Associations between Recreational and Commuter Cycling, Changes in Cycling, and Type 2 Diabetes Risk: A Cohort Study of Danish Men and Women

Health Benefits of Different Sports: a Systematic Review and Meta-Analysis of Longitudinal and Intervention Studies Including 2.6 Million Adult Participants

BACKGROUND

Several reviews have examined the health benefits of participation in specific sports, such as baseball, cricket, cross-country skiing, cycling, downhill skiing, football, golf, judo, rugby, running and swimming. However, new primary studies on the topic have recently been published, and the respective meta-analytic evidence needs to be updated.

OBJECTIVES

To systematically review, summarise and appraise evidence on physical health benefits of participation in different recreational sports.

METHODS

Searches for journal articles were conducted in PubMed/MEDLINE, Scopus, SpoLit, SPORTDiscus, Sports Medicine & Education Index and Web of Science. We included longitudinal and intervention studies investigating physical health outcomes associated with participation in a given sport among generally healthy adults without disability.

RESULTS

A total of 136 papers from 76 studies conducted among 2.6 million participants were included in the review. Our meta-analyses of available evidence found that: (1) cycling reduces the risk of coronary heart disease by 16% (pooled hazard ratio [HR] = 0.84; 95% confidence interval [CI]: 0.80, 0.89), all-cause mortality by 21% (HR = 0.79; 95% CI: 0.73, 0.84), cancer mortality by 10% (HR = 0.90; 95% CI: 0.85, 0.96) and cardiovascular mortality by 20% (HR = 0.80; 95% CI: 0.74, 0.86); (2) football has favourable effects on body composition, blood lipids, fasting blood glucose, blood pressure, cardiovascular function at rest, cardiorespiratory fitness and bone strength (p < 0.050); (3) handball has favourable effects on body composition and cardiorespiratory fitness (p < 0.050); (4) running reduces the risk of all-cause mortality by 23% (HR = 0.77; 95% CI: 0.70, 0.85), cancer mortality by 20% (HR = 0.80; 95% CI: 0.72, 0.89) and cardiovascular mortality by 27% (HR = 0.73; 95% CI: 0.57, 0.94) and improves body composition, cardiovascular function at rest and cardiorespiratory fitness (p < 0.010); and (5) swimming reduces the risk of all-cause mortality by 24% (HR = 0.76; 95% CI: 0.63, 0.92) and improves body composition and blood lipids (p < 0.010).

CONCLUSIONS

A range of physical health benefits are associated with participation in recreational cycling, football, handball, running and swimming. More studies are needed to enable meta-analyses of health benefits of participation in other sports. PROSPERO registration number CRD42021234839.

The association of work physical activity and recreational physical activity with periodontitis in the NHANES (2009-2014)

BACKGROUND

The aim of this study was to investigate the association between different types and intensity of physical activities (PA) and periodontitis in a nationally representative sample of adults in the United States.

METHODS

The data of periodontal condition and PA of 10,714 individuals were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014 and the Global Physical Activity Questionnaire (GPAQ). The association between the prevalence of periodontitis and two PAs (work PA and recreational PA) was respectively analyzed and adjusted by uni- and multi-variable logistic regression models. The odd ratios (ORs), adjusted odd ratios (ORad ), and 95% confidence interval (95% CI) were calculated as the main outcome indicators.

RESULTS

After adjusted by age, sex, race, poverty-income ratio (PIR), diabetes, smoking status, alcohol use, and floss frequency, moderate and vigorous work PAs were significantly correlated with higher odds of periodontitis (ORad  = 1.22, 95% CI = 1.02-1.46; ORad  = 1.40, 95% CI = 1.04-1.89, respectively) while moderate and vigorous recreational PAs were correlated with lower odds of periodontitis (ORad  = 0.81, 95% CI = 0.69-0.95; ORad  = 0.55, 95% CI = 0.43-0.71, respectively).

CONCLUSIONS

Work PAs and recreational PAs have opposite associations on the prevalence of developing periodontitis and their aggravating or protective associations enhance with the increase of intensity.

Benefits, risks, barriers, and facilitators to cycling: a narrative review

There is large potential to increase cycling participation worldwide. Participation in cycling is associated with lower risk of mortality from any cause, and incidence of cardiovascular disease and type 2 diabetes, as well as positive mental health and well-being. The largest potential for health gains likely to come from increasing participation amongst those who do not currently cycle regularly, rather than encouraging those who already cycle regularly to cycle more. Replacing car journeys with cycling can lead to reductions in air pollution emissions and lower pollutant exposure to the general population. Important gaps and uncertainties in the existing evidence base include: the extent to which the health benefits associated with cycling participation are fully causal due to the observational nature of much of the existing evidence base; the real-world economic cost-benefits of pragmatic interventions to increase cycling participation; and the most effective (combination of) approaches to increase cycling participation. To address these uncertainties, large-scale, long-term randomised controlled trials are needed to: evaluate the effectiveness, and cost-effectiveness, of (combinations of) intervention approaches to induce sustained long-term increases in cycling participation in terms of increases in numbers of people cycling regularly and number of cycling journeys undertaken, across a range of population demographic groups; establish the effects of such interventions on relevant outcomes related to health and wellbeing, economic productivity and wider societal impacts; and provide more robust quantification of potential harms of increasing cycling participation, such as collision risks.

Transportation-related Environmental Mixtures and Diabetes Prevalence and Control in Urban/Metropolitan Counties in the United States

Diabetes rates in the United States are staggering and climbing. Importantly, traditional risk factors fail to completely account for the magnitude of the diabetes epidemic. Environmental exposures, including urban and metropolitan transportation quality, are implicated as contributors to disease. Using data from the county-level Environmental Quality Index (EQI) developed for the United States, we analyzed associations between transportation and air quality environmental metrics with overall diabetes prevalence and control within urban/metropolitan counties in the United States from 2006 to 2012. Additionally, we examined effect modification by race/ethnicity through stratification based on the county-level proportion of minority residents. Last, we applied mixture methods to evaluate the effect of simultaneous poor transportation factors and worse air quality on the same outcomes. We found that increased county-level particulate matter air pollution and nitrogen dioxide along with reduced public transportation usage and lower walkability were all associated with increased diabetes prevalence. The minority proportion of the population influences some of these relationships as some of the effects of air pollution and the transportation-related environment are worse among counties with more minority residents. Furthermore, the transportation and air quality mixtures were found to be associated with increased diabetes prevalence and reduced diabetes control. These data further support the burgeoning evidence that poor environments amplify diabetes risk. Future cohort studies should explore the utility of environmental policies and urban planning as tools for improving metabolic health.

Effects of cycling on the morphology and spinal posture in professional and recreational cyclists: a systematic review

The aim was to know if cycling affects spinal morphology in postures off the bicycle, such as adapting the spinal curvatures on the bicycle depending on the handlebar type and position on the handlebars. A systematic review was conducted following the PRISMA guidelines. The studies selected met the following criteria: a) the study design was cross-sectional or longitudinal (experimental or cohorts); b) the study evaluated the sagittal morphology of the spine on the bicycle; c) the study included healthy and trained participants without injuries or cyclists reporting low back pain. Fifteen studies reported that a greater pelvic tilt was observed that when the handlebar was in a lower position. Sixteen studies found that lumbar kyphosis was greater when the handlebar grip was lower and farther from the saddle. Twelve studies reported that a tendency towards greater thoracic flexion as the time spent pedalling on the bicycle increased. In conclusion, the practice of cycling produces adaptations in the morphology of the spine of the cyclist compared to non-cyclists, such as an increase in pelvic tilt and a greater capacity for lumbar flexion in trunk flexion positions, and a greater thoracic kyphosis in the standing position.

Development and optimisation of a multi-component workplace intervention to increase cycling for the Cycle Nation Project

The Cycle Nation Project (CNP) aimed to develop, test the feasibility of and optimize a multi-component individual-/social-level workplace-based intervention to increase cycling among office staff at a multinational bank (HSBC UK). To do this, we first explored barriers to cycling in a nationally-representative survey of UK adults, then undertook focus groups with bank employees to understand any context-specific barriers and ways in which these might be overcome. These activities led to identification of 10 individual-level, two social-level, and five organizational-level modifiable factors, which were mapped to candidate intervention components previously identified in a scoping review of cycling initiatives. Interviews with HSBC UK managers then explored the practicality of implementing the candidate intervention components in bank offices. The resultant pilot CNP intervention included 32 core components across six intervention functions (education, persuasion, incentivisation, training, environmental restructuring, enablement). Participants received a loan bike for 12-weeks (or their own bike serviced), and a 9-week cycle training course (condensed to 6 weeks for those already confident in basic cycling skills), including interactive information sharing activities, behavior change techniques (e.g., weekly goal setting), bike maintenance training, practical off-road cycling skill games and on-road group rides. Sessions were delivered by trained bank staff members who were experienced cyclists. The CNP pilot intervention was delivered across three sites with 68 participants. It was completed in two sites (the third site was stopped due to COVID-19) and was feasible and acceptable to both women and men and across different ethnicities. In addition, the CNP intervention was successful (at least in the short term) in increasing cycling by 3 rides/week on average, and improving perceptions of safety, vitality, confidence, and motivation to cycle. Following minor modifications, the long-term effectiveness and cost-effectiveness of the CNP intervention should be tested in a full-scale randomized controlled trial.

Mortality in Recreational Mountain-Biking in the Austrian Alps: A Retrospective Study over 16 Years

Despite recreational mountain-biking's growing popularity worldwide, the literature on mortality in this leisure sporting activity is scarce. Therefore, the aim of the present study was to investigate the characteristics of fatal accidents as well as resulting dead victims during recreational mountain-biking in the Austrian Alps over the past 16 years. For this purpose, a retrospective study based on Austrian institutional documentation from 2006 to 2021 was conducted. In total, 97 fatalities (1 woman) with a mean age of 55.6 ± 13.9 years were recorded by the Austrian Alpine Police. Of those, 54.6% died due to a non-traumatic (mostly cardio-vascular) and 41.2% due to a traumatic event. Mountain-bikers fatally accidented for non-traumatic reasons frequently belonged to older age classes (p = 0.05) and mostly (73.6%) died during the ascent, whereas traumatic events mainly (70.0%) happened during the descent (p < 0.001). Throughout the examined period, the absolute number of fatalities slightly increased, whereas the mortality index (proportion of deaths/accidented victims) did not (mean value: 1.34 ± 0.56%). Factors such as male sex in general, above average age and uphill riding for non-traumatic accidents, as well as downhill riding for traumatic events, seem to be associated with fatalities during recreational mountain-biking in the Austrian Alps. These results should be considered for future preventive strategies in recreational mountain-biking.

Active commuting, commuting modes, and the risk of diabetes: 14-year follow-up data from the Hisayama Study

Aims/Introduction

We aimed to investigate the association of active commuting (cycling or walking to work), as well as the association of the individual commuting modes, with the risk of diabetes in a prospective cohort of community‐dwelling adults in Japan.

Material and Methods

A total of 1,270 residents aged 40–79 years were followed up for a median of 14 years. Active commuting was defined as either cycling or walking to work. A Cox proportional hazards model was used to examine the association of active commuting with the risk of diabetes. Associations for different forms of active commuting (cycling, walking and mixed modes of cycling or walking with non‐active components) were also examined.

Results

During the follow‐up period, 191 participants developed diabetes. Active commuting was associated with a lower risk of diabetes than non‐active commuting after adjustment for potential confounders (hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.31–0.92). With regard to the commuting modes, the risk of diabetes was significantly lower in individuals who commuted by cycling alone (HR 0.46, 95% CI 0.22–0.98), and tended to be lower in individuals who commuted by walking alone (HR 0.14, 95% CI 0.02–1.02) compared with that in individuals with non‐active commuting. Meanwhile, no significant associations were observed for the mixed mode of walking and non‐active commuting (HR 1.69, 95% CI 0.77–3.71).

Conclusions

Active commuting, particularly that consisting exclusively of cycling or walking, was associated with a reduced risk of diabetes. Our findings support a public health policy that promotes the choice of active commuting for the prevention of diabetes.

High-Intensity Interval Training Improves Cardiac Autonomic Function in Patients with Type 2 Diabetes: A Randomized Controlled Trial

Different exercise models have been used in patients with type 2 diabetes mellitus (T2D), like moderate intensity continuous training (MICT) and high intensity interval training (HIIT); however, their effects on autonomic modulation are unknown. The present study aimed to compare the effects of different exercise modes on autonomic modulation in patients with T2D. In total, 44 adults with >5 years of T2D diagnosis were recruited and stratified into three groups: HIIT-30:30 (n = 15, age 59.13 ± 5.57 years) that performed 20 repetitions of 30 s at 100% of VO2peak with passive recovery, HIIT-2:2 (n = 14, age 61.20 ± 2.88) that performed 5 repetitions of 2 min at 100% of VO2peak with passive recovery, and MICT (n = 15, age 58.50 ± 5.26) that performed 14 min of continuous exercise at 70% of VO2peak. All participants underwent anamnesis and evaluation of cardiorespiratory fitness and cardiac autonomic modulation. All protocols were equated by total distance and were performed two times per week for 8 weeks. Group × time interactions were observed for resting heart rate (HRrest) [F(2.82) = 3.641; p = 0.031] and SDNN [F(2.82) = 3.462; p = 0.036]. Only the HIIT-30:30 group significantly reduced SDNN (p = 0.002 and 0.025, respectively). HRrest reduced more in the HIIT-30:30 group compared with the MICT group (p = 0.038). Group × time interactions were also observed for offTAU [F(2.82) = 3.146; p = 0.048] and offTMR [F(2.82) = 4.424; p = 0.015]. The MICT group presented increased values of offTAU compared with the HIIT-30:30 and HIIT-2:2 groups (p = 0.001 and 0.013, respectively), representing a slower HR response after eight weeks of intervention. HIIT, specially HIIT-30:30, represents a promising measure for improving autonomic modulation in patients with T2D.

National Trends in Cycling in Light of the Norwegian Bike Traffic Index

National and international strategies and recommendations are intended to increase physical activity in the general population. Active transportation is included in interdisciplinary strategies to meet these recommendations. Cycling seems to be more health enhancing than walking for transportation since cycling seems to reduce the risk of cardiovascular disease and associated risk factors. Furthermore, the health benefits of cycling are proven to outrun the risk of injuries and mortality. Politicians seem to approve costly infrastructure strategies to increase the amount of cycling in the population to improve public health and shift to more sustainable travel habits. A linear relationship between cycle-friendly infrastructure and the amount of commuter cycling has been demonstrated. However, in Norway and on a global level, there is a lack of robust evaluations of actions and sensitive monitoring systems to observe possible change. Therefore, we aimed to develop the Norwegian bike traffic index and describe the national, regional, and local trends in counted cycle trips. We used a transparent methodology so that the index can be used, developed, and adapted in other countries. We included 89 stationary counters from the whole country. Counters monitored cycling from 2018 onward. The index is organized at local, regional, and national levels. Furthermore, the index is adjusted for population density at the counter level and presented as ratio of counted cycle trips, comparing 2018 to subsequent years. The index is presented as a percentage change with 95% confidence intervals. In Norway, counted cycle trips increased by 11% from 2018 (100, 100-100) to 2020 (111.0, 106.2-115.1), with large geographical differences. In Southern Norway, there was a significant increase of 23%, and in Northern Norway, there was a nonsignificant decrease by 8% from 2018 to 2020. The indices may indicate possible related effects of local to national cycling strategies and how the COVID-19 pandemic has affected Norwegian travel habits in urban areas.

Are Latin American cycling commuters "at risk"? A comparative study on cycling patterns, behaviors, and crashes with non-commuter cyclists

INTRODUCTION

As part of the transformation of urban transportation dynamics, commuter cycling has acquired a high relevance as an alternative mode of transport in different countries, and Latin America seems to be one of the main focus of this worldwide "revolution". However, the high rates of crashes and injuries suffered by commuters have become a relevant issue in the field of road safety, especially in emerging regions with low cycling tradition, where social and infrastructural gaps may endanger the cyclists' safety.

OBJECTIVES

This study had two objectives. First, to compare key safe cycling-related variables between cycling commuters and non-commuters; and second, to differentially asses the effect of individual and cycling-related variables on their self-reported crash rates.

METHOD

For this cross-sectional research, the data provided by 577 Latin American urban cyclists from three countries (Argentina, Colombia and Mexico) with a mean age of 32.7 years was used. They answered a questionnaire on cycling habits, risk perception, rule knowledge, cycling behaviors and riding crashes.

RESULTS

The outcomes of this study showed that, despite having a higher risk perception, cycling commuters perform deliberate risky cycling behaviors (traffic violations) more frequently, and they suffer more crashes; cycling commuters report higher rates of psychological distress, and a lower degree of rule knowledge and protective behaviors than non-commuters. Furthermore, structural similarities and differences in the explanation of cycling crashes were found across commuters and non-commuters.

CONCLUSION

The results of this study suggest that non-commuters, whose purposes for cycling are more aimed at leisure and occasional trips, perform less risky behaviors but suffer more cycling distractions, whereas commuters are comparatively more exposed to behavioral-based safety risks, and suffer more frequent crashes. Since recent evidence forecasts that urban cycling will keep growing in Latin American cities, it is necessary to implement policies and educational/training improvements that may enhance the safety and health of cyclists in these countries.

What Policies Address Both the Coronavirus Crisis and the Climate Crisis?

The coronavirus pandemic has led many countries to initiate unprecedented economic recovery packages. Policymakers tackling the coronavirus crisis have also been encouraged to prioritize policies which help mitigate a second, looming crisis: climate change. We identify and analyze policies that combat both the coronavirus crisis and the climate crisis. We analyze both the long-run climate impacts from coronavirus-related economic recovery policies, and the impacts of long-run climate policies on economic recovery and public health post-recession. We base our analysis on data on emissions, employment and corona-related layoffs across sectors, and on previous research. We show that, among climate policies, labor-intensive green infrastructure projects, planting trees, and in particular pricing carbon coupled with reduced labor taxation boost economic recovery. Among coronavirus policies, aiding services sectors (leisure services such as restaurants and culture, or professional services such as technology), education and the healthcare sector appear most promising, being labor intensive yet low-emission-if such sectoral aid is conditioned on being directed towards employment and on low-carbon supply chains. Large-scale green infrastructure projects and green R&D investment, while good for the climate, are unlikely to generate enough employment to effectively alleviate the coronavirus crisis.

The Association Between Pelvic Discomfort and Erectile Dysfunction in Adult Male Bicyclists

BACKGROUND

Bicycle riding's impact on erectile function remains a topic of great interest given cycling's popularity as a mode of transportation and exercise.

AIM

We evaluated risk factors for sexual dysfunction in male cyclists with the primary intention of determining if genital/pelvic pain and numbness are associated with erectile dysfunction (ED).

METHODS

We surveyed male cyclists using an online anonymous questionnaire. Cyclists were queried on their demographics, cycling experience, and sexual function using the Sexual Health Inventory for Men (SHIM). ED was diagnosed when a completed SHIM score was <22. Regression analysis was used to evaluate the risk of ED in men with genital/pelvic pain or numbness after riding. The survey was designed in the United States.

OUTCOMES

Quantitative characterization of cycling habits, onset and timing of genital pain and numbness, and SHIM score.

RESULTS

A total of 1635 participants completed the survey. A majority of men were over the age of 50 (58%, 934/1,607), Caucasian (88%, 1,437/1,635), had been active cyclists for over 10 years (63%, 1,025/1,635) and used road bikes (97%, 1,578/1,635). Overall, 22%, 30%, and 57% of men reported ED, genital pain, and genital numbness, respectively. While controlling for cohort demographics, body mass index, cycling intensity and equipment, and medical comorbidities, no saddle characteristics were associated with the risk of developing genital numbness. However, men reporting penile numbness were at higher risk of reporting ED (odds ratio [OR] = 1.453, P = .048). In addition, quicker onset of numbness and resolution of numbness within a day was associated with impaired erectile function. For example, numbness occurring less than 1 hour after cycling had greater odds of leading to ED than numbness after 5 hours (OR = 2.002, P = .032). Similarly, genital pain occurring less than 1 hour (OR = 2.466, P = .031) after cycling was associated with higher ED risk.

STRENGTHS & LIMITATIONS

Strengths include a large sample size of high-intensity cyclists and validated questionnaire use. Limitations include reliance on anonymous self-reported survey data and minimal inquiry into the riding preferences and terrain traversed by cyclists.

CONCLUSIONS

Pelvic pain and numbness are common complaints among male riders in the United States. Men with such complaints are more likely to also report ED especially if it occurs earlier in the ride. Although direction of causality and temporality are uncertain, alleviation of factors resulting in pelvic discomfort may reduce cycling's impact on sexual function. Such interventions are critical given that cycling for both active travel and aerobic exercise confers numerous health benefits. Balasubramanian A, Yu J, Breyer BN, et al. The Association Between Pelvic Discomfort and Erectile Dysfunction in Adult Male Bicyclists. J Sex Med 2020;17:919-929.

Effectiveness of Lilly Connected Care Program (LCCP) App-Based Diabetes Education for Patients With Type 2 Diabetes Treated With Insulin: Retrospective Real-World Study

Background

Diabetes poses heavy economic and social burdens worldwide. Mobile apps show great potential for diabetes self-management education. However, there is limited evidence for the effectiveness of providing general diabetes education through mobile apps.

Objective

The aim of this study was to clarify the effectiveness of Lilly Connected Care Program (LCCP) app-based diabetes education for glycemic control.

Methods

This retrospective cohort study included patients with diabetes recruited to the LCCP platform from September 1, 2018, to May 31, 2019. Each patient was followed for 12 weeks. According to the number of diabetes education courses they had completed, the patients were divided into the following three groups: group A (0-4 courses), group B (5-29 courses), and group C (≥30 courses). The main outcomes were the change in blood glucose at the 12th week compared with baseline and the differences in blood glucose at the 12th week among the three groups. The associations of the number of diabetes education courses completed with the average blood glucose and frequency of self-monitoring of blood glucose (SMBG) at the 12th week were assessed by multivariate linear regression analyses controlling for other confounding covariates. Univariate and multivariate linear regression analyses were used to assess factors influencing patients’ engagement in the diabetes education courses.

Results

A total of 5011 participants were enrolled. Their mean fasting blood glucose (FBG) and postprandial blood glucose (PBG) were significantly lower at the 12th week than at baseline (FBG, 7.46 [standard deviation (SD) 1.95] vs 7.79 [SD 2.18] mmol/L, P<.001; PBG, 8.94 [SD 2.74] vs 9.53 [SD 2.81] mmol/L, P<.001). The groups that completed more diabetes education courses had lower FBG (group B, β=−0.14, 95% CI −0.26 to −0.03; group C, β=−0.29, 95% CI −0.41 to −0.16; P for trend <.001) and PBG (group B, β=−0.29, 95% CI −0.46 to −0.11; group C, β=−0.47, 95% CI −0.66 to −0.28; P for trend <.001) and a higher frequency of SMBG at the 12th week (group B, β=1.17, 95% CI 0.81-1.53; group C, β=4.21, 95% CI 3.81-4.62; P for trend <.001) when compared with the findings in group A. Age and education were related to patients’ engagement in the diabetes education courses. Middle-aged patients (35-59 years old) and elderly patients (≥60 years old) completed more diabetes education courses (middle-aged group, β=2.22, P=.01; elderly group, β=2.42, P=.02) than young patients (18-34 years old).

Conclusions

LCCP app-based diabetes education is effective for glycemic control and SMBG behavior improvement in patients with type 2 diabetes receiving insulin therapy. Young patients’ engagement in the education courses was relatively low. We need to conduct in-depth interviews with users to further improve the curriculum.

Does Environmental Walkability Matter? The Role of Walkable Environment in Active Commuting

Since walkability plays an important role in active commuting, several cities are actively promoting its integration into urban and environmental planning policies. This study examined the association between walkability and active commuting in Seoul, Korea. A multilevel logistic regression model was used to examine the correlation between Walkability Score and the probability of active commuting after controlling for individual variables. The analysis used 129,044 individual samples nested within 424 administrative districts (dongs). In this study, three models were tested: Model 1 contained only individual variables, Model 2 contained individual variables and Walkability Score, and Model 3 included neighborhood-level variables in addition to the variables of Model 2. The results showed that the Walkability Score was significantly correlated with the odds of active commuting. Specifically, every additional one-point increase in Walkability Score was associated with 0.3% higher odds of active commuting (Model 2: odds ratio (OR) = 1.003, 95% confidence interval (CI) = 1.001-1.005; Model 3: OR = 1.003, 95% CI = 1.001-1.006). Additionally, public transportation density was also positively correlated with the odds of active commuting. The odds of active commuting were positively correlated with younger age, female, lower-income, and having no car. Based on the findings, policy recommendations in urban planning and design, transport engineering, and environmental planning are provided.

A systematic review of the effect of infrastructural interventions to promote cycling: strengthening causal inference from observational data

Background

Previous reviews have suggested that infrastructural interventions can be effective in promoting cycling. Given inherent methodological complexities in the evaluation of such changes, it is important to understand whether study results obtained depend on the study design and methods used, and to describe the implications of the methods used for causality. The aims of this systematic review were to summarize the effects obtained in studies that used a wide range of study designs to assess the effects of infrastructural interventions on cycling and physical activity, and whether the effects varied by study design, data collection methods, or statistical approaches.

Methods

Six databases were searched for studies that evaluated infrastructural interventions to promote cycling in adult populations, such as the opening of cycling lanes, or the expansion of a city-wide cycling network. Controlled and uncontrolled studies that presented data before and after the intervention were included. No language or date restrictions were applied. Data was extracted for any outcome presented (e.g. bikes counted on the new infrastructure, making a bike trip, cycling frequency, cycling duration), and for any purpose of cycling (e.g. total cycling, recreational cycling, cycling for commuting). Data for physical activity outcomes and equity effects was extracted, and quality assessment was conducted following previous methodologies and the UK Medical Research Council guidance on natural experiments. The PROGRESS-Plus framework was used to describe the impact on subgroups of the population.

Studies were categorized by outcome, i.e. changes in cycling behavior, or usage of the cycling infrastructure. The relative change was calculated to derive a common outcome across various metrics and cycling purposes. The median relative change was presented to evaluate whether effects differed by methodological aspects.

Results

The review included 31 studies and all were conducted within urban areas in high-income countries. Most of the evaluations found changes in favor of the intervention, showing that the number of cyclists using the facilities increased (median relative change compared to baseline: 62%; range: 4 to 438%), and to a lesser extent that cycling behavior increased (median relative change compared to baseline: 22%; range: − 21 to 262%). Studies that tested for statistical significance and studies that used subjective measurement methods (such as surveys and direct observations of cyclists) found larger changes than those that did not perform statistical tests, and those that used objective measurement methods (such as GPS and accelerometers, and automatic counting stations). Seven studies provided information on changes of physical activity behaviors, and findings were mixed. Three studies tested for equity effects following the opening of cycling infrastructure.

Conclusions

Study findings of natural experiments evaluating infrastructural interventions to promote cycling depended on the methods used and the approach to analysis. Studies measuring cycling behavior were more likely to assess actual behavioral change that is most relevant for population health, as compared to studies that measured the use of cycling infrastructure. Triangulation of methods is warranted to overcome potential issues that one may encounter when evaluating environmental changes within the built environment.

Trial registration

The protocol of this study was registered at PROSPERO (CRD42018091079).

Correlates of Commuter Cycling in Three Norwegian Counties

Globally, there is an increasing challenge of physical inactivity and associated diseases. Commuter cycling is an everyday physical activity with great potential to increase the health status in a population. We aimed to evaluate the association of self-reported factors and objectively measured environmental factors in residence and along commuter routes and assessed the probability of being a commuter cyclist in Norway. Our study included respondents from a web-based survey in three Norwegian counties and we used a Geographic Information Systems (GIS) to evaluate the natural and built environment. Of the 1196 respondents, 488 were classified as commuter cyclists. Self-reported factors as having access to an e-bike (OR 5.99 [CI: 3.71–9.69]), being physically active (OR 2.56 [CI: 1.42–4.60]) and good self-rated health (OR 1.92 [CI: 1.20–3.07]) increased the probability of being a cyclist, while being overweight or obese (OR 0.71 [CI: 0.54–0.94]) reduced the probability. Environmental factors, such as high population density (OR 1.49 [CI: 1.05–2.12]) increased the probability, while higher slope (trend p = 0.020), total elevation along commuter route (trend p = 0.001), and >5 km between home and work (OR 0.17 [CI: 0.13–0.23]) decreased the probability of being a cyclist. In the present study, both self-reported and environmental factors were associated with being a cyclist. With the exception of being in good health, the characteristics of cyclists in Norway, a country with a low share of cyclists, seem to be similar to countries with a higher share of cyclists. With better knowledge about characteristics of cyclists, we may design better interventions and campaigns to increase the share of commuter cyclists.

A systematic review of the effect of infrastructural interventions to promote cycling: strengthening causal inference from observational data

BACKGROUND

Previous reviews have suggested that infrastructural interventions can be effective in promoting cycling. Given inherent methodological complexities in the evaluation of such changes, it is important to understand whether study results obtained depend on the study design and methods used, and to describe the implications of the methods used for causality. The aims of this systematic review were to summarize the effects obtained in studies that used a wide range of study designs to assess the effects of infrastructural interventions on cycling and physical activity, and whether the effects varied by study design, data collection methods, or statistical approaches.

METHODS

Six databases were searched for studies that evaluated infrastructural interventions to promote cycling in adult populations, such as the opening of cycling lanes, or the expansion of a city-wide cycling network. Controlled and uncontrolled studies that presented data before and after the intervention were included. No language or date restrictions were applied. Data was extracted for any outcome presented (e.g. bikes counted on the new infrastructure, making a bike trip, cycling frequency, cycling duration), and for any purpose of cycling (e.g. total cycling, recreational cycling, cycling for commuting). Data for physical activity outcomes and equity effects was extracted, and quality assessment was conducted following previous methodologies and the UK Medical Research Council guidance on natural experiments. The PROGRESS-Plus framework was used to describe the impact on subgroups of the population. Studies were categorized by outcome, i.e. changes in cycling behavior, or usage of the cycling infrastructure. The relative change was calculated to derive a common outcome across various metrics and cycling purposes. The median relative change was presented to evaluate whether effects differed by methodological aspects.

RESULTS

The review included 31 studies and all were conducted within urban areas in high-income countries. Most of the evaluations found changes in favor of the intervention, showing that the number of cyclists using the facilities increased (median relative change compared to baseline: 62%; range: 4 to 438%), and to a lesser extent that cycling behavior increased (median relative change compared to baseline: 22%; range: - 21 to 262%). Studies that tested for statistical significance and studies that used subjective measurement methods (such as surveys and direct observations of cyclists) found larger changes than those that did not perform statistical tests, and those that used objective measurement methods (such as GPS and accelerometers, and automatic counting stations). Seven studies provided information on changes of physical activity behaviors, and findings were mixed. Three studies tested for equity effects following the opening of cycling infrastructure.

CONCLUSIONS

Study findings of natural experiments evaluating infrastructural interventions to promote cycling depended on the methods used and the approach to analysis. Studies measuring cycling behavior were more likely to assess actual behavioral change that is most relevant for population health, as compared to studies that measured the use of cycling infrastructure. Triangulation of methods is warranted to overcome potential issues that one may encounter when evaluating environmental changes within the built environment.

TRIAL REGISTRATION

The protocol of this study was registered at PROSPERO (CRD42018091079).

Time spent cycling, walking, running, standing and sedentary: a cross-sectional analysis of accelerometer-data from 1670 adults in the Copenhagen City Heart Study : Physical behaviours among 1670 Copenhageners

Background

Information about how much time adults spend cycling, walking and running can be used for planning and evaluating initiatives for active, healthy societies. The objectives of this study were to describe how much time adult Copenhageners cycle, walk, run, stand and spend sedentary using accelerometers, and to describe differences between population groups.

Methods

In the fifth examination of the Copenhagen City Heart Study, 2335 individuals gave consent to wear accelerometers (skin-attached; right thigh and iliac crest; 24 h/day, 7 consecutive days) of which 1670 fulfilled our inclusion criteria (≥16 h/day for ≥5 days; median wear time: 23.8 h/day). Daily time spent cycling, walking, running, standing and sedentary was derived from accelerometer-based data using the Acti4 software, and differences between sex, age groups, level of education and BMI were investigated using Kruskal-Wallis rank sum tests.

Results

Among those cycling (61%), the median cycling time was 8.3 min/day. The median time walking, running, standing and sedentary was 82.6, 0.1, 182.5 and 579.1 min/day, respectively. About 88% walked fast (i.e., ≥100 steps/min) ≥30 min/day. The shortest duration and lowest prevalence of cycling, walking and running were found among older individuals, those with a low level of education, and individuals being overweight or obese.

Conclusions

We found a long duration and high prevalence of cycling and walking, but also that many adult Copenhageners spent much time sedentary. Population groups with low participation in physical activities such as cycling and walking should be targeted in future initiatives towards an active, healthy society.

Well-being, behavioral patterns and cycling crashes of different age groups in Latin America: Are aging adults the safest cyclists?

Objectives

This study aimed at analyzing the cycling safety-related factors and the mental health indicators of elderly cyclists in comparison with other age groups.

Methods

For this cross-sectional study, we analyzed the data of 911 bicyclists from two Latin American countries that have been experiencing a substantial growth of urban cycling during the last few years: Colombia and Argentina. Participants responded to an e-questionnaire on bicycling behaviors, mental health and cycling safety.

Results

Aging adults reported lower rates of risky behaviors and traffic crashes (around .38 in five years), and, on the other hand, more cycling protective behaviors, a higher risk perception and a better knowledge of traffic norms than both other adults (26–50 years old) and young cyclists (<26). Cycling behaviors and crashes were found to be significantly related to mental health indicators, the latter being higher in aging cyclists. However, this population remains more prone to distractions experienced while cycling than other age groups.

Conclusions

Although the behavioral features of aging adults were comparatively “safer” than the ones displayed by other age groups, factors such as cycling distractions and this population’s over-representation in traffic crashes suggest the need of enforcing policymaking for a better integration of this age segment in alternative transportation dynamics.

Changes in Cycling and Incidence of Overweight and Obesity among Danish Men and Women

PURPOSE

Overweight and obesity are associated with increased risk of several noncommunicable diseases and are a growing public health issue. The primary purpose of the current study was to investigate incidence of overweight and obesity according to 5-yr cycling habits. The secondary purpose was to investigate incidence of remission from overweight and obesity according to 5-yr cycling habits.

METHODS

We analyzed 9014 men and 8661 women without chronic disease who between 1993 and 2003 completed two assessments approximately 5 yr apart. At both assessments, participants reported habitual cycling habits. Also, body weight and waist circumference were measured by a laboratory technician at baseline and self-assessed at second examination. We computed multivariable adjusted odds ratios (OR) with 95% confidence intervals (CI) for development of and remission from abdominal and general overweight and obesity, according to 5-yr cycling habits.

RESULTS

Continued cycling was associated with lower odds for incidence of abdominal (men, >102 cm; women, >88 cm) and incidence of general (body mass index ≥30 kg·m) obesity; compared with no cycling, OR (95% CI) values were 0.82 (0.74-0.91) and 0.74 (0.60-0.92) for abdominal and general obesity, respectively. Also, those who initiated cycling had lower odds for incidence of abdominal obesity; OR (95% CI) was 0.85 (0.73-1.00) relative to no cycling. Although we found no evidence of remission from abdominal and general overweight and obesity according to 5-yr cycling habits, those who continued cycling had significantly larger decreases in waist circumference relative to noncyclists (β coefficient (95% CI), -0.95 cm (-1.56 to -0.33 cm)).

CONCLUSIONS

Continued cycling compared with no cycling was associated with lower odds for abdominal and general obesity. Also, late-in-life initiation of cycling was associated with lower odds for abdominal obesity relative to no cycling.

Passive Commuting and Higher Sedentary Time Is Associated with Vitamin D Deficiency in Adult and Older Women: Results from Chilean National Health Survey 2016⁻2017

The aim was to investigate the associations between different physical activity (PA) patterns and sedentary time (ST) with vitamin D deficiency (<12 ng/mL) in a large sample of Chilean women. In this cross-sectional study, the final sample included 1245 adult and 686 older women. The PA levels, mode of commuting, ST, and leisure-time PA were self-reported. Vitamin D deficiency was defined as <12 ng/mL and insufficiency as <20 ng/mL. A higher ST was associated with vitamin D deficiency (odds ratio (OR): 2.4, 95%: 1.6⁻4.3) in adults, and passive commuting was associated with vitamin D deficiency in older (OR: 1.7, 95%: 1.1⁻2.7). Additionally, we found a joint association in the high ST/passive commuting group in adults (OR: 2.8, 95%: 1.6⁻4.9) and older (OR: 2.8, 95%: 1.5⁻5.2) with vitamin D deficiency, in respect to low ST/active commuting. The PA levels and leisure-time PA were not associated with vitamin D deficiency. In conclusion, mode of commuting and ST seems important variables related to vitamin D deficiency. Promoting a healthy lifestyle appears important also for vitamin D levels in adult and older women. Further studies are needed to establish causality of this association and the effect of vitamin D deficiency in different diseases in this population.

Active Commuting Behaviours from High School to University in Chile: A Retrospective Study

Objective: To compare the differences in the modes and distance of the displacements in high school and university stage in the same sample. Methods: A total of 1288 volunteer university students (614 males and 674 females) participated, with an average age of 22.7 ± 5.8 years, belonging to four private and public universities in Chile where a validated self-report questionnaire was applied to the study, which included the modes, travel time, and distance at school and university. Results: The active commuting decreases from school to university when leaving home (males: 39.6% to 34.0%; p = 0.033 and females: 32.9% to 18.5%, p < 0.001), as well as when returning (males: 44.1% to 33.7%; p < 0.001 and females: 38.6% to 17.6%, p < 0.001). Conversely, non-active modes of transport increase, especially in females (go: 67.1% to 81.4%, return: 61.5% to 82.6%), affected by the increase in the use of public transportation in university. It was also defined that at both school and at university, the active commuting decreases the greater the distance travelled. Conclusion: The active modes of commuting decreased between high school and university and the non-active mode of commuting was the most frequent form of mobility to high school and university, observing that the active trips decreased when the distance from the home to high school or university increased. Public and private intervention policies and strategies are required to maintain or increase the modes of active commuting in the university stage for an active life in adulthood.

Communicating the benefits of population health interventions: The health effects can be on par with those of medication

How can we communicate to the public that population level health interventions are effective at improving health? Perhaps the most familiar "currency" of effect is that which can be brought about via medication. Comparisons of effect sizes may be effective ways of communicating the benefits of population health interventions if they are seen and understood in the same way that medications are. We developed a series of comparisons to communicate benefits of population health interventions in terms of similar gains to be obtained from statins, metformin and antihypertensive medications for prevention of cardiovascular events, type 2 diabetes, obesity and hypertension. A purposive search identified evidence of population health intervention-related benefits. This evidence ranged from meta-analyses of RCTs to that from observational cohort studies. Population health interventions included implementation of national smoke free legislation, enhanced neighbourhood walkability, increased opportunities for active travel and protection of urban green space. In some cases, the benefits of population health interventions were found to be equivalent to, or even outweighed those of the medications to which they were compared. For example, RCT-based evidence suggested that exercise taken with a view of a green space was associated with 12 mmHg and 6 mmHg reductions in systolic and diastolic blood pressure, respectively, which was at least on par with the reductions associated with antihypertensive medications. Future work will test the effectiveness of these comparisons for increasing the familiarity, credibility and acceptability of population health interventions and, in particular, examine the importance of communicating putative mechanisms and potential co-benefits.

Sex differences and risk factors for diabetes mellitus - an international study from 193 countries

Background

Increases in overweight and obesity among youths have resulted in the diagnosis of Type 2 diabetes mellitus (T2DM) at earlier ages. The impact of lifestyle-related factors has been implicated; however, its relation to morbidity and mortality and sex differences remain unclear. We aimed to document the changes in risk factors and sex differences associated with T2DM-related morbidity and mortality during 1995–2015.

Method

We used mortality rates and morbidity estimates from the Global Burden of Diseases Study 2016 using Disability-Adjusted Life Years (DALY). Multiple linear regression analyses were used to determine associations between T2DM-related mortality and related risk factors. DALYs were grouped by country income level, and were stratified by sex.

Results

Increases in mortality were observed for both sexes, and females tended to have higher mortality rates per 100,000 persons. Body mass index (BMI) continued to be the leading risk factor for T2DM-related mortality, and increases in BMI were more common in low- and middle-income countries (LIC and MIC). Low physical activity was strongly associated with mortality rates, followed by dietary risks and smoking (2.4; 1.4; 0.8 per 100,000 persons, respectively). Similar patterns were observed after adjustments for income level, sex, and age. DALYs continued to show increasing trends across all income levels during 1995–2015 (high-income (HIC):16%; MIC: 36%; LIC: 12%). Stratification by sex showed similar results; males had fewer T2DM DALYs than females, though a greater increase was observed among males.

Conclusion

Overall, T2DM related mortality was higher among females. Compared to in HIC, there appeared to be a considerable increase in the burden of T2DM in MIC and LIC, where BMI is the leading risk factor for T2DM-related mortality. Prevention programs should emphasize related risk factors according to the existing standard of care.

Bicycling participation in people with a lower limb amputation: a scoping review

BACKGROUND

To review literature on bicycling participation, as well as facilitators and barriers for bicycling in people with a lower limb amputation (LLA).

METHODS

Peer-reviewed, primary, full text, studies about bicycling in people with a LLA from midfoot level to hemipelvectomy were searched in Pubmed, Embase, Cinahl, Cochrane library, and Sportdiscus. No language or publication date restrictions were applied. Included full-text studies were assessed for methodological quality using the Effective Public Health Practice Project tool. Data were extracted, synthesized and reported following Preferred Reporting Items for Systematic Review.

RESULTS

In total, 3144 papers were identified and 14 studies were included. The methodological quality of 13 studies was weak and 1 was moderate. Bicycling participation ranged from 4 to 48%. A shorter time span after LLA and a distal amputation were associated with a higher bicycling participation rate particularly for transportation. In people with a transtibial amputation, a correct prosthetic foot or crank length can reduce pedalling asymmetry during high-intensity bicycling. People with limitations in knee range of motion or skin abrasion can use a hinged crank arm or a low profile prosthetic socket respectively.

CONCLUSION

People with a LLA bicycled for transportation, recreation, sport and physical activity. Adaptation of prosthetic socket, pylon and foot as well as bicycle crank can affect pedalling work and force, range of motion, and aerodynamic drag. Because the suggestions from this review were drawn from evidences mostly associated to competition, prosthetists should carefully adapt the existing knowledge to clients who are recreational bicyclists.

Associations Between Changes in Cycling and All-Cause Mortality Risk

INTRODUCTION

Previous cohort studies have reported relationships of active commuting, walking, and cycling with mortality. No studies have separately examined commuter and recreational cycling and how changes in cycling are related to mortality.

METHODS

Prospective cohort study among individuals who were between 50 and 65years and living in Denmark at the baseline examination between 1993 and 1997. Commuter/recreational cycling and changes in cycling were investigated in analytic samples of 28,204 and 15,272 participants, respectively. Participants were asked to provide information on cycling habits and other risk factors for mortality at baseline and 5years later and were followed for risk of death until July 2013. Data were analyzed in 2018.

RESULTS

Cycling between 1 and 60 minutes per week was associated with lower risk of all-cause mortality, with an appertaining multivariable adjusted hazard ratio of 0.76 (95% CI=0.69, 0.83) for recreational cycling and 0.78 (95% CI=0.63, 0.96) for commuter cycling when compared with no cycling. Compared with those who never cycled, the hazard ratio for those who initiated cycling was 0.78 (95% CI=0.67, 0.90) and the hazard ratio for those who consistently cycled was 0.77 (95% CI=0.71, 0.84), whereas the hazard ratio for those who stopped cycling was 0.98 (95% CI=0.87, 1.11).

CONCLUSIONS

Initiation of, or continued engagement in, cycling late in mid-life is associated with a lower risk of all-cause mortality. It may be suggested that national and local governments prioritize resources to promote cycling.

Effect of Cycling on Glycaemia, Blood Pressure, and Weight in Young Individuals with Type 2 Diabetes

INTRODUCTION

Aerobic exercise is associated with significant improvement in glycaemia and weight loss in Type 2 diabetes (T2D). Cycling, a form of aerobic exercise can benefit young (18 to <40 years) individuals with T2D.

AIM

To assess effect of cycling on glycosylated haemoglobin (HbA1c), blood pressure (BP) and weight over six months in young individuals with T2D.

MATERIALS AND METHODS

In this retrospective, observational study, young (18 to <40 years) T2D patients who were being treated without insulin and not on more than two Oral Antidiabetic Drugs (OADs) were identified from a group of cyclists in a metro city from Northern India. These individuals were involved in a regular exercise program (cycling 25 km/day for at least five days a week). Participants with consecutive six months of cycling were selected and those involved in other forms of exercise were excluded. From their medical records, participants' weight, BP, and HbA1c levels were noted at baseline (i.e., before the start) and post-six months of cycling program and evaluated with appropriate statistics.

RESULTS

From 26 cases identified with T2D, 20 participants were included in analysis. Mean age of participants was 35.6±2.6 years, five were <35 years and all of them were males. Cycling resulted in significant reduction in HbA1c% (mean change from baseline at six-month: -1.18, 95% Confidence Interval (CI) 1.12, 1.24; p<0.001). Besides, systolic (-5.2, 95% CI -3.7, -6.6; p<0.001) and diastolic (-3.1, 95% CI -1.7, -4.5; p<0.001) BP and weight (kg) (-5.0, 95% CI -4.41, -5.58; p<0.001) showed significant reduction from baseline to six-months. Among two age groups (Age < 35 and ≥ 35 years), except for reduction of diastolic BP in age < 35 years, significant reduction in all other parameters was evident in both age groups.

CONCLUSION

Regular aerobic exercise in cycling form results in significant reduction in HbA1c, BP and weight. It should be promoted as an ideal method for exercise in young T2D cases to derive maximum benefits and to improve adherence to lifestyle intervention.

Bicycling to Work and Primordial Prevention of Cardiovascular Risk: A Cohort Study Among Swedish Men and Women

BACKGROUND

Bicycling to work may be a viable approach for achieving physical activity that provides cardiovascular health benefits. In this study we investigated the relationship of bicycling to work with incidence of obesity, hypertension, hypertriglyceridemia, and impaired glucose tolerance across a decade of follow-up in middle-aged men and women.

METHODS AND RESULTS

We followed 23 732 Swedish men and women with a mean age of 43.5 years at baseline who attended a health examination twice during a 10-year period (1990-2011). In multivariable adjusted models we calculated the odds of incident obesity, hypertension, hypertriglyceridemia, and impaired glucose tolerance, comparing individuals who commuted to work by bicycle with those who used passive modes of transportation. We also examined the relationship of change in commuting mode with incidence of these clinical risk factors. Cycling to work at baseline was associated with lower odds of incident obesity (odds ratio [OR]=0.85, 95% CI 0.73-0.99), hypertension (OR=0.87, 95% CI 0.79-0.95), hypertriglyceridemia (OR=0.85, 95% CI 0.76-0.94), and impaired glucose tolerance (OR=0.88, 95% CI 0.80-0.96) compared with passive travel after adjusting for putative confounding factors. Participants who maintained or began bicycling to work during follow-up had lower odds of obesity (OR=0.61, 95% CI 0.50-0.73), hypertension (OR=0.89, 95% CI 0.80-0.98), hypertriglyceridemia (OR=0.80, 95% CI 0.70-0.90), and impaired glucose tolerance (OR=0.82, 95% CI 0.74-0.91) compared with participants not cycling to work at both times points or who switched from cycling to other modes of transport during follow-up.

CONCLUSIONS

These data suggest that commuting by bicycle to work is an important strategy for primordial prevention of clinical cardiovascular risk factors among middle-aged men and women.

Cycling and Diabetes Prevention: Practice-Based Evidence for Public Health Action

Panter and Ogilvie describe findings that link recreational and commuter cycling with reduced incidence of diabetes.