Built environment for physical activity—An urban barometer, surveillance, and monitoring

Summary The Lancet Commission on Obesity (LCO), also known as the “syndemic commission,” states that radical changes are required to harness the common drivers of “obesity, undernutrition, and climate change.” Urban design, land use, and the built environment are few such drivers. Holding individuals responsible for obesity detracts from the obesogenic built environments. Pedestrian priority and dignity, wide pavements with tree canopies, water fountains with potable water, benches for the elderly at regular intervals, access to open‐green spaces within 0.5‐km radius and playgrounds in schools are required. Facilities for physical activity at worksite, prioritization of staircases and ramps in building construction, redistribution of land use, and access to quality, adequate capacity, comfortable, and well‐networked public transport, which are elderly and differently abled sensitive with universal design are some of the interventions that require urgent implementation and monitoring. An urban barometer consisting of valid relevant indicators aligned to the sustainable development goals (SDGs), UN‐Habitat‐3 and healthy cities, should be considered a basic human right and ought to be mounted for purposes of surveillance and monitoring. A “Framework Convention on Built Environment and Physical Activity” needs to be taken up by WHO and the UN for uptake and implementation by member countries.


| INTRODUCTION
The intermeshed trap of obesity, under-nutrition, and climate change, which constitutes the Global Syndemic according to Swinburn et al, is an existential threat to the future of human and planetary health. 1 High body mass index (BMI) of the population is already leading to over 472 million deaths and 148 million attributable disability-adjusted life years (DALYs) 2 in a background of escalating climate change and global warming. High temperatures and rising sea levels threaten to severely impact health and survival and further increase the gap between have and have-nots. [3][4][5][6] The atmospheric heat trapping fossil fuel carbon has never reached such high levels before. 7 The solutions to harness rising BMI levels need to be aligned to the wider context of mitigating climate change and global warming. 8 A physical activity and climate augmenting, age and disabled inclusive built environment will have triple duty actions, enhance the population levels of physical activity, mitigate climate change, and improve health, wealth, equity, and dignity. [9][10][11] Any form of activity is better than no activity. Even light PA despite falling short of minimum recommendations is health The WHO global monitoring framework for noncommunicable diseases (NCDs) calls for a 10% reduction in physical inactivity by 2025. 23 These targets cannot be met with the current sluggish trends. 24 The Global Action Plan for Physical Activity and Health 2018 to 2030, to make up for the lost time, recommends a 15% reduction in inactivity levels by 2030. 25 Bold actions towards protecting and creating health and environment-sensitive built environments with dynamic urban barometers for monitoring and surveillance is the need of the hour. Walking is a basic human right and should be attained by one and all, in all countries. Since people have the right to life, and ability to move safely on one's own feet, included must those be on wheel chairs and with special requirements towards a legal remedy if not available. 26 Even highways need to provide segregated space for pedestrians. 26 The law is supposed to protect the liberty rights and welfare of all its citizens. That is part of the moral purpose of state laws (government laws), state machinery, land use laws, and built environment laws. Built environment consists of the physical and man-made surroundings including buildings, parks, schools, transportation systems, land-use, and other infrastructure. report also provides recommendations to enhance monitoring and measuring of physical activity for children, health care, workplaces, and community settings. 34 However, much of the evidence is from a developed country perspective. Many cities, across the world, have already got physical activity promoting urban design, where pedestrian priority and dignity is protected, and adequate capacity wellnetworked public transport is integral to their planning, laws, and thought processes. A majority of the world, especially the developing countries, nevertheless lag behind.
This review is not a formal systematic review but has been written after a deep review of the formal literature, grey literature, and recommendations. It provides the developing country climate sensitive multidisciplinary perspective embedded in the existing knowledge of physical activity and built environment. It develops a framework for a dynamic urban barometer with relevant indicators, inclusive of the developing country perspective, which would reflect (directly or as sensitive surrogates) the progress and status of different countries, cities' and towns' built environment, and the related polices. These could act as a global observatory helping government and the UN towards monitoring and surveillance at the city, state, country, and global level and sustainable development. It could also contribute to a framework convention on built environment and physical activity, which would be a major step towards achieving the SDGs, basic attainment of human rights, UN-habitat-3, and WHOs initiative for age-friendly cities. 10,26,35,36

| RESULTS
Eight (8 Ds) urban planning and transport indicators are recommended to increase active transport, use of public transport, and enhance health. At state and city level planning, the distribution of employment across regions, public transport within walkable distance, density and diversity which supports vitality of public transport and businesses, easy access to destinations like workplace, educational institutes, marketplaces, recreational areas, etc. within 30 minutes travel, and design which promotes walkable, safe and attractive catchment areas are recommended. 37 These should include well-networked, comfortable, quality, safe, and adequate capacity public transport (a) facilities for active travel, wide pavements, with benches, water fountains safe and convenient crossings with limited car lanes (b) school play grounds and policies for playing (c) at worksite-user-friendly stair cases, space and time for physical activity, walking paths (d) in developing countries-urgent attention to walkability from the public stations/bus stops, metro stops to their worksites or residences, safe useable subways (e) safe access to parks and public transport for women and children (f) wide active transport lanes, wide pavements, trees for shade and pedestrian dignity and prioritization, (g) universal designs across setting, and contextualized comfort (like tree shade to the elderly and differently abled) and (h) from a developed country perspective-mixed land use and residential density. 9,27,28,31,[38][39][40][41][42][43][44] From a developing country perspective, there are other factors that need attention. Also, there is already an unsustainable high density and mixed land use that needs decongestion for health because of specific reasons described in the relevant section.

| Mitigating high heat in daily living
Global warming is impacting the entire world with Europe too facing an unprecedented heat wave. 45 Most of the developing countries face scorching high heat most of the year around, posing a huge barrier to the pedestrians, elderly, and differently abled. The temperatures could vary from 34 to 47 C for majority of the months in a year with consequential high heat-related morbidity. 3,46,47 In the coming years, rising temperatures could further negatively impact mobility, health, and quality of life. [48][49][50] Mortality rose by 2% for every degree rise beyond 36.2 C, and the effect was greater when minimum temperature were greater than 26.5 C. 4 An initiative to improve extreme summer heat by having tree canopies covered across the city could serve as an example for many others to follow. 50 This was "once upon a time", a time tested model in many of the planned cities in developing countries, which has been or is being discarded. A study from India reported lowering of the air pollution and lower temperatures (>5 C) in the street segments with lush green tree canopies on either side of the road. On the other hand, the streets without tree canopies were found to have higher levels of "suspended particulate matter" (SPM) on roads than those with the trees. 51 Tree shades on concrete pavements had other benefits-they increased the life of the pavements and reduced the pavements' cracking, fatigue, rutting, and shoving. 52 In essence, high heat which is an important barrier to walking in the developing countries, needs to be countered with lush green, shadeproviding trees (canopies), on either side of the roads/pavements. This will make walking comfortable for all age and people. City planning which is health and climate sensitive along with protection of green spaces, forests and water bodies will thus increase mobility and dignity ofthe pedestrians, elderly, children and the disabled. 9,11,19,26,41,42  which are open to the public. (b) Safe access to the parks and attractiveness of the parks are recommended, as proximity to large green spaces are associated with greater physical activity levels in the population, besides also overall well-being and health. 38,44,[53][54][55][56][57] On the whole, urban green forests, green parks, tree canopies alongside roads and pavements, green vegetation, and trees alongside buildings contribute through multiple interconnected processes towards promoting physical activity, overall health, and well-being. 58 They also lower mortality, act as particle and carbon sinks, thereby reducing the air pollution, lower the scorching heat, mitigate climate change, and lower the greenhouse gas emissions. 59 Shaded green surroundings also help in lowering the surface and the ambient air temperatures and mitigating the noise pollution. Various studies have investigated the health benefits of greenery near residences, worksites, and educational institutions by examining the cumulative exposure to greenery.

| Green spaces: parks and tree canopies
All-cause nonaccidental mortality rates were 12% lower in women living near greener surroundings. 60 Proximity to greenness/greenery was associated with lower cardiovascular disease and stroke mortality and reduced stress with improved mental health 61 and overall-health irrespective of the urbanization and socioe-conomic status. 62,63 In addition, it is correlated with better birth weight of babies, lower postpartum depression during and after pregnancy in mothers, reduction in spectacle use, better cognitive development in children, lower risk of prostate cancer among men, and better mobility and health in the elderly. 62,[64][65][66][67][68][69] Trees/greenery also lower air pollution, both particulate and gaseous-nitric oxide, enhance property value, reduce fossil fuel consumption due to reduced requirements for air conditioning of cars on the roads and buildings, control water run-offs and flooding, reduce street repair costs, and provide attractive recreational opportunities for the residents. 52,70 All the above are aligned to SDGs and UN-Habitat 3. The heat island effects of urban structures can be addressed with trees and will be aligned to UN-habitat 3 and SDGs.
Sadly, in actual terms, greenery has been found to be lower in the socio-economically marginalized societies. 71

| Pedestrian priority-pavements, sidewalks, pathways, and safety
Road traffic-and transport-related injuries are the leading causes of preventable deaths among the youth. 72 The majority (93%) of these fatalities are reported from LMICs and LICs 73 and involve pedestrians, cyclists and motorized two-wheelers. 74,75 Countries that do not invest in wide pavements, sidewalks, pedestrian priority, and other active transport facilities and safe road designs could eat into 7% to 22% of their per capita GDP growth over a 24-year period. 76 Inadequate and inappropriate provision for pedestrians and active transporters in the developing countries leads to compromised safety with consequential decline in its social desirability. This is seen especially in the remodeled cities or newly urbanizing towns in the developing countries. Periodic expanding multilane motor carriageways at the cost of pedestrian and active transport lanes escalates the risk to pedestrians and active transporters even further. Walking and other active travel modalities are a constant struggle, and when the average person is finding it difficult, what would the elderly and those physically challenged must go through. Often a common occurrence are multilane motor carriageways along with narrow or filthy and distressed sidewalks with pedestrians walking on the carriageway/the road itself jostling with the upcoming traffic. 74 High-speed traffic alongside sidewalks is a known deterrent to pedestrians. 30 Frequent maintenance work, road widening, encroachments, garbage dumps, signages, etc make pavements unsuitable for walking. This is common across most developing countries, in the South-east Asian region and much of Africa. Pedestrians are the most vulnerable among road users. 77 They may die, while walking for basic facilities, fall in pits and manholes, and get electrocuted in many cities in the developing countries.
The worst pavements are visible in the socio-economically marginalized areas, plummeting safety and inequity further. Safety needs to be a non-negotiable prerequisite in urban design and road design even before other aspects are looked at.
Pavements, as wide as the roads, making pedestrians feel safe and comfortable, are a critical and basic requirement that needs strong action at the ground level. Walking, pedestrianism, and active travel, with universal design, should be a non-negotiable component of all planning and transport. Contrastingly, in many European countries and in London, pedestrian priority and pedestrian dignity are upper most in the minds of urban designers and planners. For example, in London, the already narrow roads/motor carriageways with only double carriageways (single on each side) are being narrowed further, to broaden the pavements to more than carriageway widths.
Additionally, age and disable sensitivity is integral to their design. It is naturally being done without people having to talk, write, and implore the civic authorities nor is the government flaunting it. This is complemented with a strong underground and overground public transport network.
Historically, some of the world's best pedestrian and physical activity-friendly cities were laid out many decades ago, not for health concerns but, primarily because of common civic sense for public good. 41 Such thinking needs to be applauded and restored. Pavements need to be of adequate width, preferably as wide as the motor carriageways in the cities with an unobstructed clean, unencroached walking zone. The kerb height should not exceed 150 mm with kerb ramps disable and age comfortable. Heat mitigations through lush green canopies alongside the pavements and roads, provision of benches, and water fountains intermittently are required especially in the LMICs and LICs. Additionally and most importantly, the accompanying motor carriageway should not be more than two lanes wide. Pedestrians feel threatened with high-speed multilanes of cars moving along. Urban planning and transport needs to be detailed and pedestrian centric, and age and disable sensitive. For example, the safety of pedestrians and active transporters due to a potential collision between the left-turning vehicles at intersections and on the crosswalks through the road design needs addressal. 77,78 Other essentials being-frequent zebra crossings/crosswalks withappropriate width and sufficient signal time for pedestrians to conveniently cross-over. Figure 1 illustrates the established built environment features (x-axis), which enhance the physical activity levels (y-axis), these being, residential density, intersection density, public transport density, parks within 0.5-km radius, street lighting, beachfront, cycle lanes, and green spaces. In addition, the other attributes, which promoted PA in both adults and children, are a higher proportion of paved streets, 79 improved neighbourhood walkability, quality of pavements, quality of parks, playgrounds, and their access, and importantly, slower speed of traffic on the roads. 28,80,81 In developing countries, with 3-to 4wheeled pushcarts and cycling, the cycling lanes need to be made wider, as wide as the car lanes and provided with lush green tree canopies to protect active travellers from the scorching heat and consequential heat morbidity without the luxury of air conditioning. Green canopies and greenery make walking and cycling attractive, act as carbon sinks, and lower carbon emissions. In many developing countries, highway designs need to consider active transport lanes because people are walking anyway, where they part walk and part hitch rides.
Unlike the developing countries, in developed countries, "walking and walkability" go hand in hand. Therefore, walkability can be assessed by how much people walk. In developing countries, on the other hand, walking and walkability do not go hand in hand as people walk (or cycle) as they have no choice. They walk despite the craters, the non-useable pavements, high pollution and dust levels, and old motorized transport puffing exhaust black smoke into the noses. They all walk between the upcoming high-speed highway traffic and parked vehicles-children, those in wheel chairs, and elderly included. 41 Often, pavements get encroached by either parked vehicles, hawkers, other important aspects that have to be ensured for pedestrian's safety. People are jumping over displaced and broken stones, garbage, encroachments dogging motorized two wheelers, and cars to be able to walk. The absence of subways or crossings require pedestrians to dart across, at times, multilane roads, narrowly missing or dodging vehicles, a nightmare for disabled and elderly. Walking and other forms of active transport, thus, get socially downgraded. People give up walking as soon as they can buy any motorized transport-a motorized two-wheeler or a car or access to any motorized transportmotorcycle, tuk-tuks, or others. Noise is not even looked at in the overall scheme of things, neither its absence considered a necessity of living nor a consideration in planning. On the other hand, hour-long, multiple-lane, traffic jams on many roads is common. In developing countries, there are more than 50 different types of vehicles-both active and motorized. The typical divisions on roads for buses, cars, and cycles will not work in most developing countries.

| Equity and pedestrian dignity in developing countries
Pedestrian dignity is paramount for pedestrian activity. Pedestrian dignity in design, which is taken for granted in the developed countries, is lacking in many developing countries. The Scandinavian countries, the United Kingdom, and many European countries are miles ahead of the developing countries when it comes to pedestrian safety, dignity, and comfort; sadly in many cities, in the developing countries across the world, remodelling has seen the pavements literally vanish or become impossible to use. Thankfully, worldwide pedestrian rights are now being looked at as an integral component of human rights, 26 an important public health priority, and is to be included in the upcoming United Nations SDGs. 35 Thus land use, urban planning, universal design, which is climate-resilient from the developing country's perspective needs to be a public health priority.
Providing a pedestrian active transport-friendly built environment is equity-promoting. 28 In LICs/LMICs, on highways where people walk, part walk, and part hitch rides, highway design should consider incorporating active transport facilities for safety, health, and equity.
Providing an environment and facilities for sports to deprived and marginalized children is an established instrument for development. 82 The built environment should directly or indirectly make physical activity in everyday living, the easy choice, the affordable choice, the accessible choice, and the most desirable choice, across the life course, especially in the elderly, the disabled, women, and children. [9][10][11]19,35,36 How do you action these multidisciplinary complexities at the ground level for population level change? As time is running out, how do you monitor and hold communities and countries responsible and accountable. We developed an urban barometer, which comprehensively captures the wide range of macro and micro structural/environmental social and policy indicators, for active transport, active schools, active cities, and active workplaces, in Table 1. Each of these are aligned to the SDGs. Given the wide-ranging potential benefits of physical activity promoting built environment for all, we need a Global Framework convention for physical activity, built environment, and city planning. WHO and UN need to table it and motivate countries to be signatories and move forward in a phased manner. A WHO urban barometer observatory would further enhance reaching these goals.
Live country-specific global dashboard will give an opportunity to countries to showcase their achievements and to others to work towards their targets. It can help in surveillance and monitoring. A feedback loop with citizens themselves could further help in implementation. 90

| Public transport increases population physical activity
The use of public transport is an established booster of population physical activity levels. A systematic review by Rissel et al elucidated an increased walking time of 8 to 33 minutes per day in public transport users. 91 This also saves fossil fuel lowering the carbon emissions.
Public transport needs to be age and disabled sensitive, climate sensitive, and should restore the dignity of public transport users in all human habitations.  % of schools which actively support active transport to school. "walking school bus," "walk-to-school," safe routes to school SDG 3,11,13 % of schools having an after school play/dance program and information for families % of schools having an after school play/dance program and information for families for both sexes SDG 3, 4 SDG 3,5

Individual Indicators-Adults-Women and Men (3)
Physical activity in adults (men and women) % of adults who meet minimum recommended physical activity guidelines % of men and women who meet minimum recommended physical activity guidelines (Men, women) % of adults (men and women) who met the 150 min/week of aerobic exercise guidelines % of adults (men and women) who met the 300 min/week of aerobic exercise guidelines SDG 3,5 Active transport to work/college % of adults who bicycle/walked/used public transport to work/college in the last week % of adults who bicycle/walked/used public transport to work despite having access to cars/private motorized transport in the last week (developing countries) % of women, girls, boys and men who bicycle/walked/used public transport to work/college in the last week % of women, girls, boys, and men who bicycle/walked/used public transport to work despite having access to cars/ private motorized transport in the last week (developing countries)

Environmental Indicators-Adults (4)
Supportive environment-market, college and work % of people who perceive they can walk to the local market-safety, feasibility % of people who feel that they can use active transport and public transport to work/college as its safe and feasible % of men and women, boys and girls who feel that they can use active transport and public transport to work/college as its safe and feasible and the market SDG 3, 16, 11 SDG 5 Adequate capacity and density of public transports and stops is known to increase physical activity levels % of people who prefer to take public transport % of people despite having access to personalized cars yet prefer to take public transport % of population who have availability of facilities for recreation, sports, dance within walking distance SDG 3, 10, 11, 13 SDG 3, 10, 11

Environmental Indicators-Pedestrian Priority, Street Scale Design Street-Scale and Community-Scale Design Policy
Walkability is how friendly an area is to walking.
The international walkability index consists of 4 (1-4) components or indicator variables (http://health-design.spph.ubc.ca/ tools/walkability-index/) of different sections/locations in cities towns: 1. Residential density is the number of houses in an acre of land in a neighbourhood. Higher the value is indicative of more people live in that area.
2. Commercial density is the area meant for commercial use in a neighbourhood. Higher value denotes that there are more businesses, restaurants, retail shops, and commercial establishments in that area. Density of bus stations/metro stations/ferry stops Developed country perspective: The above is from a developed country perspective; it is assumed that public transport is safe, and adequate capacity and pedestrian pathways are useable and safe, which may not be the case in a developing country scenario. Developing country perspective: That considered as high density in developed countries is actually low density in developing countries. The walkability may decrease after a certain value high density above in the context of developing countries, where over density is creating a vulnerable unsafe environments to walk and people still walk as there is no other option. SDG 3 10, 11,13,15,16 Tackling the contextual barriers to active transport including walkability-developing country perspective: In developing countries, there are many other barriers to walking that include high pollution, high dust levels, and high heat making it uncomfortable, at times prone to dehydration and heat strokes, pollution.
There are many more motorized and nonmotorized transports as compared with developed countries. So there is a need for greenery, hydration, segregation of motorized and nonmotorized transports rather than the traditional bus lanes, cycle lanes, and car lanes in developed countries. Plus the population density is many times over. SDG 3,10,11,13,15,16 Pedestrian paths, street scale design and urban design Pedestrian pathways • % (proportion) of pedestrian pathways, which are safe, unencroached, usability, % of roads-where the width and quality of the pedestrian paths as comparable with the width of road; • % of roads, which have well-networked pedestrian pathways, crossings, subways • Developing countries: % proportion of interstate highways, which provide for pedestrians and subways as people any ways hitch rides, and there are villages and schools on either side of the interstate highways

Environmental Indicators-Pedestrian Priority, Street Scale Design Street-Scale and Community-Scale Design Policy
• Quality of the pedestrian paths-wide, unencroached, well-maintained-where mothers can walk with child prams, wheel chairs, etc can move.
• % of roads in cities/towns/settlements, where there is a definite priority to pedestrians, and nonmotorized transport.
• % of roads in cities/towns/settlements where there is a definite priority to disabled and are age-sensitive for elderly • % of roads, which have green canopies on either side to provide shade (they increase likelihood of active transport and also lower air-conditioning requirements) • % of roads, where the motorized transport (car, etc) lanes are not more than 10-11 ft wide, and overall width is comfortable for the Pedestrian • % or roads with "water fountains"-at regular distance/crossings (to counter the hot climate, for hydration purposes) • In tropical countries, high heat countries, green trees for shade-to lower pollution, temperature, comfort in walking and resting on either side of the road. % of roads and pedestrian paths/sidewalks and active transport lane which have shade (cove) provided by lush green trees • % of road length which have benches for people to take breaks and sit.
• How you treat your pedestrian_ dignity in being a pedestrian (Respect for pedestrian rights (disabled friendly, universal design, heat mitigation, reinforcement through trees and water fountains).
• Adequate frequency of crossings, subways • % of crossings, which have CURB cuts • Car lanes/motorized transport lanes • % of roads where the Width of car lane-for car should be less than 11 feet (10-11 ft), with restriction on number of lanes in cities, so that the road is not too wide and that pedestrians can cross.
• Division of road space for motorized and nonmotorized transport • Separation of the motorized and nonmotorized lanes with greenery. Walkability within urban conglomerates/cities, towns Pedestrian priority, safety comfort, need for hydration, greenery, disable friendly. Pedestrian being the heart of city planning Developing countries have more than 50 different types of transport, motorized, and active (nonmotorized). This is unique to developing countries as compared to developed countries of predominantly cars, buses and bicycles. The width has thus to be divided into "motorized lanes(10 ft each approx.), nonmotorized lanes and pedestrian paths Active transport (developing countries) Nonmotorized lanes-for multiple different active transport vehicles in developing countries Developing country Public transport density Public transport density-measured on randomly selected routes in each city. Each county and city can decide that.

SDG 3, 10, 11
Priority to other forms of active transport/ cycling at crossing % of crossings in a town/city, where priority is given to cyclists and other forms of nonmotorized transport SDG 3,10,11,13 Indicators at Worksite 1. % worksite/business enterprises, where the staircases/stair wells are well maintained, useable, attractive, and safe, measures that will increase the safety in the using stairs and safety treading, non-skid tiles or treading, railings, temperature controlled in extreme temperatures. Natural lighting where ever possible. Railing to hold on. Attractiveness of staircases congestion and decreasing the densities are the requirements, also limiting construction and commercial activity to ensure it is commensurate with the water supply, public transport, road and other civic amnesties with adequate open spaces, and greenery. Also, one needs to be cognizant that in developing countries, where safety is major concern (from crime, rape, and carcinogens) and land mafia encroachments the norm, having recommendations to increase densities and mixed land use will give fodder to legitimize such illegal violations and disease-creating built environments.
In developed countries however, where there are many kilometres of urban sprawls, cities need to get more compact and move away from being car-centric environment. 37 Compact design, with green spaces, improves physical activity levels and health. 93,95 Residential buildings and educational institutions including schools need to be located away from the high-traffic zones both in the developing and the developed countries. 41

| Worksite built environment and policies for promoting physical activity
Employed people spend most of their waking time at offices.
Worksite-based programmes provide opportunities for employees to take up physical activity pursuits. These are also known to be productivity and confidence boosters and also reduce absenteeism. [97][98][99][100] Workplaces surrounded by a variety of attractive and pedestrianfriendly neighbourhoods encourage walking, bicycling, and use of public transport. 101 Small changes like introducing a sit-stand device for the employees could significantly reduce sitting time by 66 minutes per day and achieve health benefits like improvement in neck and back pain. 102 Staircases as a central and focal aspect of the architecture (as against the elevator) encourages employees to take stairs rather than lifts. Self-servicing policies for accessing beverages, having lunch in the canteen area rather than at the work stations, 2 minutes standing/walking breaks after every 20 minutes of sedentary work, and availability of yoga and zumba classes before and after work schedules are some of the in-house interventions that worksites could include in their employee programmes. 103

| Schools built environment and policies for promoting physical activity
Children's physical activity should be enhanced through school-based interventions-a conducive built environment and supportive polices.
An exclusive games period of 30 to 40 minutes per day ensures that children engage in WHO recommended MVPA levels of 60 minutes to some extent. 106 In a recent meta-analysis by Hollis et al, only 40% of the total school physical education (PE) lesson time was utilized for actual MVPA. 107 The school-built environment including availability of facilities and equipment had a great impact in addition. 108 The schoolbuilt environment has a positive association with MVPA among students (P < .001). 109 [110][111][112] Creating a safe and enjoyable environment will encourage girls to engage in physical activity pursuits. 113 In addition, providing green and safe routes to school will also encourage children and parents to consider walking to school and, thus, increase the physical activity beyond the school premises. 114

| CONCLUSION
Built environment has a profound influence on the physical activity levels of the population, in preventing a pathology from becoming a disability and enhancing health across the lifespan. 11