Surveys of school administrators in lower-income communities or communities of color cite issues such as liability, staffing, maintenance and cost as barriers to opening schools for recreational use outside of school hours
  • The Institute of Medicine recommends that local governments "collaborate with school districts and other organizations to establish shared use of facilities agreements allowing playing fields, playgrounds, and recreation centers to be used by community residents when schools are closed; and if necessary, adopt regulatory and legislative policies to address liability issues that might block implementation." 
  • Schools, community groups and local governments can enter into shared use agreements to address the perceived barriers to sharing recreational facilities and programs.

A new report by the Department of Transportation’s Federal Highway Administration (FHWA) found that when the rate of walking and biking went up, the crash rate did not. The Report to the U.S. Congress on the Outcomes of the Nonmotorized Transportation Pilot Program SAFETEA-LU Section 1807 was released in honor of National Bike Month, which occurs every May. Transportation Secretary Ray LaHood wrote in his blog “FastLane” that the report is eye-opening regarding the value of investing in nonmotorized transportation, acknowledging the value of bicycling as a transportation option and as exercise.  The report is the summation of the FHWA’s four-year effort “to construct a network of sidewalks, bicycle lanes, and pedestrian and bicycle trails connecting directly with schools, residences, businesses, recreation areas, transit centers, and other community activity centers,” LaHood noted.  Some of the major findings:

  • Over four years, people in these four communities alone walked or bicycled an estimated 32 million miles they would have otherwise driven.
  • The communities saw an average increase of 49 percent in the number of bicyclists and a 22 percent increase in the number of pedestrians.
  • The percentage of trips taken by bike instead of car increased 36 percent, and those taken on foot increased 14 percent.
  • While each pilot community experienced increases in bicycling and walking, fatal bicycle and pedestrian crashes held steady or decreased in all of the communities.
  • In the pilot communities in 2010, additional nonmotorized trips reduced the economic cost of mortality by an estimated $6.9 million; an estimated 22 pounds of CO2 per person were saved, which is the equivalent to saving more than one gallon of gas per person, or nearly 1.7 million gallons of gas from 2007 to 2010; and many people tried bicycling for the first time.

Bridging the Gap (BTG), an RWJF-funded research program, has issued two new research briefs. Income Disparities in Street Features that Encourage Walking examines the prevalence of pedestrian-friendly features and amenities on neighborhood streets, including sidewalks, street lighting, traffic calming devices, and marked crosswalks, in communities throughout the U.S. The brief also summarizes differences in the prevalence of these features by community income. Using Local Land Use Laws to Facilitate Physical Activity examines the extent to which local land use laws in communities throughout the U.S. require structural improvements that facilitate physical activity, such as requirements for pedestrian-oriented provisions, open space, playgrounds, sports fields, trails, and bike lanes. It also shows how requirements vary based on community income.


Bicycling and Walking in the U.S.: 2012 Benchmarking Report is an essential resource and tool for government officials, advocates, and those working to promote bicycling and walking. The Benchmarking Project is an ongoing effort by the Alliance for Biking & Walking to collect and analyze data on bicycling and walking in all 50 states and the 51 largest U.S. cities. This third biennial report reveals data including: bicycling and walking levels and demographics; bicycle and pedestrian safety; funding for bicycle and pedestrian projects; written policies on bicycling and walking; bicycle infrastructure; bike-transit integration; bicycling and walking education and encouragement activities; public health indicators; and the economic impact of bicycling and walking. The report is full of data tables and graphs that show how your state or city stacks up, and provides unprecedented statistics to help support your case for increasing safe bicycling and walking in your community. This report was funded by the Centers for Disease Control and Prevention and made possible through the additional support of AARP and Planet Bike.


See Archived Publications from 2011 or Earlier