The relationship between active travel to school and health-related fitness in children and adolescents: a systematic review

Higher levels of physical activity are associated with superior physical, social and psychological health in young people. Physical activity is inversely related to overweight and obesity in youth [1, 2] and poor body composition in childhood is associated with an increased risk of coronary heart disease in adulthood [3]. While there has been debate about whether or not physical activity levels have declined in the last 30 years [4], evidence suggests that there has been a decline in active travel to school (ATS) among children and adolescents in many countries [5–7]. For example, data from the US National Personal Transportation Survey revealed that the number of students who walked or cycled to school decreased from 41% in 1969 to only 13% in 2001 [6].

ATS includes various modes of travel such as walking, cycling, and skateboarding, and has been identified as an important source of physical activity for young people [8]. Previous reviews [9–11] have examined the relationship between ATS, body composition and physical activity and reported strong evidence for a positive association between ATS and overall physical activity level, but little evidence linking ATS to leaner body composition. However, these reviews did not stratify their results or conclusions by study quality or risk of bias [12]. While previous reviews included studies that examined the relationship between ATS and cardiorespiratory fitness, the authors were unable to determine the association due to limited evidence. Since the publication of these reviews there has been an increase in the number of studies exploring this relationship.

It has been suggested that much of the activity completed by children and adolescents is of insufficient volume and intensity to improve health-related fitness (i.e., body composition, cardiorespiratory fitness, muscular fitness and flexibility) [13]. While the exact volume and intensity of activity required to improve fitness in young people is not clear [14], it is plausible to suggest that habitual ATS has the potential to improve health-related fitness (HRF) among youth. ATS provides a regular opportunity for young people to accumulate physical activity, but evidence to support or refute the health benefits of active transportation is limited due to the focus on assessing time spent in vigorous activity [8]. Furthermore, few studies have explored the effects of ATS on HRF among young people in longitudinal studies [15]. The aim of this review, therefore, was to systematically examine the potential health benefits associated with ATS among children and adolescents. The secondary aim was to explore the quality of studies that have examined the relationship between ATS and HRF and to determine whether study quality may have confounded these relationships.

The aim of this review was to systematically examine the potential health benefits associated with ATS among children and adolescents. Of the 27 studies that were included in the review, 25 examined the relationship between ATS and weight status/body composition. While only 48% of these studies reported significant inverse associations between ATS and weight status/body fatness, this increased to 55% once poor quality studies were removed. Based on the findings from five studies, including one longitudinal study, it appears that ATS may be associated with superior cardiorespiratory fitness in youth. It was not possible to draw any conclusions about the associations between ATS, muscular fitness and flexibility due to the small number of studies exploring these relationships.

Despite methodological differences, these results are similar to those of previous reviews [9, 10]. Two previous ATS and health reviews reached the same conclusion about a lack of association between body weight and ATS despite not assessing the quality of their included studies. The decision to use an assessment of study quality or risk of bias was both pragmatic and justified. The application of this metric allowed for the removal the studies with the greatest risk of bias. Faulkner and colleagues' review [10] reported just over half the studies included in this review (n = 10), that had examined associations between ATS and body weight. One explanation for this difference lies in the recent increase in ATS-related publication since their review's search date (06/2008). Their review not only focused on the relationship between ATS and overall physical activity, but also adopted inclusion criteria for studies for the assessment of physical activity using an objective measure (pedometer or accelerometer). Despite these differences, the findings of both reviews were consistent, concluding that there is little evidence to suggest an association between body weight and ATS.

Previous reviews that examined the relationship between ATS and cardiorespiratory fitness were unable to draw conclusions due to the small number of studies. However, evidence from a number of recent well designed studies suggests a positive association between ATS and cardiorespiratory fitness. One partial explanation for these positive associations may be the use of cycle ergometers to measure fitness in three of the five studies, which may have favored those children who cycled to school [15, 32, 33]. However, the two other studies that used running-based fitness assessments also observed differences in fitness between ATS and non ATS groups, with one significant [29] and one borderline nonsignificant [25] result. Furthermore, a recent study, not included in the current review, found that CRF levels were higher among young Swedish and Estonians adolescents who cycled to school compared to those who walked or used passive transportation methods [44]. There appears, therefore, to be some evidence supporting the observation that fitness is associated with ATS, but future studies must account for loss to follow-up and validated assessments of ATS to improve confidence in these observations.

Similar limitations to the overall quality of studies were observed, particularly in the definition and measurement of ATS. There were a range of definitions for classifying a participant as an active traveler. These definitions used different categories for frequency, duration and type of activity that counted as ATS. For example, studies often used questions about "usual mode of travel to and from school", and only 11 of the 27 studies reported an acceptable reliability of their methodology for ATS assessment in the sample population. Thus, standardized definition and measurement should be addressed in future studies, as active travel is a collection of behaviors that vary by purpose and duration [45], e.g. journey to and from school. The potential for misclassification of ATS was also reflected in the actual measurement of ATS mode, with no study reporting a validated measure of ATS by travel mode. With the advent of both portable global positioning system devices and digital image capture systems, the opportunity to improve this potential source of bias must be addressed. These new systems, which allow the confirmation of journey mode, duration and distance, are currently being evaluated in a number of international studies [46, 47]. Such systems would also address the issue of possible confounding or mediation of ATS behavior and health outcome by the built environment characteristics of study areas [48].

The majority of studies did not examine associations by population sub- groups, e.g. gender or age. Indeed, study populations were treated as homogeneous, being usually dichotomized into ATS v non-ATS groups. Such an approach is limited as it ignores the broader social, environmental and personal level correlates of behavior. Indeed, Panter and colleagues [48] highlighted the importance of facilities to assist active travel and urban design in the neighborhood, as well as shorter distances and road safety in-route in relation to active travel. A recent review of qualitative studies of children's experiences of active travel not only supported these observations, but also highlighted the importance of the constraining influence of parents' restrictions on independent movement, as well as children's own fears of traffic [49]. All these factors clearly have a major impact on children's ability to undertake ATS and may provide an explanation why some studies fail to report consistent associations [9, 10]. Only two studies reported power calculations in their methods sections. While the majority of the studies included large samples and were likely to have adequate power to detect hypothesized relationships, the reporting of power calculations should be considered by others in the future.

Body composition/weight status was measured in a variety of ways, with most studies employing BMI z-scores or percentiles to classify youth as healthy, overweight or obese. Two studies [21, 37] used parental proxy reports of their children's height and weight and both studies found no association between BMI and method of transportation to school. Alternatively, two studies [19, 30] used students' self-reported BMI and found significant associations between ATS and weight status. More consistency in using a more objective assessment of this exposure variable in future studies would help to establish the association in relation to ATS.

This is the first systematic review to report the relationship between ATS and HRF in youth. In addition, the assessment of study eligibility and quality was conducted independently by two authors and consensus was reached for every decision. However, the limitations of this review should be noted. First, the measurement and classification of ATS were different across studies, which may explain some of the inconsistencies found. Second, the quality assessment was not extensive and additional criteria may provide additional insights. Finally, the search strategy was limited to published studies identified through the selected search engines. As more studies continue to be published, it will be important to reconsider and refine these findings. Despite these shortcomings, it seems that the majority of higher quality studies reported consistent associations between ATS and the important health indexes of weight status/body composition and cardiorespiratory fitness. With such health benefits for children, the promotion of ATS provides a real opportunity for public health interventions to tackle the double challenge of obesity and poor fitness.

There is some evidence to suggest that active travel to school is associated with a healthier body composition and level of cardiorespiratory fitness among youth. However, as this review included only two longitudinal studies, more interventions and longitudinal studies exploring the relationship between changes in health-related fitness and active travel are needed to investigate the causal nature of such relationships. While it is important that researchers continue to monitor children and adolescents school transportation behaviours, there is a need to broaden the research on young people's active transport to include journeys to destinations other than school, e.g. walking/cycling trips from home to a variety of neighbourhood destinations. Distance to school has been identified as a barrier to active transportation [50] and public health strategies promoting active transportation to more proximal destinations are clearly warranted.