Green space exposure on mortality and cardiovascular outcomes in older adults: a systematic review and meta-analysis of observational studies

The impact of residential environment on stroke onset and its spatial heterogeneity: A multiscale exploration in Shanghai

BACKGROUND

Stroke is a worldwide concern due to its high disability and mortality rates, especially in many countries entering ageing societies. This study aims to understand the spatial heterogeneity of stroke onset and residential environment influence scopes from multiscale.

METHODS

The 2013 to 2022 spatiotemporal distribution pattern of stroke onset was obtained via out-patient data from a hospital in Shanghai. Then nine residential environmental factors were selected to estimate the association of stroke onset by multiscale geographically weighted regression (MGWR), in three scenarios.

RESULTS

Accessibility to pubs/bars (PUB) and building density (BD) were the top two residential environmental factors both for the entire sample and by gender. Stress-related environmental factors have a greater impact on the onset of stroke in men but are limited in scope. The population of elderly people have relevance to environmental variables heterogeneity. The indicators relating to unhealthy food and alcohol suggest that habit-inducing environmental factors have a limited impact on stroke onset, but rather that pre-existing habits play a greater role.

CONCLUSIONS

MGWR analyses individual components across multiple bandwidths, revealing geographical disparities in the impact of elements that would otherwise be undetected on a global scale. Environmental factors have a limited impact on the onset of stroke. When society is faced with both heavy ageing and fiscal constraints, some of the blue-green space budgets can be scaled back to invest in more secure facilities.

Credibility of the evidence on green space and human health: an overview of meta-analyses using evidence grading approaches

BACKGROUND

Green space is an important part of the human living environment, with many epidemiological studies estimating its impact on human health. However, no study has quantitatively assessed the credibility of the existing evidence, impeding their translations into policy decisions and hindering researchers from identifying new research gaps. This overview aims to evaluate and rank such evidence credibility.

METHODS

Following the PRISMA guideline, we systematically searched PubMed, Web of Science, and Embase databases for systematic reviews with meta-analyses concerning green spaces and health outcomes published up to January 15, 2024. We categorized the credibility of meta-analytical evidence from interventional studies into four levels (i.e., high, moderate, low, and very low) using the Grading of Recommendation, Assessment, Development and Evaluations framework, based on five domains including risk of bias, inconsistency, indirectness, imprecision, and publication bias. Further, we recalculated all the meta-analyses from observational studies and classified evidence into five levels (i.e., convincing, highly suggestive, suggestive, weak, and non-significant) by considering stringent thresholds for P-values, sample size, robustness, heterogeneity, and testing for biases.

FINDINGS

In total, 154 meta-analysed associations (interventional = 44, observational = 110) between green spaces and health outcomes were graded. Among meta-analyses from interventional studies, zero, four (wellbeing, systolic blood pressure, negative affect, and positive affect), 20, and 20 associations between green spaces and health outcomes were graded as high, moderate, low, and very low credibility evidence, respectively. Among meta-analyses from observational studies, one (cardiovascular disease mortality), four (prevalence/incidence of diabetes mellitus, preterm birth, and small for gestational age infant, and all-cause mortality), 12, 22, and 71 associations were categorized as convincing, highly suggestive, suggestive, weak, and non-significant evidence, respectively.

INTERPRETATION

The current evidence largely confirms beneficial associations between green spaces and human health. However, only a small subset of these associations can be deemed to have a high or convincing credibility. Hence, future better designed primary studies and meta-analyses are still needed to provide higher quality evidence for informing health promotion strategies.

FUNDING

The National Natural Science Foundation of China of China; the Guangzhou Science and Technology Program; the Guangdong Medical Science and Technology Research Fund; the Research Grant Council of the Hong Kong SAR; and Sino-German mobility program.

Impact of green space and built environment on metabolic syndrome: A systematic review with meta-analysis

Metabolic Syndrome presents a significant public health challenge associated with an increased risk of noncommunicable diseases such as cardiovascular conditions. Evidence shows that green spaces and the built environment may influence metabolic syndrome. We conducted a systematic review and meta-analysis of observational studies published through August 30, 2023, examining the association of green space and built environment with metabolic syndrome. A quality assessment of the included studies was conducted using the Office of Health Assessment and Translation (OHAT) tool. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment was used to evaluate the overall quality of evidence. Our search retrieved 18 studies that met the inclusion criteria and were included in our review. Most were from China (n = 5) and the USA (n = 5), and most used a cross-sectional study design (n = 8). Nine studies (50 %) reported only green space exposures, seven (39 %) reported only built environment exposures, and two (11 %) reported both built environment and green space exposures. Studies reported diverse definitions of green space and the built environment, such as availability, accessibility, and quality, particularly around participants' homes. The outcomes focused on metabolic syndrome; however, studies applied different definitions of metabolic syndrome. Meta-analysis results showed that an increase in normalized difference vegetation index (NDVI) within a 500-m buffer was associated with a lower risk of metabolic syndrome (odds ratio [OR] = 0.90, 95%CI = 0.87-0.93, I2 = 22.3 %, n = 4). A substantial number of studies detected bias for exposure classification and residual confounding. Overall, the extant literature shows a 'limited' strength of evidence for green space protecting against metabolic syndrome and an 'inadequate' strength of evidence for the built environment associated with metabolic syndrome. Studies with more robust study designs, better controlled confounding factors, and stronger exposure measures are needed to understand better what types of green spaces and built environment features influence metabolic syndrome.

Greenspaces And Cardiovascular Health

Accumulating evidence suggests that living in areas of high surrounding greenness or even brief exposures to areas of high greenery is conducive to cardiovascular health, which may be related to the environmental, social, psychological, and physiological benefits of greenspaces. Recent data from multiple cross-sectional, longitudinal, and cohort studies suggest that living in areas of high surrounding greenness is associated with a lower risk of all-cause and cardiovascular mortality. High levels of neighborhood greenery have been linked also to a decrease in the burden of cardiovascular disease risk factors as reflected by lower rates of hypertension, dyslipidemia, and diabetes. Those who live in greener environments report better mental health and more frequent social interactions, which can benefit cardiovascular health as well. In this narrative review, we discuss evidence linking greenspaces to cardiovascular health as well as the potential mechanisms underlying the beneficial effects of greenspaces, including the impact of vegetation on air, noise and light pollution, ambient temperature, physical activity, mental health, and biodiversity. We review literature on the beneficial effects of acute and chronic exposure to nature on cardiovascular disease risk factors, inflammation and immune function, and we highlight the potential cardiovascular effects of biogenic volatile organic compounds that are emitted by trees and shrubs. We identify current knowledge gaps in this area and underscore the need for additional population studies to understand more clearly and precisely the link between greenness and health. Such understanding is urgently needed to fully redeem the promise of greenspaces in preventing adverse environmental exposures, mitigating the effects of climate change, and creating healthier living environments.

The Urban Environment and Cardiometabolic Health

Urban environments contribute substantially to the rising burden of cardiometabolic diseases worldwide. Cities are complex adaptive systems that continually exchange resources, shaping exposures relevant to human health such as air pollution, noise, and chemical exposures. In addition, urban infrastructure and provisioning systems influence multiple domains of health risk, including behaviors, psychological stress, pollution, and nutrition through various pathways (eg, physical inactivity, air pollution, noise, heat stress, food systems, the availability of green space, and contaminant exposures). Beyond cardiometabolic health, city design may also affect climate change through energy and material consumption that share many of the same drivers with cardiometabolic diseases. Integrated spatial planning focusing on developing sustainable compact cities could simultaneously create heart-healthy and environmentally healthy city designs. This article reviews current evidence on the associations between the urban exposome (totality of exposures a person experiences, including environmental, occupational, lifestyle, social, and psychological factors) and cardiometabolic diseases within a systems science framework, and examines urban planning principles (eg, connectivity, density, diversity of land use, destination accessibility, and distance to transit). We highlight critical knowledge gaps regarding built-environment feature thresholds for optimizing cardiometabolic health outcomes. Last, we discuss emerging models and metrics to align urban development with the dual goals of mitigating cardiometabolic diseases while reducing climate change through cross-sector collaboration, governance, and community engagement. This review demonstrates that cities represent crucial settings for implementing policies and interventions to simultaneously tackle the global epidemics of cardiovascular disease and climate change.

Toward Heart-Healthy and Sustainable Cities: A Policy Statement From the American Heart Association

Nearly 56% of the global population lives in cities, with this number expected to increase to 6.6 billion or >70% of the world's population by 2050. Given that cardiometabolic diseases are the leading causes of morbidity and mortality in people living in urban areas, transforming cities and urban provisioning systems (or urban systems) toward health, equity, and economic productivity can enable the dual attainment of climate and health goals. Seven urban provisioning systems that provide food, energy, mobility-connectivity, housing, green infrastructure, water management, and waste management lie at the core of human health, well-being, and sustainability. These provisioning systems transcend city boundaries (eg, demand for food, water, or energy is met by transboundary supply); thus, transforming the entire system is a larger construct than local urban environments. Poorly designed urban provisioning systems are starkly evident worldwide, resulting in unprecedented exposures to adverse cardiometabolic risk factors, including limited physical activity, lack of access to heart-healthy diets, and reduced access to greenery and beneficial social interactions. Transforming urban systems with a cardiometabolic health-first approach could be accomplished through integrated spatial planning, along with addressing current gaps in key urban provisioning systems. Such an approach will help mitigate undesirable environmental exposures and improve cardiovascular and metabolic health while improving planetary health. The purposes of this American Heart Association policy statement are to present a conceptual framework, summarize the evidence base, and outline policy principles for transforming key urban provisioning systems to heart-health and sustainability outcomes.

Green space, genetic susceptibility, and risk of osteoporosis:a cohort study from the UK Biobank

OBJECTIVE

This study aimed to investigate the effect of residential exposure to green space on the incident osteoporosis and further explore the modification effect of genetic susceptibility.

METHODS

Participants from the UK Biobank were followed from 2006 to 2010 (baseline) to December 31st, 2022. Using land use coverage, we evaluated exposure to residential surrounding green space, natural environment, and domestic gardens. We used the Cox regression to examine the association between the residential environment and incident osteoporosis. The interactive effects between polygenic risk score (PRS) of osteoporosis and residential environments on incident osteoporosis were investigated.

RESULTS

This study included 292,662 participants. Over a median follow-up period of 13.65 years, we documented 9177 incidents of osteoporosis. Per interquartile (IQR) increase in greenness and natural environment at a 300 m buffer was associated with a 4% lower risk of incident osteoporosis [HR = 0.96 (95% CI: 0.93, 0.99)] and [HR = 0.96 (95% CI: 0.93, 0.98)], respectively. We did not identify any interactive effects between genetic risk and residential environment on incident osteoporosis.

CONCLUSIONS

This study found that public greenness and natural environments could reduce the risk of incident osteoporosis regardless of genetic predisposition. Developing sustainable and publicly accessible natural environments might benefit populations' bone health.

Exposure to green spaces, cardiovascular risk biomarkers and incident cardiovascular disease in older adults: The Seniors-Enrica II cohort

INTRODUCTION

The impact of residential green spaces on cardiovascular health in older adults remains uncertain.

METHODS

Cohort study involving 2114 adults aged ≥ 65 years without cardiovascular disease (CVD), residing in five dense municipalities (Prince et al., 2015) of the Madrid region and with detailed characterization of their socioeconomic background, health behaviors, CVD biological risk factors, and mental, physical, and cognitive health. Greenness exposure was measured using the Normalized Difference Vegetation Index (NDVI) at varying distances from participants' homes. Traffic exposure, neighborhood environment, neighborhood walkability, and socioeconomic deprivation at the census level were also assessed. Serum N-terminal pro-B-type natriuretic peptide (NT-ProBNP), high-sensitivity troponin T (hs-TnT), interleukin 6 (IL-6), and Growth Differentiation Factor 15 (GDF-15) were measured at baseline, and incident CVD events identified through electronic medical records (International Classification of Primary Care-2 codes K74, K75, K77, K90, and K92).

RESULTS

After adjusting for sex, age, educational attainment, financial hardship and socioeconomic deprivation at the census level, an interquartile range (IQR) increase in NDVI at 250, 500, 750, and 1000 m around participants' homes was associated with mean differences in ProBNP of -5.56 % (95 %CI: -9.77; -1.35), -5.05 % (-9.58; -0.53), -4.24 % (-8.19, -0.19), and -4.16 % (-7.59; -0.74), respectively; and mean differences in hs-TnT among diabetic participants of -8.03 % (95 %CI: -13.30; -2.77), -9.52 % (-16.08; -2.96), -8.05 % (-13.94, -2.16) and -5.56 % (-10.75; -0.54), respectively. Of similar magnitude, although only statistically significant at 250 and 500 m, were the observed lower IL-6 levels with increasing greenness. GDF-15 levels were independent of NDVI. In prospective analyses (median follow-up 6.29 years), an IQR increase in residential greenness at 500, 750, and 1000 m was associated with a lower risk of incident CVD. The variables that contributed most to the apparent beneficial effects of greenness on CVD were lower exposure to traffic, improved cardiovascular risk factors, and enhanced physical performance. Additionally, neighborhood walkability and increased physical activity were notable contributors among individuals with diabetes.

CONCLUSION

Increased exposure to residential green space was associated with a moderate reduction in CVD risk in older adults residing in densely populated areas.

The use of Enhanced Vegetation Index for assessing access to different types of green space in epidemiological studies

BACKGROUND

Exposure to green space can protect against poor health through a variety of mechanisms. However, there is heterogeneity in methodological approaches to exposure assessments which makes creating effective policy recommendations challenging.

OBJECTIVE

Critically evaluate the use of a satellite-derived exposure metric, the Enhanced Vegetation Index (EVI), for assessing access to different types of green space in epidemiological studies.

METHODS

We used Landsat 5-8 (30 m resolution) to calculate average EVI for a 300 m radius surrounding 1.4 million households in Wales, UK for 2018. We calculated two additional measures using topographic vector data to represent access to green spaces within 300 m of household locations. The two topographic vector-based measures were total green space area stratified by type and average private garden size. We used linear regression models to test whether EVI could discriminate between publicly accessible and private green space and Pearson correlation to test associations between EVI and green space types.

RESULTS

Mean EVI for a 300 m radius surrounding households in Wales was 0.28 (IQR = 0.12). Total green space area and average private garden size were significantly positively associated with corresponding EVI measures (β = < 0.0001, 95% CI: 0.0000, 0.0000; β = 0.0001, 95% CI: 0.0001, 0.0001 respectively). In urban areas, as average garden size increases by 1 m2, EVI increases by 0.0002. Therefore, in urban areas, to see a 0.1 unit increase in EVI index score, garden size would need to increase by 500 m2. The very small β values represent no 'measurable real-world' associations. When stratified by type, we observed no strong associations between greenspace and EVI.

IMPACT

It is a widely implemented assumption in epidiological studies that an increase in EVI is equivalent to an increase in greenness and/or green space. We used linear regression models to test associations between EVI and potential sources of green reflectance at a neighbourhood level using satellite imagery from 2018. We compared EVI measures with a 'gold standard' vector-based dataset that defines publicly accessible and private green spaces. We found that EVI should be interpreted with care as a greater EVI score does not necessarily mean greater access to publicly available green spaces in the hyperlocal environment.

Green space and stroke: A scoping review of the evidence

BACKGROUND

Global industrialisation and urbanisation has led to an increased interest in the link between the environment and health. Stroke is a major cause of morbidity and mortality, and there is increased evidence that environmental factors may affect both the incidence and severity of stroke. This review summarises the evidence for relationship between green space exposure and stroke incidence and outcomes.

METHODS

We conducted a literature search in Medline and Scopus until 1 August 2023, and screened references of relevant articles. Selected articles were appraised for their relevance, and critically reviewed. The findings were thematically categorised.

RESULTS

Of the 1342 papers identified, 27 were included. These involved a mix of study designs (cohort, cross-sectional, quasi-experimental, time stratified case crossover and ecological). There was consistent evidence indicating a protective association between green space exposure and disability and stroke-related death with mortality hazard ratios between 0.66 and 0.95. Most studies also showed that green space was inversely associated with stroke risk, with risk estimates from studies showing a protective effect ranging between 0.4 and 0.98; however, results were more mixed and some did not reach statistical significance. The moderating effects of green spaces on ambient temperatures, noise and air pollution, and psychosocial health plus greater enjoyment and opportunity for exercise and enrichment of the human microbiome may underly these associations.

CONCLUSION

There is likely some protective effect of green space on stroke, with the benefits most convincingly shown for post-stroke outcomes. More research is recommended to confirm the protective association between green space exposure and reduced stroke risk.

Potential causal links and mediation pathway between urban greenness and lung cancer mortality: Result from a large cohort (2009 to 2020)

Urban greenness, as a vital component of the urban environment, plays a critical role in mitigating the adverse effects of rapid urbanization and supporting urban sustainability. However, the causal links between urban greenness and lung cancer mortality and its potential causal pathway remain poorly understood. Based on a prospective community-based cohort with 581,785 adult participants in southern China, we applied a doubly robust Cox proportional hazard model to estimate the causal associations between urban greenness exposure and lung cancer mortality. A general multiple mediation analysis method was utilized to further assess the potential mediating roles of various factors including particulate matter (PM1, PM2.5-1, and PM10-2.5), temperature, physical activity, and body mass index (BMI). We observed that each interquartile range (IQR: 0.06) increment in greenness exposure was inversely associated with lung cancer mortality, with a hazard ratio (HR) of 0.89 (95 % CI: 0.83, 0.96). The relationship between greenness and lung cancer mortality might be partially mediated by particulate matter, temperature, and physical activity, yielding a total indirect effect of 0.826 (95 % CI: 0.769, 0.887) for each IQR increase in greenness exposure. Notably, the protective effect of greenness against lung cancer mortality could be achieved primarily by reducing the particulate matter concentration.

Disentangling associations between multiple environmental exposures and all-cause mortality: an analysis of European administrative and traditional cohorts

Background

We evaluated the independent and joint effects of air pollution, land/built environment characteristics, and ambient temperature on all-cause mortality as part of the EXPANSE project.

Methods

We collected data from six administrative cohorts covering Catalonia, Greece, the Netherlands, Rome, Sweden, and Switzerland and three traditional cohorts in Sweden, the Netherlands, and Germany. Participants were linked to spatial exposure estimates derived from hybrid land use regression models and satellite data for: air pollution [fine particulate matter (PM2.5), nitrogen dioxide (NO₂), black carbon (BC), warm season ozone (O3)], land/built environment [normalized difference vegetation index (NDVI), distance to water, impervious surfaces], and ambient temperature (the mean and standard deviation of warm and cool season temperature). We applied Cox proportional hazard models accounting for several cohort-specific individual and area-level variables. We evaluated the associations through single and multiexposure models, and interactions between exposures. The joint effects were estimated using the cumulative risk index (CRI). Cohort-specific hazard ratios (HR) were combined using random-effects meta-analyses.

Results

We observed over 3.1 million deaths out of approximately 204 million person-years. In administrative cohorts, increased exposure to PM2.5, NO2, and BC was significantly associated with all-cause mortality (pooled HRs: 1.054, 1.033, and 1.032, respectively). We observed an adverse effect of increased impervious surface and mean season-specific temperature, and a protective effect of increased O3, NDVI, distance to water, and temperature variation on all-cause mortality. The effects of PM2.5 were higher in areas with lower (10th percentile) compared to higher (90th percentile) NDVI levels [pooled HRs: 1.054 (95% confidence interval (CI) 1.030-1.079) vs. 1.038 (95% CI 0.964-1.118)]. A similar pattern was observed for NO2. The CRI of air pollutants (PM2.5 or NO2) plus NDVI and mean warm season temperature resulted in a stronger effect compared to single-exposure HRs: [PM2.5 pooled HR: 1.061 (95% CI 1.021-1.102); NO2 pooled HR: 1.041 (95% CI 1.025-1.057)]. Non-significant effects of similar patterns were observed in traditional cohorts.

Discussion

The findings of our study not only support the independent effects of long-term exposure to air pollution and greenness, but also highlight the increased effect when interplaying with other environmental exposures.

Geographic uncertainties in external exposome studies: A multi-scale approach to reduce exposure misclassification

BACKGROUND

Many studies on environment-health associations have emphasized that the selected buffer size (i.e., the scale of the geographic context when exposures are assigned at people's address location) may affect estimated effect sizes. However, there is limited methodological progress in addressing these buffer size-related uncertainties.

AIM

We aimed to 1) develop a statistical multi-scale approach to address buffer-related scale effects in cohort studies, and 2) investigate how environment-health associations differ between our multi-scale approach and ad hoc selected buffer sizes.

METHODS

We used lacunarity analyses to determine the largest meaningful buffer size for multiple high-resolution exposure surfaces (i.e., fine particulate matter [PM2.5], noise, and the normalized difference vegetation index [NDVI]). Exposures were linked to 7.7 million Dutch adults at their home addresses. We assigned exposure estimates based on buffers with fine-grained distance increments until the lacunarity-based upper limit was reached. Bayesian Cox model averaging addressed geographic uncertainties in the estimated exposure effect sizes within the exposure-specific upper buffer limits on mortality. Z-tests assessed statistical differences between averaged effect sizes and those obtained through pre-selected 100, 300, 1200, and 1500 m buffers.

RESULTS

The estimated lacunarity curves suggested exposure-specific upper buffer size limits; the largest was for NDVI (960 m), followed by noise (910 m) and PM2.5 (450 m). We recorded 845,229 deaths over eight years of follow-up. Our multi-scale approach indicated that higher values of NDVI were health-protectively associated with mortality risk (hazard ratio [HR]: 0.917, 95 % confidence interval [CI]: 0.886-0.948). Increased noise exposure was associated with an increased risk of mortality (HR: 1.003, 95 % CI: 1.002-1.003), while PM2.5 showed null associations (HR:0.998, 95 % CI: 0.997-1.000). Effect sizes of NDVI and noise differed significantly across the averaged and prespecified buffers (p < 0.05).

CONCLUSIONS

Geographic uncertainties in residential-based exposure assessments may obscure environment-health associations or risk spurious ones. Our multi-scale approach produced more consistent effect estimates and mitigated contextual uncertainties.

Residential Greenness and Long-term Mortality Among Patients Who Underwent Coronary Artery Bypass Graft Surgery

BACKGROUND

Studies have reported inverse associations between exposure to residential greenness and mortality. Greenness has also been associated with better surgical recovery. However, studies have had small sample sizes and have been restricted to clinical settings. We investigated the association between exposure to residential greenness and all-cause mortality among a cohort of cardiac patients who underwent coronary artery bypass graft (CABG) surgery.

METHODS

We studied this cohort of 3,128 CABG patients between 2004 and 2009 at seven cardiothoracic departments in Israel and followed patients until death or 1st May 2021. We collected covariate information at the time of surgery and calculated the patient-level average normalized difference vegetation index (NDVI) over the entire follow-up in a 300 m buffer from the home address. We used Cox proportional hazards regression models to estimate associations between greenness and death, adjusting for age, sex, origin, socioeconomic status, type of hospital admission, peripherality, air pollution, and distance from the sea.

RESULTS

Mean age at surgery was 63.8 ± 10.6 for men and 69.5 ± 10.0 for women. During an average of 12.1 years of follow-up (37,912 person-years), 1,442 (46%) patients died. A fully adjusted Cox proportional hazards model estimated a 7% lower risk of mortality (HR: 0.93, 95% CI = [0.85, 1.00]) per 1 interquartile range width increase (0.04) in NDVI. Results were robust to the use of different buffer sizes (100 m-1,250 m from the home) and to the use of average NDVI exposure during the first versus the last 2 years of follow-up.

CONCLUSIONS

Residential greenness was associated with lower risk of mortality in CABG patients.

The complex role of air pollution on the association between greenness and respiratory mortality: Insight from a large cohort, 2009-2020

BACKGROUND

Although emerging studies have illuminated the protective association between greenness and respiratory mortality, efforts to quantify the potentially complex role of air pollution in the causal pathway are still limited. We aimed to examine the potential roles of air pollution in the causal pathway between greenness and respiratory mortality in China.

METHODS

We used data from a community-based prospective cohort of 654,115 participants in southern China (Jan 2009-Dec 2020). We evaluated the greenness exposure as a three-year moving average Normalized Difference Vegetation Index (NDVI) within the 500 m buffer around the residence. Cox proportional hazards model was applied to estimate the association between greenness and respiratory mortality. Causal mediation analysis combined with a four-way dimensional decomposition method was utilized to simultaneously quantify the interaction and mediation role of air pollution including PM2.5, PM10, or NO2 on the greenness-respiratory mortality relationship.

FINDINGS

We observed 6954 respiratory deaths during 12 years of follow-up. Increasing NDVI level from the lowest to the highest quartile is associated with a 19 % (95%CI: 13-25 %) reduction in the respiratory mortality risk. For the total protective effect, the proportion attributable to the overall negative interaction between greenness and air pollution (PM2.5, PM10, or NO2) was 2.2 % (1.7-3.2 %), 3.5 % (0.4-3.7 %), or 25.0 % (22.8-27.1 %), respectively. Simultaneously, we estimated 25.5 % (20.1-32.0 %), 49.5 % (32.5-71.9 %), or 1.0 % (0.8-1.2 %) of the total protective association was mediated through a reduction in PM2.5, PM10, or NO2, respectively.

INTERPRETATION

Increased greenness exposure mitigated respiratory mortality through both the antagonistic interaction and mediation pathway of air pollution (PM2.5, PM10, or NO2).

The built environment and cardiovascular disease: an umbrella review and meta-meta-analysis

AIMS

To provide a comprehensive overview of the current evidence on objectively measured neighbourhood built environment exposures in relation to cardiovascular disease (CVD) events in adults.

METHODS AND RESULTS

We searched seven databases for systematic reviews on associations between objectively measured long-term built environmental exposures, covering at least one domain (i.e. outdoor air pollution, food environment, physical activity environment like greenspace and walkability, urbanization, light pollution, residential noise, and ambient temperature), and CVD events in adults. Two authors extracted summary data and assessed the risk of bias independently. Robustness of evidence was rated based on statistical heterogeneity, small-study effect, and excess significance bias. Meta-meta-analyses were conducted to combine the meta-analysis results from reviews with comparable exposure and outcome within each domain. From the 3304 initial hits, 51 systematic reviews were included, covering 5 domains and including 179 pooled estimates. There was strong evidence of the associations between increased air pollutants (especially PM2.5 exposure) and increased residential noise with greater risk of CVD. Highly suggestive evidence was found for an association between increased ambient temperature and greater risk of CVD. Systematic reviews on physical activity environment, food environment, light pollution, and urbanization in relation to CVD were scarce or lacking.

CONCLUSION

Air pollutants, increased noise levels, temperature, and greenspace were associated with CVD outcomes. Standardizing design and exposure assessments may foster the synthesis of evidence. Other crucial research gaps concern the lack of prospective study designs and lack of evidence from low-to-middle-income countries (LMICs).

REGISTRATION

PROSPERO: CRD42021246580.

Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

Long-term exposure to low-level air pollution and greenness and mortality in Northern Europe. The Life-GAP project

BACKGROUND

Air pollution has been linked to mortality, but there are few studies examining the association with different exposure time windows spanning across several decades. The evidence for the effects of green space and mortality is contradictory.

OBJECTIVE

We investigated all-cause mortality in relation to exposure to particulate matter (PM2.5 and PM10), black carbon (BC), nitrogen dioxide (NO2), ozone (O3) and greenness (normalized difference vegetation index - NDVI) across different exposure time windows.

METHODS

The exposure assessment was based on a combination of the Danish Eulerian Hemispheric Model and the Urban Background Model for the years 1990, 2000 and 2010. The analysis included a complete case dataset with 9,135 participants from the third Respiratory Health in Northern Europe study (RHINE III), aged 40-65 years in 2010, with mortality follow-up to 2021. We performed Cox proportional hazard models, adjusting for potential confounders.

RESULTS

Altogether, 327 (3.6 %) persons died in the period 2010-2021. Increased exposures in 1990 of PM2.5, PM10, BC and NO2 were associated with increased all-cause mortality hazard ratios of 1.40 (95 % CI1.04-1.87 per 5 μg/m3), 1.33 (95 % CI: 1.02-1.74 per 10 μg/m3), 1.16 (95 % CI: 0.98-1.38 per 0.4 μg/m3) and 1.17 (95 % CI: 0.92-1.50 per 10 μg/m3), respectively. No statistically significant associations were observed between air pollution and mortality in other time windows. O3 showed an inverse association with mortality, while no association was observed between greenness and mortality. Adjusting for NDVI increased the hazard ratios for PM2.5, PM10, BC and NO2 exposures in 1990. We did not find significant interactions between greenness and air pollution metrics.

CONCLUSION

Long term exposure to even low levels of air pollution is associated with mortality. Opening up for a long latency period, our findings indicate that air pollution exposures over time may be even more harmful than anticipated.

Targeted health promotion with guided nature walks or group exercise: a controlled trial in primary care

Background

Contact with nature promotes wellbeing through diverse pathways, providing a potential way of supporting health especially in primary care, where patients commonly suffer from multimorbidity and poor general health. Social prescribing is a non-pharmaceutical approach for improving health as well as social inclusion. This field study explores and compares the effects of a nature-based and an exercise-based social prescribing scheme on mental wellbeing and sleep, in a primary care population.

Methods

Primary care patients identified to benefit from a general improvement to their health were recruited by nurses, doctors, or social workers to this non-randomized, intention-to-treat, pilot field-study. Participants (n = 79) chose between the group interventions, either taking part in guided walks in nature, including immersion in a forest with high biodiversity, or participating in a versatile sports program. Mental wellbeing was assessed with the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), with additional questions evaluating self-rated health and sleep. Impact on mental wellbeing was explored in relation to perceived health. The amount and quality of sleep was measured with wrist-worn accelerometers. With a focus on everyday life impacts, the assessments took place before and after the 8-week intervention. All participants lived in Sipoo, Finland, an area with abundant accessible green space.

Results

Participants (mean age 57 years, 79% female) rated their general and mental health lower than the general population. Participation in the Nature-group resulted in improved mental wellbeing (change in WEMWBS by 3.15, p = 0.008), with a positive change for feeling relaxed, being cheerful, having energy to spare, feeling able to deal well with problems, feeling good about oneself and feeling close to other people. The Sports-group was beneficial for those initially rating their health as good. Sleep duration improved in the Sports-group, while participants in the Nature-group reported better sleep quality. Following the interventions there was improvement in perceived health and ability to function in both groups, while perceived mental health improved only in the Nature-group.

Conclusion

We attest that even in areas surrounded by greenery, active interventions can further improve health in a primary care population, and that nature-based interventions are beneficial for those in poor health.

Clinical trial registration

ClinicalTrials.gov, Identifier NCT05893212.

Association between greenspace and cancer: evidence from a systematic review and meta-analysis of multiple large cohort studies

Cancer is a chronic disease that seriously endangers human health, and studies on its association with greenspace have been published. We aimed to systematically review the epidemiological evidence and obtain the best available evidence. PubMed, Web of Science, Embase, and Cochrane Library were used as search databases, the time limit was September 12, 2022, and the cited articles were manually supplemented. Two researchers independently performed literature screening and data extraction. We performed a meta-analysis of data using a normalized difference vegetation index (NDVI) as the greenspace measure, providing hazard ratio (HR) and corresponding 95% CI. After standardization of the data, we used a random effects model for pooling. We also assessed the risk of bias for each study and the quality of each evidence body. We identified 10,108 items and included 14 studies from 11 institutions in eight countries. All studies had a low risk of bias. Quantitative analysis of 13 studies found a beneficial association of greenspace with the mortality of lung cancer (pooled HR [95% CI]=0.965 [0.947, 0.983]) and prostate cancer (HR [95% CI]=0.939 [0.898, 0.980]) based on 0.1-unit NDVI increment and a potential beneficial association with the incidence of prostate, lung, and breast cancer. Greenspace had opposite associations with cancer mortality for urban and rural populations. Indirect comparisons did not find statistically significant differences in the effects of greenspace on different cancer outcomes. The evidence body assessment was considered to be "very low." This review indicated potential beneficial associations between greenspace for lung, prostate, and breast cancer outcomes. However, there was a lack of mediation analysis to explore the underlying mechanism of a causal association. Meanwhile, the interstudy heterogeneity was large. Therefore, future studies should consider more accurate exposure assessment and more comprehensive covariate coverage, while focusing on mediating analysis. PROSPERO: CRD42022361068.

Global association of greenness exposure with risk of nervous system disease: A systematic review and meta-analysis

Nervous system disease (NSD) is a global health burden with increasing prevalence in the last 30 years. There is evidence that greenness can improve nervous system health through a variety of mechanisms; however, the evidence is inconsistent. In the present systematic review and meta-analysis, we examined the relationship between greenness exposure and NSD outcomes. Studies on the relationship between greenness and NSD health outcomes published till July 2022 were searched in PubMed, Cochrane, Embase, Scopus, and Web of Science. In addition, we searched the cited literature and updated our search on Jan 20, 2023, to identify any new studies. We included human epidemiological studies that assess the association of greenness exposure with the risk of NSD. Greenness exposure was measured using NDVI (the normalized difference vegetation index) and the outcome was the mortality or morbidity of NSD. The pooled relative risks (RRs) were estimated using a random effects model. Of 2059 identified studies, 15 studies were included in our quantitative evaluation, in which 11 studies found a significant inverse relationship between the risk of NSD mortality or incidence/prevalence and an increase in surrounding greenness. The pooled RRs for cerebrovascular diseases (CBVD), neurodegenerative diseases (ND), and stroke mortality were 0.98 (95 % CI: 0.97, 1.00), 0.98 (95 % CI: 0.98, 0.99), and 0.96 (95 % CI: 0.93, 1.00), respectively. The pooled RRs for PD incidence and stroke prevalence/incidence were 0.89 (95 % CI: 0.78, 1.02) and 0.98 (95 % CI: 0.97, 0.99), respectively. The confidence of evidence for ND mortality, stroke mortality, and stroke prevalence/incidence was downgraded to "low", while CBVD mortality and PD incidence were downgraded to "very low" due to inconsistency. We found no evidence of publication bias and the sensitivity analysis results of all subgroups are robust except for the stroke mortality subgroup. This is the first comprehensive meta-analysis of greenness exposure and NSD outcomes in which an inverse relationship was observed. It is necessary to conduct further research to ascertain the role greenness exposure plays in various NSDs and the management of greenness should be considered a public health strategy.

It's time to take a sustainable approach to health care in the face of the challenges of the 21st century

Health challenges in the 21st century have become increasingly complex and global. The recent COVID-19 pandemic has only exacerbated the many problems faced by health care systems around the world and sadly, exposed various flaws. With ageing populations, particularly in Canada, as well as unavoidable factors such as globalization and accelerating climate change, it is becoming imperative to implement a new health care approach based on intersectorality and interdisciplinarity. Furthermore, links must be forged between all the stakeholders, i.e. the researchers, the health system and its specialists, the communities and the individuals themselves. It is in this perspective, where everyone concerned must be equally involved in attaining a better quality of life, that the concepts of One Health and sustainable health must be deployed.

Built Environment Accessibility and Disability as Predictors of Well-Being among Older Adults: A Norwegian Cross-Sectional Study

Knowledge about the influence environmental factors have on well-being is important to deliver policies supporting healthy ageing and sustainable health equity. An under-researched question is whether and how the built environment plays a role on well-being among older adults with disabilities. This study explores the relationship between built environment accessibility and disability on psychosocial well-being among older adults. Data were used from the Norwegian Counties Public Health Survey collected during February 2021 in Møre and Romsdal county (N = 8274; age = 60-97, mean = 68.6). General linear modelling was performed to examine the relationship and interaction between built environment accessibility (services, transportation, and nature) and disability on psychosocial well-being (quality of life, thriving, loneliness, and psychological distress). Higher levels of disability and poorer accessibility were each significantly related to lower psychosocial well-being across all variables (p < 0.001). Significant interaction effects were observed between disability and built environment accessibility on thriving (F(8, 5936) = 4.97, p < 0.001, η² = 0.006) and psychological distress (F(8, 5957) = 3.09, p = 0.002, η² = 0.004). No significant interaction effects were found for quality of life and loneliness. These findings indicate good built environment accessibility is associated with thriving and reduces psychological distress among older adults with disabilities. This study supports and extends previous findings on the importance of accessible and equipped environments for well-being and may aid policy makers when planning built environments to foster healthy ageing among this population group.

Investigation on urban greenspace in relation to sociodemographic factors and health inequity based on different greenspace metrics in 3 US urban communities

BACKGROUND

Study results are inconclusive regarding how access to greenspace differs by sociodemographic status potentially due to lack of consideration of varying dimensions of greenspace.

OBJECTIVE

We investigated how provision of greenspace by sociodemographic status varies by greenspace metrics reflecting coverage and accessibility of greenspace.

METHODS

We used vegetation levels measured by Enhanced Vegetation Index (EVI), percent of greenspace, percent tree cover, percent tree cover along walkable roads, and percent of people living ≤500 m of a park entrance (park accessibility). We considered data for 2008-2013 in Census block groups in 3 US regions: New Haven, Connecticut; Baltimore, Maryland; and Durham, North Carolina. We examined geographical distribution of greenspace metrics and their associations with indicators of income, education, linguistic isolation, race/ethnicity, and age. We used logistic regression to examine associations between these greenspace metrics and age-standardized mortality controlling for sociodemographic indicators.

RESULTS

Which region had the highest greenspace depended on the greenspace metric used. An interquartile range (33.6%) increase in low-income persons was associated with a 6.2% (95% CI: 3.1, 9.3) increase in park accessibility, whereas it was associated with 0.03 (95% CI: -0.035, -0.025) to 7.3% (95% CI: -8.7, -5.9) decreases in other greenspace metrics. A 15.5% increase in the lower-education population was associated with a 2.1% increase (95% CI: -0.3%, 4.6%) in park accessibility but decreases with other greenspace metrics (0.02 to 5.0%). These results were consistent across the 3 study areas. The odds of mortality rate more than the 75th percentile rate were inversely associated with all greenspace metrics except for annual average EVI (OR 1.27, 95% CI: 0.43, 3.79) and park accessibility (OR 1.40, 95% CI: 0.52, 3.75).

SIGNIFICANCE

Environmental justice concerns regarding greenspace differ by the form of natural resources, and pathways of health benefits can differ by form of greenspace and socioeconomic status within communities.

IMPACT STATEMENT

Comparisons of exposure to greenspace between different greenspace metrics should be incorporated in decision-making within local contexts.

Neighborhood infrastructure-related risk factors and non-communicable diseases: a systematic meta-review

BACKGROUND

With rapid urbanization, the urban environment, especially the neighborhood environment, has received increasing global attention. However, a comprehensive overview of the association between neighborhood risk factors and human health remains unclear due to the large number of neighborhood risk factor-human health outcome pairs.

METHOD

On the basis of a whole year of panel discussions, we first obtained a list of 5 neighborhood domains, containing 33 uniformly defined neighborhood risk factors. We only focused on neighborhood infrastructure-related risk factors with the potential for spatial interventions through urban design tools. Subsequently, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic meta-review of 17 infrastructure-related risk factors of the 33 neighborhood risk factors (e.g., green and blue spaces, proximity to major roads, and proximity to landfills) was conducted using four databases, Web of Science, PubMed, OVID, and Cochrane Library, from January 2000 to May 2021, and corresponding evidence for non-communicable diseases (NCDs) was synthesized. The review quality was assessed according to the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) standard.

RESULTS

Thirty-three moderate-and high-quality reviews were included in the analysis. Thirteen major NCD outcomes were found to be associated with neighborhood infrastructure-related risk factors. Green and blue spaces or walkability had protective effects on human health. In contrast, proximity to major roads, industry, and landfills posed serious threats to human health. Inconsistent results were obtained for four neighborhood risk factors: facilities for physical and leisure activities, accessibility to infrastructure providing unhealthy food, proximity to industry, and proximity to major roads.

CONCLUSIONS

This meta-review presents a comprehensive overview of the effects of neighborhood infrastructure-related risk factors on NCDs. Findings on the risk factors with strong evidence can help improve healthy city guidelines and promote urban sustainability. In addition, the unknown or uncertain association between many neighborhood risk factors and certain types of NCDs requires further research.

Leafier Communities, Healthier Hearts: An Australian Cohort Study of 104,725 Adults Tracking Cardiovascular Events and Mortality Across 10 Years of Linked Health Data

OBJECTIVE

Green space reduces cardiovascular disease (CVD) risk, but few studies examine what types of green space matter, which is an important consideration as cities densify and apartments become more common.

METHOD

Participants were 86,727 in houses and 17,998 in apartments from the 45 and Up Study (Sax Institute) baseline survey with 10 years of linked hospitalisation and death data used to define: (i) all-cause; and (ii) CVD-mortality; (iii) fatal and non-fatal CVD events; and (iv) acute myocardial infarction (AMI). Associations with total green space, tree canopy cover and open grass within 1.6 km buffers were assessed using survival analysis adjusted for potential confounders.

RESULTS

Mean percentage green space indicators were all higher among participants in houses than in apartments. Among residents of houses, a 10% increase in total green space was associated with reduced risk of CVD mortality (HR 0.97, 95%CI 0.95-1.00). A 10% increase in tree canopy cover was associated with reduced risks of all-cause mortality (HR 0.97, 95%CI 0.95-0.99), CVD mortality (HR 0.96, 95%CI 0.93-0.98), and fatal or non-fatal AMI (HR 0.93, 95%CI 0.89-0.96). In contrast, a 10% increase in open grass was associated with an increased risk of fatal or non-fatal AMI (HR 1.15, 95%CI 1.09-1.20) in residents of houses. Among residents of apartments, a 10% increase in total green space was associated with increased risk of all-cause mortality (HR 1.04, 95%CI 1.00-1.08) and CVD mortality (HR 1.03, 95%CI 1.00-1.08).

CONCLUSIONS

Urban reforestation may be a population-level intervention to protect cardiovascular health, especially for people living in houses. The intersection of urban greening and cardiovascular health among residents of apartments warrants further investigation.

Long-term exposure to traffic-related air pollution and stroke: A systematic review and meta-analysis

BACKGROUND

Stroke remains the second cause of death worldwide. The mechanisms underlying the adverse association of exposure to traffic-related air pollution (TRAP) with overall cardiovascular disease may also apply to stroke. Our objective was to systematically evaluate the epidemiological evidence regarding the associations of long-term exposure to TRAP with stroke.

METHODS

PubMed and LUDOK electronic databases were searched systematically for observational epidemiological studies from 1980 through 2019 on long-term exposure to TRAP and stroke with an update in January 2022. TRAP was defined according to a comprehensive protocol based on pollutant and exposure assessment methods or proximity metrics. Study selection, data extraction, risk of bias (RoB) and confidence assessments were conducted according to standardized protocols. We performed meta-analyses using random effects models; sensitivity analyses were assessed by geographic area, RoB, fatality, traffic specificity and new studies.

RESULTS

Nineteen studies were included. The meta-analytic relative risks (and 95% confidence intervals) were: 1.03 (0.98-1.09) per 1 μg/m³ EC, 1.09 (0.96-1.23) per 10 μg/m³ PM₁₀, 1.08 (0.89-1.32) per 5 μg/m³ PM_2.5, 0.98 (0.92; 1.05) per 10 μg/m³ NO₂ and 0.99 (0.94; 1.04) per 20 μg/m³ NO_x with little to moderate heterogeneity based on 6, 5, 4, 7 and 8 studies, respectively. The confidence assessments regarding the quality of the body of evidence and separately regarding the presence of an association of TRAP with stroke considering all available evidence were rated low and moderate, respectively.

CONCLUSION

The available literature provides low to moderate evidence for an association of TRAP with stroke.

Neighborhood Beauty and the Brain in Older Japanese Adults

People have a preference for, and feel better in, beautiful natural environments. However, there are no epidemiological studies on the association between neighborhood beauty and neuroimaging measures. We aimed to determine association between neighborhood beauty and regional brain volume. Participants were 476 community-dwelling older adults from the Neuron to Environmental Impact across Generations (NEIGE) study. Subjective neighborhood beauty was assessed through participants’ perception of beautiful scenery within 1 km of their home. Objective measures of neighborhood indicators (green spaces, blue spaces, and plant diversity) within 1 km of participants’ homes were obtained using a geographic information system. Volumes of brain regions associated with experience of beauty were measured using magnetic resonance imaging. We estimated associations between neighborhood beauty and regional brain volume using linear regression. Of the participants, 42% rated their neighborhoods as very beautiful, and 17% rated them as not at all beautiful. Higher subjective neighborhood beauty was associated with larger bilateral medial orbitofrontal cortex and insula volumes (all p for trend < 0.01). Brain volume was not associated with objective neighborhood measures. Subjective neighborhood beauty was associated with brain regions related to rewards and decision making, suggesting that these brain regions underpin the perception of neighborhood beauty.

Association between residential greenspace and health-related quality of life in children aged 0-12 years

INTRODUCTION

Greenspaces generate several perceived health benefits, including an overall improvement in the quality of life. However, little is known about the effects of greenspaces through pregnancy and early childhood in promoting health-related quality of life (HRQoL) among children.

METHOD

Participants were from the Mothers and their Children's Health Study (MatCH), a 2016/17 sub-study of a national prospective study since 1996 known as the Australian Longitudinal Study on Women's Health (ALSWH). Mothers (n=3,048) self-reported on their three youngest children aged under 13 years (n=5,799, mean=7.0 years, s.d=3.2 years) using the Pediatric Quality of Life Inventory (PedsQL) to measure their HRQoL. Since 1996, annual exposure to green and non-green vegetation was measured using two remote sensing indicators: Normalized Difference Vegetation Index (NDVI) and fractional cover of non-photosynthetic vegetation (fNPV), respectively, for 100 m and 500 m buffer zone around maternal residential address. Multiple exposure windows were calculated including during pregnancy, the first year of life and child's lifetime exposure. Generalised estimating equations (GEE) models, adjusting for potential confounders, were used for analyses.

RESULTS

A 1 standard deviation increase in NDVI greenness within 500 m buffer around the home at early life and during childhood was positively associated with higher HRQoL in the total scores and psychological health summary scores in the crude model only. No association was found between fNPV (non-green vegetation) at 100 m and 500 m circular buffers and children's HRQoL. The overall findings from our models remained consistent based on a series of sensitivity analyses, including the impact of maternal residential mobility status and geocoding method on the effect estimates.

CONCLUSION

Our study revealed that surrounding residential greenspace was not associated with children's HRQoL. Further longitudinal studies are required to better understand the influence of greenspace at different periods of exposure on the health and wellbeing of children.

Sociodemographic Variations in the Availability of Urban Green Spaces in an Older Swedish Population

Urban green spaces (UGS) can have a positive impact on health and thereby potentially ease the strain on the health care system. However, the availability and benefits seem to vary between different sociodemographic groups. The aim of this study was to investigate associations between sociodemographic factors and availability to UGS among people aged 65 years or older. Data on sociodemographic variables and residential coordinates were obtained for three cross-sectional cohorts in two cities (Malmö and Kristianstad) and three years (2010, 2015, and 2019). Three measures of urban green spaces; total (UGS), public (PGS) and quiet (QGS), within 300 m were used to determine availability. The results indicated higher availability to both total and publicly available urban green spaces for groups with lower socioeconomic status (SES) is positive from a health perspective. However, availability to high qualitative publicly available urban green spaces, from a noise perspective, was lower, indicating the opposite.

Green space and cardiovascular disease: A systematic review with meta-analysis

Exposure to green space has been proposed to be beneficially associated with cardiovascular morbidity and mortality. Many studies have explored this topic, but the results remain conflicting. We aimed to evaluate the epidemiological evidence on this topic by performing a systematic review with meta-analysis. We searched PubMed, Web of Science and Embase for studies on the association between green space and cardiovascular disease (CVD) that were published till January 2022. Two authors independently performed study selection, data extraction, quality assessment, and risk of bias assessment. For studies providing detailed numeric data, we also conducted quantitative meta-analyses and calculated the pooled odd ratios (ORs) for associations between the most commonly used exposure estimate (normalized difference vegetative index [NDVI]) and five CVD events: CVD mortality, ischemic heart disease (IHD) mortality, cerebrovascular disease (CBVD) mortality, and stroke incidence/prevalence. Additional analyses were conducted to explore the geographical scale effects of NDVI. Publication bias tests were also conducted. Of the 6787 records identified, 53 studies were eligible for inclusion. These studies covered 18 countries and included data from more than 100 million persons. Meta-analyses showed that a 0.1 increase in NDVI was significantly associated with 2-3% lower odds of CVD mortality (OR: 0.97, 95% CI: 0.96-0.99), IHD mortality (OR: 0.98, 95% CI: 0.96-1.00), CBVD mortality (OR: 0.98, 95% CI: 0.97-1.00), and stroke incidence/prevalence (OR: 0.98, 95% CI: 0.96-0.99). There was no significant difference between the pooled estimates for different buffer sizes. No evidence of publication bias was detected. We provide strong and robust evidence for the beneficial effects of green space exposure on cardiovascular health. More prospective studies and mechanistic studies, especially that conducted in low- and middle-income countries, are merited to strengthen our conclusions.

Air pollution, residential greenness, and metabolic dysfunction biomarkers: analyses in the Chinese Longitudinal Healthy Longevity Survey

BACKGROUND

We hypothesize higher air pollution and fewer greenness exposures jointly contribute to metabolic syndrome (MetS), as mechanisms on cardiometabolic mortality.

METHODS

We studied the samples in the Chinese Longitudinal Healthy Longevity Survey. We included 1755 participants in 2012, among which 1073 were followed up in 2014 and 561 in 2017. We used cross-sectional analysis for baseline data and the generalized estimating equations (GEE) model in a longitudinal analysis. We examined the independent and interactive effects of fine particulate matter (PM_2.5) and Normalized Difference Vegetation Index (NDVI) on MetS. Adjustment covariates included biomarker measurement year, baseline age, sex, ethnicity, education, marriage, residence, exercise, smoking, alcohol drinking, and GDP per capita.

RESULTS

At baseline, the average age of participants was 85.6 (SD: 12.2; range: 65-112). Greenness was slightly higher in rural areas than urban areas (NDVI mean: 0.496 vs. 0.444; range: 0.151-0.698 vs. 0.133-0.644). Ambient air pollution was similar between rural and urban areas (PM_2.5 mean: 49.0 vs. 49.1; range: 16.2-65.3 vs. 18.3-64.2). Both the cross-sectional and longitudinal analysis showed positive associations of PM_2.5 with prevalent abdominal obesity (AO) and MetS, and a negative association of NDVI with prevalent AO. In the longitudinal data, the odds ratio (OR, 95% confidence interval-CI) of PM_2.5 (per 10 μg/m³ increase) were 1.19 (1.12, 1.27), 1.16 (1.08, 1.24), and 1.14 (1.07, 1.21) for AO, MetS and reduced high-density lipoprotein cholesterol (HDL-C), respectively. NDVI (per 0.1 unit increase) was associated with lower AO prevalence [OR (95% CI): 0.79 (0.71, 0.88)], but not significantly associated with MetS [OR (95% CI): 0.93 (0.84, 1.04)]. PM_2.5 and NDVI had a statistically significant interaction on AO prevalence (p_interaction: 0.025). The association between PM_2.5 and MetS, AO, elevated fasting glucose and reduced HDL-C were only significant in rural areas, not in urban areas. The association between NDVI and AO was only significant in areas with low PM_2.5, not under high PM_2.5.

CONCLUSIONS

We found air pollution and greenness had independent and interactive effect on MetS components, which may ultimately manifest in pre-mature mortality. These study findings call for green space planning in urban areas and air pollution mitigation in rural areas.

Joint associations between neighborhood walkability, greenness, and particulate air pollution on cardiovascular mortality among adults with a history of stroke or acute myocardial infarction

Fine particulate matter (PM_2.5) is a known risk factor for cardiovascular disease (CVD). Neighborhood walkability and greenness may also be associated with CVD, but there is limited evidence on their joint or interacting effects with PM_2.5.

Comparing Effects of FOXO3A and Residing in Urban Areas on Longevity: A Gene-Environment Interaction Study

Forkhead box O3 (FOXO3A) is a candidate longevity gene. Urban residents are also positively associated with longer life expectancy. We conducted a gene-environment interaction to assess the synergistic effect of FOXO3A and urban/rural environments on mortality. We included 3085 older adults from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). We used single nucleotide polymorphisms (SNPs) rs2253310, rs2802292, and rs4946936 to identify the FOXO3A gene and classified residential locations as "urban" and "rural." Given the open cohort design, we used the Cox-proportional hazard regression models to assess the mortality risk. We found the minor allele homozygotes of FOXO3A to have a protective effect on mortality [HR (95% CI) for rs4946936 TT vs. CC: 0.807 (0.653, 0.996); rs2802292 GG vs TT: 0.812 (0.67, 0.985); rs2253310 CC vs. GG: 0.808 (0.667, 0.978)]. Participants living in urban areas had a lower risk of mortality [HR of the urban vs. the rural: 0.854 (0.759, 0.962)]. The interaction between FOXO3A and urban and rural regions was statistically significant (pinteraction<0.01). Higher air pollution (fine particulate matter: PM2.5) and lower residential greenness (Normalized Difference Vegetation Index: NDVI) both contributed to higher mortality. After adjusting for NDVI and PM2.5, the protective effect size of FOXO3A SNPs was slightly attenuated while the protective effect size of living in an urban environment increased. The effect size of the beneficial effect of FOXO3 on mortality is roughly equivalent to that of living in urban areas. Our research findings indicate the effect of places of residence and genetic predisposition of longevity are intertwined.

Greenspace and human health: An umbrella review

Multiple systematic reviews on greenspace and health outcomes exist, but the overall evidence base remains unclear. Therefore, we performed an umbrella review to collect and appraise all relevant systematic reviews of epidemiological studies on greenness exposure and health. We searched PubMed, Embase, and Web of Science from inception to June 28, 2021, and screened references of relevant articles. Systematic reviews with or without meta-analyses of epidemiological studies that examined the associations of greenness with any health outcome were included. Two independent investigators performed study selection and data extraction. We also evaluated the methodological quality of the included systematic reviews using the “Assessing the Methodological Quality of Systematic Reviews 2” checklist. A total of 40 systematic reviews and meta-analyses were included, of which most were cross-sectional studies conducted in high-income countries. Greenspace exposure was estimated with various objective and subjective parameters. Beneficial associations of greenspace with all-cause and stroke-specific mortality, CVD morbidity, cardiometabolic factors, mental health, low birth weight, physical activity, sleep quality, and urban crime were observed. No consistent associations between greenspace and other health outcomes (e.g., cancers) were observed. Most of the included systematic reviews and meta-analyses had one or more limitations in methodology. Our findings provide supportive evidence regarding the beneficial effects of greenspace exposure on some aspects of human health. However, the credibility of such evidence was compromised by methodological limitations. Better performed systematic reviews and meta-analyses as well as longitudinal designed primary studies are needed to validate this conclusion.

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The evidence concerning greenspace and health outcomes remains unclear

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We performed an umbrella review of 40 systematic reviews on greenspace and health

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Greenspace exposure was estimated with various objective and subjective parameters

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Greenspace was beneficially associated with several aspects of human health

A multi-scalar perspective on health and urban housing: an umbrella review

With more than half the world's population living in cities, understanding how the built environment impacts human health at different urban scales is crucial. To be able to shape cities for health, an understanding is needed of planetary health impacts, which encompass the human health impacts of human-caused disruptions on the Earth's natural ecosystems. This umbrella review maps health evidence across the spatial scales of the built environment (building; neighbourhood; and wider system, including city, regional and planetary levels), with a specific focus on urban housing. Systematic reviews published in English between January 2011 and December 2020 were searched across 20 databases, with 1176 articles identified and 124 articles screened for inclusion. Findings suggests that most evidence reports on health determinants at the neighbourhood level, such as greenspace, physical and socio-economic conditions, transport infrastructure and access to local services. Physical health outcomes are also primarily reported, with an emerging interest in mental health outcomes. There is little evidence on planetary health outcomes and significant gaps in the research literature are identified. Based on these findings, three potential directions are identified for future research.

Associations between residential greenness and self-reported heart disease in Sri Lankan men: A cross-sectional study

Cardiovascular diseases (CVDs) are major contributors to morbidity and mortality in lower-middle-income countries (LMICs). Features of the natural environment, such as greenness, are a potential, modifiable determinant of CVD, yet there is a lack of evidence, particularly in LMICs. Our study investigated associations between residential greenness, measured using the Normalized Difference Vegetation Index (NDVI), and self-reported heart disease in 5268 Sri Lankan men aged 34 to 55 years. Multivariable logistic regression models were fitted to examine associations between mean NDVI within 100 m, 400 m, 800 m, 1600 m, and 2000 m of the residential address, adjusting for age, marital status, income, education, alcohol consumption, smoking and road length. Fully adjusted models showed that a 0.1 increase in mean NDVI was associated with lower odds of heart disease when using the 400 m (OR: 0.80; 95% CI: 0.64, 1.00), 800 m (OR: 0.85; 95% CI: 0.63, 1.14), and 2000 m (OR: 0.74; 95% CI: 0.48, 1.13) buffers. Further research in different contexts, and with improved outcome measures, is needed to confirm relationships between residential greenness and heart disease in rural areas and in LMICs.

Tourism experiences and the lower risk of mortality in the Chinese elderly: a national cohort study

Background

Cohort studies about the effects of tourism experiences on the risk of death among Chinese older adults are still lacking. We aimed to examine the association between tourism experiences and mortality in Chinese aged 65 or above.

Methods

We included 9520 participants aged 65 years or above from the Chinese Longitudinal Healthy Longevity Survey at baseline in 23 provinces in 2011. They were followed up in 2014 and 2018. Cox proportional hazards models were used to assess the association between tourism experiences and the risk of death.

Results

Among 9520 participants, 7.85% had at least one tourism experience outside of their local city/county during the past 2 years. During 35,994.26 person-years of follow-up, in total 4635 deaths were observed. The crude rate of death was greater in participants who had no tourism experience than in older travelers (incidence rate: 13.70 versus 5.24 per 100 person-years). Elderly travelers had a significantly lower risk for all-cause mortality (crude hazard ratio: 0.38, 95% CI: 0.33–0.44) compared with non-travelers. After adjustment for all covariates, the risk of all-cause mortality was 27% lower among those with at least one tourism experience than among non-travelers (adjusted hazard ratio: 0.73, 95% CI: 0.62–0.85). Subgroup analysis showed that the associations between tourism and the decreased risk of mortality were stable.

Conclusions

Tourism decreases the risk of mortality in the Chinese elderly. Tourism should be considered as a modifiable lifestyle factor and an effective way to reduce mortality and promote longevity and healthy aging.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11099-8.