Geographic Distribution of Healthy Resources and Adverse Pregnancy Outcomes

Association between density of food retailers and fitness centers and gestational diabetes mellitus in Eastern Massachusetts, USA: population-based study

Background

Few studies have investigated the relationship between the food and physical activity environment and odds of gestational diabetes mellitus (GDM). This study quantifies the association between densities of several types of food establishments and fitness centers with the odds of having GDM.

Methods

The density of supermarkets, fast-food restaurants, full-service restaurants, convenience stores and fitness centers at 500, 1000 and 1500 m (m) buffers was counted at residential addresses of 68,779 pregnant individuals from Eastern Massachusetts during 2000-2016. The 'healthy food index' assessed the relative availability of healthy (supermarkets) vs unhealthy (fast-food restaurants, convenience stores) food retailers. Multivariable logistic regression quantified the cross-sectional association between exposure variables and the odds of having GDM, adjusting for individual and area-level characteristics. Effect modification by area-level socioeconomic status (SES) was assessed.

Findings

In fully adjusted models, pregnant individuals living in the highest density tertile of fast-food restaurants had higher GDM odds compared to those living in the lowest density tertile (500 m: odds ratio (OR):1.17 95% CI: [1.04, 1.31]; 1000 m: 1.33 95% CI: [1.15, 1.53]); 1500 m: 1.18 95% CI: [1.01, 1.38]). Greater residential density of supermarkets was associated with lower odds of GDM (1000 m: 0.86 95% CI: [0.74, 0.99]; 1500 m: 0.86 95% CI: [0.72, 1.01]). Similarly, living in the highest fitness center density tertile was associated with decreased GDM odds (500 m:0.87 95% CI: [0.76, 0.99]; 1500 m: 0.89 95% CI: [0.79, 1.01]). There was no evidence of effect modification by SES and no association found between the healthy food index and GDM odds.

Interpretation

In Eastern Massachusetts, living near a greater density of fast-food establishments was associated with higher GDM odds. Greater residential access to supermarkets and fitness centers was associated with lower the odds of having GDM.

Funding

NIH.

Neighborhood location and nutritional resources as a risk factor for congenital heart disease in the fetus

BACKGROUND

Congenital heart disease (CHD) is the most common birth defect, influenced by maternal health, environmental conditions, and genetics. Maternal health and nutrition, particularly maternal diabetes, is a modifiable risk factor for development of CHD in the fetus. However, the importance of food access during pregnancy on the development of CHD remains unknown. The objective of this study was to investigate the association between maternal neighborhood characteristics, particularly food access, and occurrence of prenatally diagnosed CHD.

METHODS

A retrospective case series studied maternal-fetal dyads with prenatally diagnosed CHD between 2019 and 2021 in Washington, DC. Moran's I of maternal addresses evaluated geographic clustering of disease. Negative binomial regression assessed association between census tract demographics and population-adjusted CHD rate.

RESULTS

A total of 307 dyads were analyzed. Global Moran's I showed significant CHD clustering (p-value = .004). However, degree of clustering was not clinically meaningful. After adjusting for neighborhood socioeconomic status, residing in food deserts was not a predictor for CHD. However, neighborhoods with a higher percentage of households receiving Supplemental Nutrition Assistance Program (SNAP) benefits were associated with higher rates of conotruncal heart defects (Incident Rate Ratio [IRR] = 1.04, CI = 1.01-1.08) and aggregate CHD (IRR = 1.03, CI = 1.01-1.05).

CONCLUSIONS

Neighborhood location and food access were not associated with CHD. However, increased enrollment in SNAP was associated with higher rates of CHD. The association between CHD and SNAP benefits warrants further exploration. Understanding food access and maternal nutrition may illuminate disparities in the burden of CHD.

Healthy home food environments of pregnant Black women are shaped by food outlet access and participation in nutrition assistance programs

OBJECTIVES

Improving access to healthy food in Black communities is imperative to combat intergenerational health disparities. Pregnant Black women represent an especially vulnerable population to multiple (and overlapping) sources of socioeconomic and political disenfranchisement and thus for whom maternal nutrition is crucial. This study aimed to (1) define household food environment types, (2) determine whether the distribution of community food outlets is associated with these household food environment types, and (3) determine whether the community-household food environment relationship differs by maternal education or participation in nutrition assistance programs.

METHODS

Cross-sectional data for pregnant Black women in North Carolina (n = 429) come from the Mothers & Others study, an obesity-prevention randomized control trial, with linked spatial data on all community food outlets (n = 6312) in the study area in 2015. Factor analysis was used to define household food environment types. These factor scores were regressed on access metrics to community food outlets. Adjusted linear regressions tested interaction by maternal education and nutrition assistance programs.

RESULTS

Four household food environment types were defined: Factor 1 (fresh fruits and vegetables (F/V), low snack), Factor 2 (canned F/V, sweet drinks), Factor 3 (dried/frozen F/V, candy), and Factor 4 (low F/V, soda). Having more convenience stores within 0.25 miles was associated with higher Factor 4 scores. No food outlets were associated with higher Factor 1 scores overall. However, SNAP or WIC participating households saw higher Factor 1 scores with increased access to supermarkets, convenience stores, and dollar stores.

CONCLUSIONS

Nutrition assistance programs play an important role as buffers against unhealthy community food environments which influence household food environments and maternal nutrition.

Understanding Food Security as a Social Determinant of Diabetes-Related Health during Pregnancy

Gestational and pregestational diabetes during pregnancy are substantial and growing public health issues. Low-income individuals and individuals who identify as racial and ethnic minorities are disproportionately affected. Food security, which is defined as the degree to which individuals have capacity to access and obtain food, is at the center of nutritional resources and decisions for individuals with diabetes. While increasingly recognized as an important mediator of health disparities in the United States, food insecurity is understudied during pregnancy and specifically among pregnant individuals with diabetes, for whom the impact of food-related resources may be even greater. Previous research has suggested that food insecurity is associated with type 2 diabetes mellitus diagnoses and disease exacerbation in the general adult population. An emerging body of research has suggested that food insecurity during pregnancy is associated with gestational diabetes mellitus diagnoses and adverse diabetes-related outcomes. Additionally, food insecurity during pregnancy may be associated with adverse maternal and neonatal outcomes. Future research and clinical work should aim to further examine these relationships and subsequently develop evidence-based interventions to improve diabetes-related outcomes among pregnant individuals with food insecurity. The purpose of this article is to offer a working definition of food security, briefly review issues of food insecurity and diabetes, summarize research on food insecurity and diabetes-related pregnancy health, and discuss clinical recommendations and areas for future investigation. KEY POINTS: · Research on food insecurity and diabetes-related health is limited.. · The impact of food security on diabetes management and obstetric outcomes is likely significant.. · Future work to evaluate perinatal food security screening is warranted..

The association between food desert severity, socioeconomic status, and metabolic state during pregnancy in a prospective longitudinal cohort

Poor metabolic health during pregnancy is associated with health concerns for pregnant individuals and their offspring. Lower socioeconomic status (SES) is one risk factor for poor metabolic health, and may be related to limited access to healthful and affordable foods (e.g., living in a food desert). This study evaluates the respective contributions of SES and food desert severity on metabolic health during pregnancy. The food desert severity of 302 pregnant individuals was determined using the United States Department of Agriculture Food Access Research Atlas. SES was measured using total household income adjusted for household size, years of education, and amount of reserve savings. Information about participants' glucose concentrations one hour following an oral glucose tolerance test during the second trimester was extracted from medical records and percent adiposity during the second trimester was assessed using air displacement plethysmography. Information about participants' nutritional intake during the second trimester was obtained by trained nutritionists via three unannounced 24-h dietary recalls. Structural equation models showed that lower SES predicted higher food desert severity (β = - 0.20, p = 0.008) and higher adiposity (β = - 0.27, p = 0.016) and consumption of a more pro-inflammatory diet (β = - 0.25, p = 0.003) during the second trimester of pregnancy. Higher food desert severity also predicted higher percent adiposity during the second trimester (β = 0.17, p = 0.013). Food desert severity significantly mediated the relationship between lower SES and higher percent adiposity during the second trimester (βindirect = - 0.03, 95% CI [- 0.079, - 0.004]). These findings indicate that access to healthful and affordable foods is a mechanism by which SES contributes to adiposity during pregnancy and may inform interventions intended to improve metabolic health during pregnancy.

Green space, air pollution and gestational diabetes mellitus: A retrospective cohort study in central China

Emerging evidence suggests residential surrounding green space is beneficial for human health. The association between green space and GDM showed inconsistent results, and potential effect modification of green space with air pollution is still unclear. This study aims to evaluate the association between green space and GDM, and further explore potential interaction and medication effects. Participants were recruited from a retrospective cohort study between 2015 and 2020 in Henan, China. Residential green space based on normalized difference vegetation index (NDVI) and air pollution exposure were estimated using spatial-statistical models. Multivariate logistic regression was applied to evaluate the association between per 0.1 unit increase in NDVI with 4 buffer sizes (250 m, 500 m, 1000 m, 2000 m) and GDM. We examined potential interaction of green space and air pollutants on GDM. Mediating effects of air pollution associated with green space exposure on GDM were also investigated by causal mediation analyses. A total of 46,665 eligible pregnant women were identified. There were 4092 (8.8 %) women diagnosed with GDM according to the IADPSG criteria. We found that per 0.1-unit increment in NDVI250 m, NDVI500 m, NDVI1000 m and NDVI2000 m in second trimester were associated with the decreased risk of GDM, with adjusted OR of 0.921(95 %CI: 0.890-0.953), 0.922 (95 %CI: 0.891-0.953), 0.921 (95 %CI: 0.892-0.952) and 0.921 (95 %CI: 0.892-0.951), respectively. We identified significant interactions between second trimester PM2.5 and O3 exposure and NDVI for GDM (Pinteraction < 0.001). The causal mediation analysis showed that PM2.5 mediated approximately 2.5-5.5 % of the association between green space and GDM, while the estimated mediating effect of O3 was approximately 30.1-38.5 %. In conclusion, our study indicates that residential green space was associated with a reduced risk of GDM, particularly second trimester. Green space may benefit to GDM partly mediated by a reduction in PM2.5 and O3.

The Impact of Neighborhood Deprivation on Glycemic Control for Patients with Type 2 Diabetes During Pregnancy

Background: The impact of neighborhood level factors on glycemic control and pregnancy outcomes is understudied. The primary objective was to determine whether there is an association between glycemic control during pregnancy and level of neighborhood deprivation, defined by area deprivation index (ADI). Materials and Methods: We conducted a retrospective cohort study of women with type 2 diabetes who received care at a tertiary referral center from 2007 to 2017. Patients living in more deprived neighborhoods (ADI >85th national percentile) were compared to those living in less deprived neighborhoods (ADI ≤85th percentile). The primary outcome was change in hemoglobin A1c (HbA1c) over time. Demographic characteristics were compared between groups, and trends in mean A1c through each trimester were tested with repeated measures analysis. Results: Of 237 women meeting study criteria, 93 (39.2%) lived in less deprived (low ADI) and 144 (60.8%) lived in more deprived neighborhoods (high ADI). Women living in more deprived neighborhoods were more likely to be Black (86.8% vs. 53.8%, p < 0.01), less likely to be married (11.3% vs. 31.2%, p < 0.01), and had more severe diabetes (p = 0.05). Both groups achieved significant improvement in HbA1c across each trimester using repeated measures analysis. Those living in more deprived neighborhoods had significantly more improvement in HbA1c from their initial visit to the third trimester compared to those in less deprived neighborhoods, (p = 0.01) such that there was no longer a statistically significant disparity in HbA1c by the third trimester (6.69 ± 0.97 Less deprived vs. 6.95 ± 1.22 more deprived, p = 0.19). Conclusions: Low-income women living in more deprived neighborhoods enter pregnancy with significantly worse glycemic control than those living in less deprived neighborhoods, but the gap in glycemic control largely closes by the end of pregnancy with similar maternal and neonatal outcomes.

Pregnancy-Associated Diabetes Mellitus and Stillbirths by Race and Ethnicity among Hospitalized Pregnant Women in the United States

OBJECTIVES

Racial disparities in preexisting diabetes mellitus (PDM) and gestational diabetes mellitus (GDM) remain largely unexplored. We examined national PDM and GDM prevalence trends by race/ethnicity and the association between these conditions and fetal death.

METHODS

This was a retrospective cross-sectional analysis of 69,539,875 pregnancy-related hospitalizations from 2002 to 2017 including 674,040 women with PDM (1.0%) and 2,960,797 (4.3%) with GDM from the US Nationwide Inpatient Sample Survey. Joinpoint regression was used to evaluate trends in prevalence. Survey logistic regression was used to evaluate the association between exposures (PDM and GDM) and outcome.

RESULTS

Overall, the average annual increase in prevalence was 5.2% (95% confidence interval [CI] 4.2-6.2) for GDM and 1.0% (95% CI -0.1 to 2.0) for PDM, during the study period. Hispanic (average annual percentage change 5.3, 95% CI 3.6 - 7.1) and non-Hispanic Black (average annual percentage change 0.9, 95% CI 0.1 - 1.7) women had the highest average annual percentage increase in the prevalence of GDM and PDM, respectively. After adjustment, the odds of stillbirth were highest for Hispanic women with PDM (odds ratio 2.41, 95% CI 2.23-2.60) and decreased for women with GDM (odds ratio 0.51, 95% CI 0.50-0.53), irrespective of race/ethnicity.

CONCLUSIONS

PDM and GDM prevalence is increasing in the United States, with the highest average annual percentage changes seen among minority women. Furthermore, the reasons for the variation in the occurrence of stillbirths among mothers with PDM and GDM by race/ethnicity are not clear and warrant additional research.

Racial and ethnic disparities in pregnancy complications and the protective role of greenspace: A retrospective birth cohort study

Greenspace may positively impact pregnancy health for racially and economically minoritized populations; few studies have examined local availability and accessibility of green/park space in reducing maternal morbidity. The objective of this retrospective birth cohort study was to examine the association between residential exposure to greenspace and adverse pregnancy health outcomes in a Southern US state characterized by high poverty and racial disparities in maternal health (2013-2017). National data from the Protected Area database - United States (PAD-US) and ParkServe estimated three publicly available and accessible residential greenspace measures-a more direct proxy than using remotely-sensed greenness indicators (e.g., normalized difference vegetation index (NDVI))-(a) percent area of greenspace (M1), (b) area of available greenspace per person (M2), (c) total population within a 10-minute walk (M3). Generalized Estimating Equations with logistic regression were used to examine the association between individual greenspace metrics and South Carolina hospital deliveries (n = 238,922 deliveries) for women with correlated maternal health outcomes for gestational hypertension (GHTN), gestational diabetes (GD), severe maternal morbidity (SMM), preeclampsia (PRE), mental disorders (MD), depressive disorders (DD), and preterm birth (PTB). Lowest compared to highest tertiles of all three metrics were associated with increased risk for MD, DD, and a monotonic increase in GD, particularly for black women. Women with the lowest access to M2 and M3 were more at risk for PRE, PTB, and MD. We observed that women in low-income, majority-black communities in the lowest versus highest tertile of M2 were more likely to experience a DD, MD, SMM, or PTB compared to primarily high-income majority-white communities. Available and accessible green/park space may present as an effective nature-based intervention to reduce maternal complications, particularly for gestational diabetes and other pregnancy health risks for which there are currently few known evidence-based primary prevention strategies.

The relationship between the neighborhood built and social environment and hypertensive disorders of pregnancy: A scoping review

BACKGROUND

Theory and limited empirical research suggest that the neighborhood environment influences maternal health outcomes. The goal of this scoping review is to summarize extant research considering the impact of the built and social environment of resident neighborhood on hypertensive disorders of pregnancy (HDP) globally.

METHODS

We performed a systematic search of the literature using four databases, PubMed, Web of Science, CINAHL, and Embase on July 15, 2020. We excluded articles not in English, that did not consider one or more HDP as a primary or secondary outcome, and that did not include an element of the neighborhood built or social environment as an exposure. We applied a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies to evaluate quality of included studies.

RESULTS

Our search identified 11,385 unique abstracts for screening. Following exclusions, we included 64 articles in the final review. The majority of articles measured an element of the built environment (70.3% (44)), most commonly traffic-related air pollution (42.2% (27)). A third of articles (31.3% (20)) considered an element of the neighborhood social environment, most commonly neighborhood deprivation (10.9% (7)). Global quality ratings were mostly moderate (29.7% (19)) or weak (68.8% (44)), primarily due to inattention to neighborhood-level confounding.

CONCLUSION

Critical gaps remain in understanding how the resident neighborhood may impact HDP. Future research should focus on designing high-quality studies incorporating elements of both the built and social environment to holistically understand how context may impact maternal health.

Air Pollution, Residential Greenness and Metabolic Dysfunction during Early Pregnancy in the INfancia y Medio Ambiente (INMA) Cohort

Despite extensive study, the role of air pollution in gestational diabetes remains unclear, and there is limited evidence of the beneficial impact of residential greenness on metabolic dysfunction during pregnancy. We used data from mothers in the Spanish INfancia y Medio Ambiente (INMA) Project from 2003–2008. We obtained spatiotemporally resolved estimates of fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) exposures in early pregnancy and estimated residential greenness using satellite-based Normal Difference Vegetation Index (NDVI) within 100, 300 and 500 m buffers surrounding the mother’s residence. We applied logistic regression models to evaluate associations between each of the three exposures of interest and (a) glucose intolerance and (b) abnormal lipid levels. We found limited evidence of associations between increases in PM_2.5 and NO₂ exposures and the metabolic outcomes. Though not statistically significant, high PM_2.5 exposure (≥25 µg/m³) was associated with increased odds of glucose intolerance (OR = 1.16, 95% CI: 0.82, 1.63) and high cholesterol (OR = 1.14, 95% CI: 0.90, 1.44). High NO₂ exposure (≥39.8 µg/m³) was inversely associated with odds of high triglycerides (OR = 0.70, 95% CI: 0.45, 1.08). Whereas NDVI was not associated with glucose intolerance, odds of high triglycerides were increased, although the results were highly imprecise. Results were unchanged when the air pollutant variables were included in the regression models. Given the equivocal findings in our study, additional investigations are needed to assess effects of air pollution and residential greenness on metabolic dysfunction during pregnancy.

Association between Food Deserts and Gestational Diabetes Mellitus in a Large Metropolitan Area

OBJECTIVE

The aim of this study is to determine the relationship between urban food deserts and frequency and obstetric outcomes related to gestational diabetes.

STUDY DESIGN

We conducted a retrospective cohort study of singleton births in Chicago from 2010 to 2014. Birth certificate data were analyzed and geomapped by census tract. Census tracts were categorized as "food deserts" according to the USDA Food Access Research Atlas. The primary outcome was frequency of gestational diabetes. Secondary outcomes were assessed among women with gestational diabetes and their neonates.

RESULTS

Of the 191,947 eligible women, 8,709 (4.5%) were diagnosed with gestational diabetes. Those in food deserts were more likely to be younger, obese, minority race/ethnicity, and multiparous. Women in food deserts were less likely to develop gestational diabetes (3.8 vs. 4.8%, p < 0.01; adjusted odds ratio 0.91, 95% confidence interval 0.86-0.96). Women with gestational diabetes did not experience worse maternal and neonatal outcomes after controlling for potential confounders.

CONCLUSION

In contrast to prior work, women in Chicago living within food deserts were less likely to develop gestational diabetes and did not experience poorer outcomes, suggesting environmental factors other than food access contribute to perinatal outcomes.

Association between residential greenness and glycosylated hemoglobin in pregnant women: Findings from the baseline data of Yuexiu birth cohort

BACKGROUND

Previous studies have indicated that residential greenness can affect human health, but limited studies have examined the association between residential greenness and glucose homeostasis during pregnancy. We aimed to investigate the associations of residential greenness with plasma glucose, glycosylated hemoglobin (HbA1c) and gestational diabetes mellitus (GDM).

METHODS

We recruited a total of 587 pregnant women aged 20-45 years in Guangzhou, China. We extracted normalized difference vegetation index with different buffers (NDVI-250m, 500m and 1000m) from remote satellite data based on maternal residential addresses. We measured plasma glucose levels and HbA1c during 20-28 weeks' gestation, and GDM was diagnosed with a 75-g oral glucose tolerance test. We collected the information of relevant covariates by face-to-face interviews and questionnaires. We used generalized linear regression to examine the associations of residential greenness with quantitative and categorized outcomes.

RESULTS

In the final analyses, 123 (21.0%) of the pregnant women were diagnosed as GDM at 20-28 weeks gestation. With a 0.1 unit increase in NDVI-250m, the percent of HbA1c changed by -0.05% [95% confidence interval (CI): -0.08, -0.02]. The results of HbA1c were consistent when using different resolution of NDVI [NDVI-500m: 0.03, 95%CI: -0.05, -0.01; NDVI-1000m: 0.05, 95%CI: -0.08, -0.02]. We observed non-significant associations of glucose levels and the risk of GDM in relation to NDVI with different resolutions when adjusted for confounding. The results remained robust in sensitivity analyses.

CONCLUSION

The present study in Guangzhou, China was the first to identify negative association of NDVI with HbA1c in pregnant women, but we did not observe its association with plasma glucose levels or the risk of GDM. The results support that building sufficient green infrastructure could be considered in urban design and planning to promote maternal health.

Associations of greenness with gestational diabetes mellitus: The Guangdong Registry of Congenital Heart Disease (GRCHD) study

Gestational diabetes mellitus (GDM) is associated with adverse short- and long-term health outcomes among mothers and their offspring. GDM affects 0.6%-15% of pregnancies worldwide and its incidence is increasing. However, intervention strategies are lacking for GDM. Previous studies indicated a protective association between greenspace and type 2 diabetes mellitus (T2DM), while few studies have explored the association between greenness and GDM. This study aimed to investigate the association between residential greenness and GDM among women from 40 clinical centers in Guangdong province, south China. The study population comprised 5237 pregnant mothers of fetuses and infants without birth defects, from 2004 to 2016. There were n = 157 diagnosed with GDM according to World Health Organization criteria. We estimated residential greenness using the Normalized Difference Vegetation Index (NDVI), derived from satellite imagery using a spatial-statistical model. Associations between greenness during pregnancy and GDM were assessed by confounder-adjusted random effects log-binomial regression models, with participating centers as the random effect. One interquartile increments of NDVI_250m, NDVI_500m and NDVI_1000m were associated with 13% (RR = 0.87, 95%CI: 0.87-0.87), 8% (RR = 0.92, 95%CI: 0.91-0.92) and 3% (RR = 0.97, 95%CI: 0.97-0.97) lower risks for GDM, respectively. However, NDVI_3000m was not significantly associated with GDM (RR = 0.96, 95%CI: 0.78-1.19). The risk for GDM decreased monotonically with greater NDVI. The protective effect of greenness on GDM was stronger among women with lower socioeconomic status and in environments with a lower level air pollutants. Our results suggest that greenness might provide an effective intervention to decrease GDM. Greenness and residential proximity to greenspace should be considered in community planning to improve maternal health outcomes.

Urban-Related Environmental Exposures during Pregnancy and Placental Development and Preeclampsia: a Review

PURPOSE OF REVIEW

To summarize the current knowledge of the pathophysiological implications and the clinical role of urban-related environmental exposures in pregnancy.

RECENT FINDINGS

The ongoing urbanization worldwide is leading to an increasing number of pregnant women being exposed to higher levels of urban-related environmental hazards such as air pollution and noise and, at the same time, having less contact with natural environments. Pregnancy represents a particular and vulnerable life period both for women and their children. Extensive physiological and metabolic changes, as well as changes to the cardiovascular and respiratory systems during pregnancy, could result in increased sensitivity to damage by environmental factors. Exposure to air pollution and noise is associated with placental dysfunction and damage, which, in turn, could lead to maternal complications such as preeclampsia. In contrast, more contact with greenspace during pregnancy seems to mitigate these adverse impacts. These findings open up new challenges for our understanding of the potential effect of urban living on placental function and preeclampsia, and offer new clinical and research opportunities.

Greenness, civil environment, and pregnancy outcomes: perspectives with a systematic review and meta-analysis

BACKGROUND

Various maternal conditions, especially in utero conditions and prenatal exposure to environments with air pollution and greenness, have been reviewed to address the enhancement and prevention of susceptibility to health risks, including low birthweight, preterm delivery, and preeclampsia. This study aimed to qualitatively and quantitatively investigate the associations between pregnancy outcomes and the characteristics of surrounding living environment, including greenness, air pollution, and civilization.

METHODS

A secondary search of the MEDLINE, EMBASE, Cochrane Library, K-eArticles, and CINAHL databases was conducted without language restrictions to identify the relevant publications from the time of inception of the databases to April 2019.

RESULTS

A total of 89 studies were identified, and 10 were included in the quantitative synthesis. The greenness of the environment within 100-, 250- and 500-m buffers, after adjusting for the air quality and civilization factors, was weakly but positively associated with birthweight. The pooled regression slope was 0.00134 (95% confidence interval [CI], 0.000, 0.0020). The greenness of the environment was also associated with a significant decrease in the incidence of poor pregnancy outcomes, namely, low birthweight, small for gestational age (odds ratio [OR] 0.94; 95% CI, 0.92, 0.97), and preterm delivery (OR 0.98; 95% CI, 0.97, 0.99).

CONCLUSIONS

The greenness of the environment had a positive effect on the pregnancy outcomes, despite poor air quality and civilization. Following urbanization, planning for greenness management, environmental medicine, and public health is important and thus should be proposed as preventive methods as way of increasing birthweight and life expectancy.

Examining the relationship between food environment and gestational diabetes

BACKGROUND

Studies have shown an association between the incidence of gestational diabetes and living in neighborhoods oversaturated with unhealthy foods.

OBJECTIVE

This study sought to determine if the food environment also affects the management of gestational diabetes. We hypothesized that living in areas with a higher quality of food decreased the risk of requiring medication to treat gestational diabetes.

STUDY DESIGN

This was a retrospective cohort study of singleton births at the Christiana Care Health System between 2015 and 2018. Patients with gestational diabetes who live in Delaware (N=1327) were geocoded and classified according to their census tract food environment. The food environment was assessed using the modified Retail Food Environment Index, which measures the percentage of healthy food retailers among all food retailers within a half-mile radius of the census tract boundaries. The modified Retail Food Environment Index scores were divided into 3 categories: poor (modified Retail Food Environment Index score, 0-3), average (modified Retail Food Environment Index score, 4-10), and good or above average (modified Retail Food Environment Index score, ≥11) food environments. The primary outcome was the prevalence of A2 gestational diabetes mellitus. Several neonatal and obstetrical outcomes were also examined including type II diabetes mellitus (defined as a 2-hour glucose tolerance test with at least 1 value above the threshold), cesarean delivery, shoulder dystocia, admission to the neonatal intensive care unit, neonatal hypoglycemia, neonatal hyperbilirubinemia, neonatal respiratory distress syndrome, and macrosomia.

RESULTS

A total of 689 (52%) women were diagnosed as having A2 gestational diabetes mellitus. Women in the average or good or above average food environment groups had a lower prevalence of A2 gestational diabetes mellitus than women in the poor food environment group (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.92] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.56; 95% confidence interval, 0.40-0.82]). They also had a lower prevalence of type II diabetes mellitus (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.25; 95% confidence interval, 0.09-0.72] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.48; 95% confidence interval, 0.27-0.86]). There were no differences in the other secondary outcomes of interest.

CONCLUSION

The food environment affects the requirement for medication to obtain glycemic levels that are within the target range for those with gestational diabetes.

An external exposome-wide association study of hypertensive disorders of pregnancy

It is widely recognized that exogenous factors play an important role in the development of hypertensive disorders of pregnancy (HDP). However, only a few external environmental factors have been studied, often separately, with no attempt to examine the totality of the external environment, or the external exposome. We conducted an external exposome-wide association study (ExWAS) using the Florida Vital Statistics Birth Records including 819,399 women with live births in 2010-2013. A total of 5784 factors characterizing women's surrounding natural, built, and social environment during pregnancy from 10 data sources were collected, harmonized, integrated, and spatiotemporally linked to the women based on pregnancy periods using 250 m buffers around their geocoded residential addresses. A random 50:50 split divided the data into discovery and replication sets, and a 3-phase procedure was used. In phase 1, associations between HDP and individual factors were examined, and Bonferroni adjustment was performed. In phase 2, an elastic net model was used to perform variable selection among significant variables from phase 1. In phase 3, a multivariable logistic regression model including all variables selected by the elastic net model was fitted. Variables that were significant in both the discovery and replication sets were retained. Among the 528 and 490 variables identified in Phase 1, 232 and 224 were selected by the elastic net model in Phase 2, and 67 and 48 variables remained statistically significant in Phase 3 in the discovery and replication sets, respectively. A total of 12 variables were significant in both the discovery and replication sets, including air toxicants (e.g., 2,2,4-trimethylpentane), meteorological factors (e.g., omega or vertical velocity at 125mb pressure level), neighborhood crime and safety (e.g., burglary rate), and neighborhood sociodemographic status (e.g., urbanization). This is the first large external exposome study of HDP. It confirmed some of the previously reported associations and generated unexpected predictors within the environment that may warrant more focused evaluation.

Influence of residential greenness on adverse pregnancy outcomes: A systematic review and dose-response meta-analysis

BACKGROUND

With the development of urbanization, there is a decreasing tendency for people contact with natural greenness. Whether maternal exposure to greenness has an impact on pregnancy complications and pregnancy outcomes remains to be confirmed.

OBJECTIVES

To estimate the association and dose-response relationship between residential greenness and pregnancy outcomes.

DATA SOURCES

PubMed, Embase, Ovid, Scopus and Web of Science from inception to 1st December 2019 were searched.

SYNTHESIS METHODS

The summary regression coefficient (β) and odds ratio (OR) with corresponding 95% confidence interval (95%CI) were calculated. The linear dose-response relationship between greenness and adverse pregnancy outcomes was also investigated.

RESULTS

Overall, 36 studies with a total of 11,983,089 participants were included. Birth weight was significantly higher in highest level of greenness exposure group compared to lowest level group (e.g. β:20.22, 95%CI:13.50-26.93 at 100 m buffer). The odds of low birth weight (LBW) decreased in the highest level of group compared to lowest level group (e.g. OR:0.86, 95%CI:0.75-0.99 at 100 m buffer). The odds of small for gestational age (SGA) also decreased in the highest group (OR:0.93, 95%CI:0.88-1.00 at 100 m buffer). In addition, maternal exposure to greenness was associated with increased head circumference and decreased mental disorders. The dose-response models showed a 2% decrease risk of LBW per 0.1 normalized difference vegetation index (NDVI) increase within 300 m buffer (OR:0.98, 95%CI:0.97-0.99, P < 0.001) and a 1% decrease risk of SGA per 0.1 NDVI increase within 300 m buffer (OR:0.99, 95%CI:0.98-1.00, P = 0.037). No significant associations were found on preterm birth, gestational age, gestational diabetes mellitus, gestational hypertension or preeclampsia.

CONCLUSIONS

This review confirms an inverse association between residential greenness and adverse pregnancy outcomes. Findings of our study provide evidences for pregnant women to increase greenness exposure.

A Systematic Review and Meta-Analysis of Associations between Green and Blue Spaces and Birth Outcomes

Previous studies suggest that green and blue spaces may promote several health outcomes including birth outcomes. However, no synthesis of previous work has specifically asked policy-relevant questions of how much and what type is needed in every neighborhood to elicit these benefits at the population level. A systematic review and meta-analyses were conducted to synthesize thirty-seven studies on the association between residential green and blue spaces and pregnancy outcomes. Meta-analyses were performed for birth weight (BW), small for gestational age (SGA), low birth weight (LBW) and preterm birth (PTB). Increase in residential greenness was statistically significantly associated with higher BW [β = 0.001, 95%CI: (<0.001, 0.002)] and lower odds of SGA [OR = 0.95, 95%CI: (0.92, 0.97)]. Associations between green space and LBW and PTB were as hypothesized but not statistically significant. Associations between blue spaces and pregnancy outcomes were not evident. No study explicitly examined questions of threshold, though some evidence of nonlinearity indicated that moderate amounts of green space may support more favorable pregnancy outcomes. Policy-relevant green and blue space exposures involving theory-driven thresholds warrant testing to ensure future investments in urban greening promote healthier pregnancy outcomes.

Association of Fast Food and Supermarket Density with Neonatal Outcomes of Pregnancies Affected by Gestational Diabetes

OBJECTIVE

To measure the association of fast food density (FFD) and supermarket density (SD) with adverse neonatal outcomes in pregnancies with gestational diabetes mellitus (GDM).

STUDY DESIGN

This was a retrospective cohort study of women with GDM who delivered at a tertiary care center in a large metropolitan area (1/2010-2/2016). ZIP codes were used to link women with surrounding food environment. FFD and SD were calculated as the number of establishments per 100,000 residents for each ZIP code and classified into quartiles. Quartile 1 represented lowest FFD or SD. Four neonatal outcomes were assessed: large for gestational age (LGA) neonate, shoulder dystocia, neonatal hypoglycemia, and neonatal intensive care unit admission > 3 days. Bivariable and multivariable analyses estimated associations of FFD and SD with outcomes.

RESULTS

A total of 2,373 women met eligibility criteria. Insurance, race/ethnicity, language, and body mass index differed between quartiles, although GDM type did not. High FFD was associated with lower odds of LGA but not with other outcomes. Low SD and FFD:SD ratios were not associated with any outcomes.

CONCLUSION

Among women with GDM, high FFD was associated with some neonatal outcomes, but low SD and FFD:SD ratio was not. Food environment may not be the only social determinant of neonatal outcomes in pregnancies with GDM.

Neighborhood Typology and Cardiometabolic Pregnancy Outcomes in the Maternal Adiposity Metabolism and Stress Study

OBJECTIVE

This study aimed to assess associations between neighborhood typologies classified across multiple neighborhood domains and cardiometabolic pregnancy outcomes and determine variation in effectiveness of a mindfulness-based stress-reduction intervention on outcomes across neighborhood types.

METHODS

Neighborhoods of participants in the Maternal Adiposity Metabolism and Stress (MAMAS) intervention (n = 208) were classified across dimensions of socioeconomic, food, safety, and service/resource environments using latent class analysis. The study estimated associations between neighborhood type and three cardiometabolic pregnancy outcomes-glucose tolerance (GT) during pregnancy, excessive gestational weight gain, and 6-month postpartum weight retention (PPWR)-using marginal regression models. Interaction between neighborhood type and intervention was assessed.

RESULTS

Five neighborhood types differing across socioeconomic, food, and resource environments were identified. Compared with poor, well-resourced neighborhoods, middle-income neighborhoods with low resources had higher risk of impaired GT (relative risk [RR]: 4.1; 95% confidence Interval [CI]: 1.1, 15.5), and wealthy, well-resourced neighborhoods had higher PPWR (beta: 3.9 kg; 95% CI: 0.3, 7.5). Intervention effectiveness varied across neighborhood type with wealthy, well-resourced and poor, moderately resourced neighborhoods showing improvements in GT scores. PPWR was higher in intervention compared with control groups within wealthy, well-resourced neighborhoods.

CONCLUSIONS

Consideration of multidimensional neighborhood typologies revealed important nuances in intervention effectiveness on cardiometabolic pregnancy outcomes.

Air pollution, land use, and complications of pregnancy

BACKGROUND

Mounting evidence suggests that the natural and built environment can affect human health, but relatively few studies have considered links between features of the residential natural and built environment other than air pollution and complications of pregnancy.

OBJECTIVES

To quantify the impact of features of the maternal residential natural and built environments on risk of gestational diabetes mellitus (GDM), gestational hypertension and preeclampsia among 61,640 women who delivered at a single hospital in Rhode Island between 2002 and 2012.

METHODS

We estimated residential levels of ambient fine particulate matter (PM_2.5) and black carbon (BC) using spatiotemporal models, neighborhood green space using remote sensing and proximity to recreational facilities, and neighborhood blue space using distance to coastal and fresh water. We used logistic regression to separately estimate the association between each feature and GDM, gestational hypertension, and preeclampsia, adjusting for individual and neighborhood markers of socioeconomic status.

RESULTS

GDM, gestational hypertension, and preeclampsia were diagnosed in 8.0%, 5.0%, and 3.6% of women, respectively. We found 2nd trimester PM_2.5 (OR = 1.08, 95% CI: 1.00, 1.15 per interquartile range increase in PM_2.5) and living close to a major roadway (1.09, 95% CI: 1.00, 1.19) were associated with higher odds of GDM, while living <1 km from the coast was associated with lower odds of GDM (0.87, 95% CI: 0.78, 0.96). Living <500 m from a recreational facility was associated with lower odds of gestational hypertension (0.89, 95% CI: 0.80, 0.99). None of these features were associated with odds of preeclampsia. Results were qualitatively similar in mutually-adjusted models and sensitivity analyses.

CONCLUSIONS

In this small coastal US state, risk of GDM was positively associated with PM_2.5 and proximity to busy roadways, and negatively associated with proximity to blue space, highlighting the importance of the natural and built environment to maternal health.

Mitigation of air pollution by greenness: A narrative review

Air pollution represents one of the world's most important environmental health risks, being associated with an increased rate of multiple diseases (mainly cardiopulmonary) and of premature deaths. A number of actions have been suggested and implemented to mitigate the deleterious health effects of air pollution. Accordingly, recent research has attempted to estimate the beneficial effect of exposure to greenness on human health. In this narrative review, we summarize and review the current literature on the favourable association between greenness and human health in both the outdoor and indoor environments. The potential mechanisms underlying this benefit will be also addressed.

Residential greenness: current perspectives on its impact on maternal health and pregnancy outcomes

Recent research in environmental epidemiology has attempted to estimate the effects of exposure to nature, often operationalized as vegetation, on health. Although many analyses have focused on vegetation or greenness with regard to physical activity and weight status, an incipient area of interest concerns maternal health and birth outcomes. This paper reviews 14 studies that examined the association between greenness and maternal or infant health. Most studies were cross-sectional and conducted in birth cohorts. Several studies found evidence for positive associations between greenness and birth weight and maternal peripartum depression. Few studies found evidence for an association between greenness and gestational age or other birth outcomes, or between greenness and preeclampsia or gestational diabetes. Several assessed effect modification by individual or area-level socioeconomic status and found that effects were stronger among those of lower socioeconomic status. Few studies conducted mediation analyses of any kind. Future research should include more diverse birth outcomes and focus on maternal health (especially mental health) and capitalize on richer exposure information during pregnancy rather than cross-sectional assessment at birth.