In Praise of Walking: An Antidote to Increasing Health Care Costs in the Elderly?

A burning political issue is what to do about the coverage of prescription drug costs for the 40 million Americans on Medicare. An increase in prescription drugs is the single most important factor underlying the increase of total health care costs that has been occurring in the past few years. From 1999–2000, drug expenditures rose by 18.8%, from $111 billion to $132 billion. ¹ More than one half of this increase was attributable to chronic diseases, which particularly afflict the elderly. These include high cholesterol, high blood pressure, diabetes, arthritis, and depression. Three factors contributed to this increase: more prescriptions written (up 42%); a shift from low‐ to high‐priced drugs (up 36%); and an increase in the price of individual drugs (up 22%). The greater number of prescriptions can, in turn, be explained by three factors: an increase in the population, with a shift to older people; more people being prescribed drugs; and more prescriptions per person.

The increase in prescription drug costs is likely to continue in the foreseeable future for several other reasons. We are living longer, and older people consume more prescription medicines than the young. We are also getting fatter, and obesity increases the risk of developing most of the chronic conditions for which older people take pills. The cluster of risk factors in the insulin resistance (metabolic) syndrome includes obesity, high blood pressure, high cholesterol, and diabetes—a potentially lethal combination, but also one that is largely the result of our sedentary lifestyles. While the death rate from heart disease has decreased steadily over the past 30 years, the incidence of new cases has not declined; what has happened is that people are living longer once it is diagnosed. ² Also, there has been a much smaller decline in mortality in people with diabetes, whose numbers are steadily increasing. An analysis of the National Health and Nutrition Examination Survey (NHANES) over a 10‐year period (from 1971–1975 and 1982–1984) found a reduction in mortality of 36% in nondiabetic men, but of only 13% in diabetic men. ³ In women, mortality declined by 27% in non‐diabetics, but actually increased by 23% in diabetics.

The focus in the debate on health care costs has been almost exclusively on limiting the supply, while at the same time demand is actively being fueled by direct advertising of prescription medicines to the consumer. Little attention has been given to reducing the demand, but what if there were a treatment that could cut the number of strokes and heart attacks by one third, prevent the onset of diabetes, and at the same time reduce arthritis pain and disability and lessen the chance of developing osteoporosis? And what if it were free, so that reimbursement of its costs were not an issue?

Actually, there is such a treatment, and it is known as walking. One of the causes of the epidemic of obesity is physical inactivity, and obesity, in turn, leads to many of the chronic conditions affecting the elderly—heart disease, diabetes, and arthritis. When we think of exercise as a therapeutic modality, we tend to think of such activities as running, bicycling, and swimming, which require special clothes and equipment, and which can be done at only predetermined times of the day. The beauty of walking is that it does not require any of these things.

Here are some facts about the benefits of walking. In the Nurses' Health Study (which included nearly 100,000 women), it was found that women who walked regularly had a one third lower probability of developing diabetes relative to women who were less active, ⁴ and also a lower risk of cardiovascular morbidity. ⁵ The incidence of strokes was also cut by one third. The Honolulu Heart Study showed that men who walked at least a half mile every day had one half the risk of developing coronary heart disease as men who walked less than a quarter mile. ⁶ A study of older hypertensives ⁷ demonstrated that a walking program was associated with a substantial reduction in casual blood pressure (about 8/6 mm Hg) and a smaller reduction in daytime systolic ambulatory pressure (6 mm Hg), but no change in diastolic or nighttime pressures. Another, similar study ⁸ showed that older hypertensives randomized to an exercise group (walking 45 minutes a day, 3–4 days a week for 6 months) showed a fall in blood pressures of 7/5 mm Hg, while the control group showed no change. In addition, there were increases in the minimal vascular resistance in the arm and the leg, as measured by reactive hyperemia, suggesting that structural changes in the arteries had occurred. Exercise also appears to preserve normal endothelial function. ⁹ A Japanese group had subjects walk at least 10,000 steps (3–4 miles) per day for 12 weeks, using a pedometer to record the number of steps. This lowered the blood pressure of hypertensives by 10/8 mm Hg, but had no effect in normotensive controls. ¹⁰ An indirect measure of sympathetic nerve activity, the low‐frequency component of beat‐to‐beat blood pressure variability, was also decreased as a result of the training.

A study of obese adults over the age of 60 with arthritis of the knees revealed that an exercise program, which included walking and weight training, improved both knee pain and physical performance. ¹¹ The chances of developing osteoporosis are also reduced. ¹² People who walk more than 2 hours per week make 50% fewer emergency room visits and are less likely to be hospitalized. ¹³

There are two additional pieces of good news about walking: the first is that the benefits of walking as an integral part of one's lifestyle are as great as those from a supervised exercise program, ¹⁴ and the second is that if the total time spent walking is 30 minutes a day, the benefits are the same whether the walking is done in bouts of as little as 5 minutes at a time or if it is done in one session. ¹⁵ These changes include modest falls in blood pressure and an increase in fitness (measured as exercise tolerance). Not surprisingly, it can be shown that incorporating walking into one's everyday lifestyle is more cost‐effective than a supervised exercise program. ¹⁶ Walking requires no training and no special equipment, and it can be done by anybody, anywhere.

Unfortunately, our society does little to promote walking, and in many cases actively discourages it. In the United Kingdom, which historically has been less obsessed with the automobile than the United States, the number of trips made on foot fell by 20% over the past 10 years. There is one possible bright spot on the horizon. In Japan, there is a new technology fad called 10,000 Steps a Day, which involves the use of an electronic pedometer that can be strapped to the thigh. American consumers are now beginning to buy these in large numbers, at a unit cost of about $20. Nevertheless, physicians rarely ask their patients how far they walk, and many people seem to believe that a regular exercise program requires joining a gym. The myth of “no pain, no gain” dies hard. We need a national strategy to promote walking; this should include legislating pedestrian‐friendly sidewalks as an integral part of urban and suburban planning, and rewarding health care providers for promoting walking to their patients. Such a strategy would take some years to have any impact, but in the meantime, the problem is going to get a lot worse before it gets better.