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

Intra-neighborhood associations between residential greenness and blood pressure

INTRODUCTION

Previous investigations have reported that individuals living in greener neighborhoods have better cardiovascular health. It is unclear whether the effects reported at large geographic scales persist when examined at an intra-neighborhood level. The effects of greenness have not been thoroughly examined using high-resolution metrics of greenness exposure, and how they vary with spatial scales of assessment or participant characteristics.

METHODS

We conducted a cross-sectional assessment of associations between blood pressure and multiple high-resolution measures of residential area greenness in spatially concentrated HEAL Study cohort of the Green Heart Project. We employed generalized linear models, accounting for individual-level covariates, to examine associations between different high-resolution measures of greenness and blood pressure among 667 participants in a 4 sq. mile contiguous neighborhood area in Louisville, KY.

RESULTS

In adjusted models, we observed significant inverse associations between residential greenness, measured by leaf area index (LAI), and systolic blood pressure (SBP) within 150-250 m and 500 m of homes, but not for Normalized Difference Vegetation Index (NDVI) or grass cover. Weaker associations were also found with diastolic blood pressure (DBP). Significant positive associations were observed between LAI and SBP among participants who reported being female, White, without obesity, non-exercisers, non-smokers, younger age, of lower income, and who had high nearby roadway traffic. We found few significant associations between grass cover and SBP, but an inverse association in those with obesity, but positive associations for those without obesity.

CONCLUSIONS

We found that leaf surface area of trees around participants home is strongly associated with lower blood pressure, with little association with grass cover. These effects varied with participant characteristics and spatial scales. More research is needed to test causative links between greenspace types and cardiovascular health and to develop population-, typology-, and place-based evidence to inform greening interventions.

Confounding associations between green space and outdoor artificial light at night: Systematic investigations and implications for urban health

Excessive urbanization leads to considerable nature deficiency and abundant artificial infrastructure in urban areas, which triggered intensive discussions on people's exposure to green space and outdoor artificial light at night (ALAN). Recent academic progress highlights that people's exposure to green space and outdoor ALAN may be confounders of each other but lacks systematic investigations. This study investigates the associations between people's exposure to green space and outdoor ALAN by adopting the three most used research paradigms: population-level residence-based, individual-level residence-based, and individual-level mobility-oriented paradigms. We employed the green space and outdoor ALAN data of 291 Tertiary Planning Units in Hong Kong for population-level analysis. We also used data from 940 participants in six representative communities for individual-level analyses. Hong Kong green space and outdoor ALAN were derived from high-resolution remote sensing data. The total exposures were derived using the spatiotemporally weighted approaches. Our results confirm that the negative associations between people's exposure to green space and outdoor ALAN are universal across different research paradigms, spatially non-stationary, and consistent among different socio-demographic groups. We also observed that mobility-oriented measures may lead to stronger negative associations than residence-based measures by mitigating the contextual errors of residence-based measures. Our results highlight the potential confounding associations between people's exposure to green space and outdoor ALAN, and we strongly recommend relevant studies to consider both of them in modeling people's health outcomes, especially for those health outcomes impacted by the co-exposure to them.

Association of residential greenness with incident pneumonia: A prospective cohort study

Residential greenness is considered beneficial to human health, and its association with respiratory function has been found in previous studies. However, its link with pneumonia remains unclear. To explore the association of residential greenness with incident pneumonia, we conducted a prospective cohort study based on participants of the UK Biobank, followed from 2006 to 2010 to the end of 2019. Residential greenness was measured by Normalized Difference Vegetation Index (NDVI) within 500 m and 1000 m buffer. Cox proportional hazard models were conducted to assess the association, and restricted cubic spline models were also constructed to estimate their exposure-response relationship. Results demonstrate that residential greenness was negatively related to the risk of incident pneumonia. An interquartile (IQR) increase in NDVI 500-m buffer was associated with 4 % [HR (95 % CI) =0.96 (0.94, 0.97), P < 0.001] lower risk of incident pneumonia. Compared to the lowest greenness quartile (Q1), the highest quartile (Q4) had a lower risk of incident pneumonia, with the HR (95 % CI) estimated to be 0.91 (0.87, 0.95) (P values <0.001). Analyses based on NDVI 1000-m buffer obtained similar results. Furthermore, a significant effect of modifications by age and income on the linkage between residential greenness and incident pneumonia was found. These findings propose a potential effective prevention of incident pneumonia and provide the scientific basis for promoting the construction of residential greenness.

Long-term exposure to air pollution, greenness and temperature and survival after a nonfatal myocardial infarction

BACKGROUND

Little is known about the impact of environmental exposures on mortality risk after a myocardial infarction (MI).

OBJECTIVE

The goal of this study was to evaluate associations of long-term temperature, air pollution and greenness exposures with mortality among survivors of an MI.

METHODS

We used data from the US-based Nurses' Health Study to construct an open cohort of survivors of a nonfatal MI 1990-2017. Participants entered the cohort when they had a nonfatal MI, and were followed until death, loss to follow-up, end of follow-up, or they reached 80 years old, whichever came earliest. We assessed residential 12-month moving average fine particulate matter (PM2.5) and nitrogen dioxide (NO2), satellite-based annual average greenness (in a circular 1230 m buffer), summer average temperature and winter average temperature. We used Cox proportional hazard models adjusted for potential confounders to assess hazard ratios (HR and 95% confidence intervals). We also assessed potential effect modification.

RESULTS

Among 2262 survivors of a nonfatal MI, we observed 892 deaths during 19,216 person years of follow-up. In single-exposure models, we observed a HR (95%CI) of 1.20 (1.04, 1.37) per 10 ppb NO2 increase and suggestive positive associations were observed for PM2.5, lower greenness, warmer summer average temperature and colder winter average temperature. In multi-exposure models, associations of summer and winter average temperature remained stable, while associations of NO2, PM2.5 and greenness attenuated. The strength of some associations was modified by other exposures. For example, associations of greenness (HR = 0.88 (0.78, 0.98) per 0.1) were more pronounced for participants in areas with a lower winter average temperature.

CONCLUSION

We observed associations of air pollution, greenness and temperature with mortality among MI survivors. Some associations were confounded or modified by other exposures, indicating that it is important to explore the combined impact of environmental exposures.

Food Environments and Cardiovascular Disease: Evidence From the Health and Retirement Study

INTRODUCTION

Residential food environments are one of the important determinants of cardiovascular health. However, past literature has been limited by short-term follow-ups, time-invariant environmental measurements at baseline, and/or not investigating both healthy and unhealthy aspects of the food environment. This study examines the effects of time-varying healthy and unhealthy food environments on incident cardiovascular disease (CVD) over 10 years, extracting data from the Health and Retirement Study (2006-2016; N=10,413).

METHODS

Cox proportional hazards modeling was performed with inverse probability weighting to assess the association between time-varying food environmental measures (i.e., densities of grocery stores, supercenters/club stores, full-service restaurants, and fast-food restaurants) and incident CVD over 10 years. Education level and race/ethnicity were tested as potential moderators. Analyses were conducted in 2022-2023.

RESULTS

Race/ethnicity had a significant interaction effect with supercenters/club stores and indicated that a 1-standard-deviation increase in the density of supercenters/club stores was associated with a 6%-8% lower risk of incident CVD in non-Hispanic Black (HR=0.78, 95% CI=0.70-0.87) and Hispanic older adults (HR=0.69, 95% CI=0.50-0.96), but not non-Hispanic White older adults. Additionally, education had a significant interaction effect with full-service restaurants, indicating that a 1-standard-deviation increase in the density of full-service restaurants was associated with a 10% lower risk of incident CVD in individuals with 13+ years of schooling, but not those with 0-12 years of schooling.

CONCLUSIONS

Findings suggest that public policymakers should be aware of the benefits and nuances of varying food environment components as they can contribute to positive or negative cardiovascular health.

The joint impact of PM2.5 constituents on the risk of cerebrovascular diseases hospitalization: A large community-based cohort study

Air pollution poses significant health risks to urban areas, with limited focus on the chronic association of PM2.5 and its constituents on cerebrovascular diseases (CERs), especially regarding the joint associations. This study explores the individual and joint associations between PM2.5 constituents and CER hospitalization risks through a cohort analysis of 36,271 adults in the Pearl River Delta, South China, from 2015 to 2020. Cox proportional hazards regression and quantile-based g-computation models were used to quantify the individual and joint associations of annual mean concentrations of PM2.5 constituents with hospitalization for CERs. 1151 participants were hospitalized due to CERs during the five-year follow-up period. Joint associations analyses identified that one quartile increase in co-exposure may result in hazard ratios of 1.530 (1.441-1.623), 1.840 (1.710-1.980), and 1.609 (1.491-1.737) for CERs, total, and ischemic stroke hospitalization, respectively. The adverse effect was primarily driven by organic matter and chlorine. Men, those with a history of tobacco or alcohol use or with low residential greenness, were more susceptible to CERs hospitalization following PM2.5 constituents co-exposure. Upcoming strategies should focus on monitoring and regulating PM2.5 constituents, encouraging healthy lifestyles, and enhancing urban greenery.

The effect of residential greenness on cardiovascular mortality from a large cohort in South China: An in-depth analysis of effect modification by multiple demographic and lifestyle characteristics

BACKGROUND

The potential for residential greenness to improve cardiovascular health through both physical and psychological mechanisms is well recognized. However, evidence from rapidly urbanizing developing countries and cohort-based causal inference approaches, remains limited. We aim to examine the effect of residential greenness and time to cardiovascular mortality in South China.

METHODS

We utilized data from a community-based population survey involving 748,209 participants at baseline from 2009 to 2015, followed up until 2020. Residential greenness exposure was assessed by the annual Normalized Difference Vegetation Index (NDVI) in the 500 m radius of each participant's residence. We used time-varying proportional hazard Cox models coupled with inverse probability weighting to fit marginal structural models and obtain hazard ratios (HRs) for cardiovascular disease (CVD) mortality after adjusting for confounders. Multiple effect modifiers on both additive and multiplicative scales were further explored.

RESULTS

A total of 15,139 CVD-related deaths were identified during a median of 7.9 years of follow-up. A protective effect was found between higher greenness exposure and reduced CVD mortality, with a 9.3 % lower rate of total CVD mortality (HR 0.907, 95 % CI 0.859-0.957) based on a 0.1 increase in annual average NDVI. Demographic (age, marital status) and lifestyle factors (smoking, drinking status) were found to modify the association between residential greenness and CVD mortality (all P interaction values < 0.05 or 95 %CI for RERI excluded the value 0). Notably, this effect was more pronounced among older adults, married, and individuals having healthier lifestyles, indicating a greater benefit from greenness for these subgroups.

CONCLUSIONS

Our findings support a causal link between increased residential greenness exposure and a reduced risk of CVD mortality in South China with marked heterogenous effects, which has public health implications for cultivating greener urban environments to mitigate the impact of CVD within the context of rapid urbanization.

Long-term exposure to air pollution, road traffic noise and greenness, and incidence of myocardial infarction in women

BACKGROUND

Emerging evidence shows that long-term exposure to air pollution, road traffic noise, and greenness can each be associated with cardiovascular disease, but only few studies combined these exposures. In this study, we assessed associations of multiple environmental exposures and incidence of myocardial infarction using annual time-varying predictors.

MATERIALS AND METHODS

In a population-based cohort of 20,407 women in Sweden, we estimated a five-year moving average of residential exposure to air pollution (PM2.5, PM10 and NO2), road traffic noise (Lden), and greenness (normalized difference vegetation index, NDVI in 500 m buffers), from 1998 to 2017 based on annually varying exposures and address history. We used adjusted time-varying Cox proportional hazards regressions to estimate hazard ratios (HR) and 95 % confidence intervals (95 % CI) of myocardial infarction per interquartile range (IQR). Furthermore, we investigated interactions between the exposures and explored potential vulnerable subgroups.

RESULTS

In multi-exposure models, long-term exposure to greenness was inversely associated with incidence of myocardial infarction (HR 0.89; 95 % CI 0.80, 0.99 per IQR NDVI increase). Stronger associations were observed in some subgroups, e.g. among women with low attained education and in overweight (BMI ≥ 25 kg/m2) compared to their counterparts. For air pollution, we observed a tendency of an increased risk of myocardial infarction in relation to PM2.5 (HR 1.07; 95 % CI 0.93, 1.23) and the association appeared stronger in women with low attained education (HR 1.30; 95 % CI 1.06, 1.58). No associations were observed for PM10, NO2 or road traffic noise. Furthermore, there were no clear interaction patterns between the exposures.

CONCLUSION

Over a 20-year follow-up period, in multi-exposure models, we found an inverse association between residential greenness and risk of myocardial infarction among women. Furthermore, we observed an increased risk of myocardial infarction in relation to PM2.5 among women with low attained education. Road traffic noise was not associated with myocardial infarction.

Association between greenery and health indicators in urban patients with symptomatic heart failure: a retrospective cohort study in Lithuania

Urban green spaces benefit physical, mental health, and reduses the risk of cardiovascular disease. A study in Kaunas, Lithuania collected health data from 100 patients with symptomatic heart failure (HF) during 2006-2009. Residential greenness was measured by the normalized difference vegetation index (NDVI). We assessed the impact of greenness on health indicators and on changes in health markers after 6 months. Higher greenness levels based on the NDVI 1-km radius were related to higher mean values of heart rate (HR) and ejection fraction and lower left ventricular (LV) end-diastolic diameter index (LV EDDI), LV end-systolic volume (ESV), left atrium size (LAS), and right atrium size (RAS) at baseline. After 6 months, a decrease in DBP and HR and an improvement in spiroergometric parameters were associated with exposure to high levels of greenness.  The long-term rehabilitation group experienced significant changes in spiroergometric indicators. The results confirm that the greenness of the residential environment can improve health indicators in patients with HF.

Residential greenspace and COVID-19 Severity: A cohort study of 313,657 individuals in Greater Manchester, United Kingdom

BACKGROUND

Greenspaces contribute positively to mental and physical well-being, promote social cohesion, and alleviate environmental stressors, such as air pollution. Ecological studies suggest that greenspace may affect incidence and severity of Coronavirus Disease 2019 (COVID-19).

OBJECTIVE

This study examines the association between residential greenspace and COVID-19 related hospitalization and death.

METHOD

In this retrospective cohort based on patient records from the Greater Manchester Care Records, all first COVID-19 cases diagnosed between March 1, 2020, and May 31, 2022 were followed until COVID-19 related hospitalization or death within 28 days. Residential greenspace availability was assessed using the Normalized Difference Vegetation Index per lower super output area in Greater Manchester. The association of greenspace with COVID-19 hospitalization and mortality were estimated using multivariate logistic regression models after adjusting for potential individual, temporal, and spatial confounders. We explored potential effect modifications of the associations with greenspace and COVID-19 severity by age, sex, body mass index, smoking, deprivation, and certain comorbidities. Combined effects of greenspace and air pollution (NO2 and PM2.5) were investigated by mutually adjusting pairs with correlation coefficients ≤ 0·7.

RESULTS

Significant negative associations were observed between greenspace availability and COVID-19 hospitalization and mortality with odds ratios [OR] (95 % Confidence Intervals [CI]) of 0·96 (0·94-0·97) and 0·84 (0·80-0·88) (per interquartile range [IQR]), respectively. These were significantly modified by deprivation (P-value for interaction < 0.05), showing that those most deprived obtained largest benefits from greenspace. Inclusion of NO2 and PM2.5 diminished associations to null for COVID-19 hospitalization, but only reduced them slightly for mortality, where inverse associations remained.

CONCLUSION

In the Greater Manchester area, residential greenspace is associated with reduced risk of hospitalization or death in individuals with COVID-19, with deprived groups obtaining the greatest benefits. Associations were strongest for COVID-19 mortality, which were robust to inclusion of air pollutants in the models.

Association of ambient ozone exposure and greenness exposure with hemorrhagic stroke mortality at different times: A cohort study in Shandong Province, China

Evidence on the association between long-term ozone exposure and greenness exposure and hemorrhagic stroke (HS) is limited, with mixed results. One potential source of this inconsistency is the difference in exposure time metrics. This study aimed to investigate the association between long-term exposure to ambient ozone, greenness, and mortality from HS using exposure metrics at different times. We also examined whether greenness exposure modified the relationship between ozone exposure and mortality due to HS. The study population consisted of 45771 participants aged ≥40 y residing in 20 counties in Shandong Province who were followed up from 2013 to 2019. Ozone exposure metrics (annual mean and warm season) and the normalized difference a measure of greenness exposure, were calculated. The relationship between environmental exposures (ozone and greenness exposures) and mortality from HS was assessed using time-dependent Cox proportional hazards models, and the modification of greenness exposure was examined using stratified analysis with interaction terms. The person-years at the end of follow-up were 90,663. With full adjustments, the risk of death from hemorrhagic stroke increased by 5% per interquartile range increase in warm season ozone [hazard ratio =1.05; 95 % confidence interval: 1.01-1.08]. No clear association was observed between annual ozone and mortality HS. Both the annual and summer NDVI were found to reduce the risk of HS mortality. The relationships were influenced by age, sex, and residence (urban or rural). Furthermore, greenness exposure was shown to have a modifying effect on the relationship between ozone exposure and the occurrence of HS mortality (P for interaction = 0.001). Long-term exposure to warm season O3 was positively associated with HS mortality, while greenness exposure was inversely associated with HS mortality. Greenness exposure may mitigate the negative effects of warm season ozone exposure on HS mortality.

Racial and Ethnic Disparities in Primary Prevention of Cardiovascular Disease

Cardiovascular disease (CVD) disproportionately affects ethnic-minority groups globally. Ethnic-minority groups face particularly high CVD burden and mortality, exacerbated by disparities across modifiable risk factors, wider determinants of health, and limited access to preventative interventions. This narrative review summarizes evidence on modifiable risk factors, such as physical activity, hypertension, diet, smoking, alcohol consumption, diabetes, and the polypill for the primary prevention of CVD in ethnic minorities. Across these factors, we find inequities in risk factor prevalence. The evidence underscores that inequalities in accessibility to interventions and treatments impede progress in reducing CVD risk using primary prevention interventions for ethnic-minority people. Although culturally tailored interventions show promise, further research is required across the different risk factors. Social determinants of health and structural inequities also exacerbate CVD risk for ethnic-minority people and warrant greater attention. Additionally, we find that only limited ethnicity-specific data and guidelines are available on CVD primary prevention interventions for most risk factors. To address these gaps in research, we provide recommendations that include the following: investigating the sustainability and real-world effectiveness of culturally sensitive interventions; ensuring that ethnic-minority peoples' perspectives are considered in research; longitudinal tracking of risk factors; interventions and outcomes in ethnic-minority people; and ensuring that data collection and reporting of ethnicity data are standardized.

Exploring residential relocation- differences between newcomers and settled residents in health, travel behaviour and neighbourhood perceptions

This study explores whether people who have recently moved to an area differ from longer-term residents in their health, travel behaviour, and perceptions of the environment. Using a large, representative sample from the UKHLS, Newcomers demonstrate significantly lower mental and physical health, reduced car commuting, and a higher likelihood of liking their neighbourhood. Area deprivation, urbanicity, household income, and age emerge as influential moderators with i.e. Newcomers in affluent areas experiencing lower physical health than Settled Residents, and rural Newcomers expressing less neighbourhood satisfaction. Our findings highlight that Newcomers' perceptions of their environment diverge and environmental influences vary among population segments, potentially impacting related health behaviours such as active travel. Furthermore, residential relocation introduces Newcomers with distinct characteristics into areas, affecting the context in which potential population health interventions aiming to influence health behaviours operate. This necessitates a deeper understanding of what influences reactions to the environment as well as ongoing adaptation of environmental interventions to respond to changing contexts within the same location over time.

Key drivers of the oxidative potential of PM2.5 in Beijing in the context of air quality improvement from 2018 to 2022

The mass concentration of atmospheric particulate matter (PM) has been continuously decreasing in the Beijing-Tianjin-Hebei region. However, health endpoints do not exhibit a linear correlation with PM mass concentrations. Thus, it is urgent to clarify the prior toxicological components of PM to further improve air quality. In this study, we analyzed the long-term oxidative potential (OP) of water-soluble PM2.5, which is generally considered more effective in assessing hazardous exposure to PM in Beijing from 2018 to 2022 based on the dithiothreitol assay and identified the crucial drivers of the OP of PM2.5 based on online monitoring of air pollutants, receptor model, and random forest (RF) model. Our results indicate that dust, traffic, and biomass combustion are the main sources of the OP of PM2.5 in Beijing. The complex interactions of dust particles, black carbon, and gaseous pollutants (nitrogen dioxide and sulfur dioxide) are the main factors driving the OP evolution, in particular, leading to the abnormal rise of OP in Beijing in 2022. Our data shows that a higher OP is observed in winter and spring compared to summer and autumn. The diurnal variation of the OP is characterized by a declining trend from 0:00 to 14:00 and an increasing trend from 14:00 to 23:00. The spatial variation in OP of PM2.5 was observed as the OP in Beijing is lower than that in Shijiazhuang, while it is higher than that in Zhenjiang and Haikou, which is primarily influenced by the distribution of black carbon. Our results are of significance in identifying the key drivers influencing the OP of PM2.5 and provide new insights for advancing air quality improvement efforts with a focus on safeguarding human health in Beijing.

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.

Environmental Impacts on Cardiovascular Health and Biology: An Overview

Environmental stressors associated with human activities (eg, air and noise pollution, light disturbance at night) and climate change (eg, heat, wildfires, extreme weather events) are increasingly recognized as contributing to cardiovascular morbidity and mortality. These harmful exposures have been shown to elicit changes in stress responses, circadian rhythms, immune cell activation, and oxidative stress, as well as traditional cardiovascular risk factors (eg, hypertension, diabetes, obesity) that promote cardiovascular diseases. In this overview, we summarize evidence from human and animal studies of the impacts of environmental exposures and climate change on cardiovascular health. In addition, we discuss strategies to reduce the impact of environmental risk factors on current and future cardiovascular disease burden, including urban planning, personal monitoring, and mitigation measures.

Outdoor artificial light at night exposure and gestational diabetes mellitus: a case-control study

Objective

This study aims to explore the association between outdoor artificial light at night (ALAN) exposure and gestational diabetes mellitus (GDM).

Methods

This study is a retrospective case-control study. According with quantiles, ALAN has been classified into three categories (Q1-Q3). GDM was diagnosed through oral glucose tolerance tests. Conditional logistic regression models were used to evaluate the association between ALAN exposure and GDM risk. The odds ratio (OR) with 95% confidence interval (CI) was used to assess the association. Restricted cubic spline analysis (RCS) was utilized to investigate the no liner association between ALAN and GDM.

Results

A total of 5,720 participants were included, comprising 1,430 individuals with GDM and 4,290 matched controls. Pregnant women exposed to higher levels of ALAN during the first trimester exhibited an elevated risk of GDM compared to those with lower exposure levels (Q2 OR = 1.39, 95% CI 1.20-1.63, p < 0.001); (Q3 OR = 1.70, 95% CI 1.44-2.00, p < 0.001). Similarly, elevated ALAN exposure during the second trimester also conferred an increased risk of GDM (second trimester: Q2 OR = 1.70, 95% CI 1.45-1.98, p < 0.001; Q3 OR = 2.08, 95% CI 1.77-2.44, p < 0.001). RCS showed a nonlinear association between ALAN exposure and GDM risk in second trimester pregnancy, with a threshold value of 4.235.

Conclusion

Outdoor ALAN exposure during pregnancy is associated with an increased risk of GDM.

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 and blue space exposure and non-communicable disease related hospitalizations: A systematic review

The global increase in non-communicable diseases (NCDs) presents a critical public health concern. Emerging evidence suggests that exposure to natural environments may reduce the risk of developing NCDs through multiple pathways. The present systematic review aims to synthesize and evaluate the observational evidence regarding associations between exposure to green and blue spaces and hospital admissions related to NCDs. A comprehensive literature search strategy was conducted in Embase (Ovid), PubMed, and Web of Science. The risk of bias and quality of the evidence were assessed using The Navigation Guide methodology, an approach specifically designed for environmental health research. Of 3060 search results, 17 articles were included. Notably, the majority of the studies (n = 14; 82.4%) were published from 2020 onwards. Most studies were conducted in the United States (n = 6; 35.3%) and China (n = 4; 23.5%). Exposure to green spaces was assessed through all studies, while only three included blue spaces. In terms of study design, cohort design was employed in nearly half of the studies (n = 8; 47.1%), followed by case-crossover design (n = 3, 17.6%). Over 75% of the included studies (n = 13) had a high or probably high rating in the risk of bias assessment. The studies encompassed diverse NCD outcome domains; cardiovascular diseases (CVDs) (n = 10), respiratory diseases (RSDs) (n = 2), heat-related diseases (n = 1), metabolic diseases (n = 2), cancer (n = 1), neurodegenerative diseases (NDDs) (n = 2), and mental health disorders (n = 2). The present review suggests that a clear link between blue space exposure and NCD hospital admissions is not evident. However, exposure to green spaces appears to predominantly have a protective effect, although the direction of the association varies across different outcome domains. The heterogeneity among the outcome domains together with the limited number of studies, emphasizes the need for more robust evidence.

The economics of nature's healing touch: A systematic review and conceptual framework of green space, pharmaceutical prescriptions, and healthcare expenditure associations

Green spaces play a crucial role in promoting sustainable and healthy lives. Recent evidence shows that green space also may reduce the need for healthcare, prescription medications, and associated costs. This systematic review provides the first comprehensive assessment of the available literature examining green space exposure and its associations with healthcare prescriptions and expenditures. We applied Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search MEDLINE, Scopus, and Web of Science for observational studies published in English through May 6, 2023. A quality assessment of the included studies was conducted using the Office of Health Assessment and Translation (OHAT) tool, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment was used to evaluate the overall quality of evidence. Our search retrieved 26 studies that met the inclusion criteria and were included in our review. Among these, 20 studies (77 % of the total) showed beneficial associations of green space exposure with healthcare prescriptions or expenditures. However, most studies had risks of bias, and the overall strength of evidence for both outcomes was limited. Based on our findings and related bodies of literature, we present a conceptual framework to explain the possible associations and complex mechanisms underlying green space and healthcare outcomes. The framework differs from existing green space and health models by including upstream factors related to healthcare access (i.e., rurality and socioeconomic status), which may flip the direction of associations. Additional research with lower risks of bias is necessary to validate this framework and better understand the potential for green space to reduce healthcare prescriptions and expenditures.

Show me the money! Associations between tree canopy and hospital costs in cities for cardiovascular disease events in a longitudinal cohort study of 110,134 participants

Health benefits from urban greening are assumed to translate into reduced healthcare expenditure, yet few studies have tested this. A total of 110,134 participants in the Sax Institute's 45 and Up Study in the Australian cities of Sydney, Newcastle, or Wollongong were linked with hospital cost data for cardiovascular disease (CVD) events (e.g., acute myocardial infarctions) up to 30 June 2018. Associations between percentages of total green space, tree canopy, and open grass within 1.6 km of participants homes and annual per person measured CVD-related hospital costs were analysed using generalised linear model (GLM) with gamma density as a component of a two-part mixture model, adjusting for confounders. Overall, 26,243 participants experienced a CVD-related hospitalisation. Incidence was lower among participants with 10 % more tree canopy (OR 0.98, 95 %CI 0.96, 0.99), but not with higher total green space or open grass percentages. Total costs of hospitalisations per year were lower with 10 % more tree canopy (means ratio 0.96, 95 %CI 0.95, 0.98), but also higher with 10 % more open grass (means ratio 1.04, 95 %CI 1.02, 1.06). It was estimated that raising tree canopy cover to 30 % or more for individuals with currently less than 10 % could lead to a within-sample annual saving per person of AU$ 193 overall and AU$ 569 for those who experienced one or more CVD-related hospital admissions. This projects to an estimated annual health sector cost reduction of AU$ 19.3 million per 100,000 individuals for whom local tree canopy cover is increased from less than 10 % to 30 % or higher. In conclusion, this longitudinal study is among the first to analyse measured healthcare cost data in relation to urban green space in general, and with differentiation between major types of greenery relevant to urban planning policies in cities around the world. In sum, this study advances an increasingly important and international focus of research by reporting on the lower burden of CVD and fewer associated hospitalisations stemming from upstream investments that protect and restore urban tree canopy, which not only translates into substantial reduced costs for the health sector, but also helps to create regenerative cities and flourishing communities.

Concomitant exposure to air pollution, green space and noise, and risk of myocardial infarction: a cohort study from Denmark

AIMS

The three correlated environmental exposures (air pollution, road traffic noise, and green space) have all been associated with the risk of myocardial infarction (MI). The present study aimed to analyse their independent and cumulative association with MI.

METHODS AND RESULTS

In a cohort of all Danes aged 50 or older in the period 2005-17, 5-year time-weighted average exposure to fine particles (PM2.5), ultrafine particles, elemental carbon, nitrogen dioxide (NO2), and road traffic noise at the most and least exposed façades of residence was estimated. Green space around residences was estimated from land use maps. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence interval (CI), and cumulative risk indices (CRIs) were calculated. All expressed per interquartile range. Models were adjusted for both individual and neighbourhood-level socio-demographic covariates. The cohort included 1 964 702 persons. During follow-up, 71 285 developed MI. In single-exposure models, all exposures were associated with an increased risk of MI. In multi-pollutant analyses, an independent association with risk of MI was observed for PM2.5 (HR: 1.026; 95% CI: 1.002-1.050), noise at most exposed façade (HR: 1.024; 95% CI: 1.012-1.035), and lack of green space within 150 m of residence (HR: 1.018; 95% CI: 1.010-1.027). All three factors contributed significantly to the CRI (1.089; 95% CI: 1.076-1.101).

CONCLUSION

In a nationwide cohort study, air pollution, noise, and lack of green space were all independently associated with an increased risk of MI. The air pollutant PM2.5 was closest associated with MI risk.

Associations of the neighbourhood built and natural environment with cardiometabolic health indicators: A cross-sectional analysis of environmental moderators and behavioural mediators

BACKGROUND

Most studies examining the effects of neighbourhood urban design on cardiometabolic health focused solely on the built or natural environment. Also, they did not consider the roles of neighbourhood socio-economic status (SES) and ambient air pollution in the observed associations, and the extent to which these associations were mediated by physical activity and sedentary behaviours.

METHODS

We used data from the AusDiab3 study (N = 4141), a national cohort study of Australian adults to address the above-mentioned knowledge gaps. Spatial data were used to compute indices of neighbourhood walkability (population density, intersection density, non-commercial land use mix, commercial land use), natural environment (parkland and blue spaces) and air pollution (annual average concentrations of nitrogen dioxide (NO2) and fine particulate matter <2.5 μm in diameter (PM2.5)). Census indices were used to define neighbourhood SES. Clinical assessments collected data on adiposity, blood pressure, blood glucose and blood lipids. Generalised additive mixed models were used to estimate associations.

RESULTS

Neighbourhood walkability showed indirect beneficial associations with most indicators of cardiometabolic health via resistance training, walking and sitting for different purposes; indirect detrimental associations with the same indicators via vigorous gardening; and direct detrimental associations with blood pressure. The neighbourhood natural environment had beneficial indirect associations with most cardiometabolic health indicators via resistance training and leisure-time sitting, and beneficial direct associations with adiposity and blood lipids. Neighbourhood SES and air pollution moderated only a few associations of the neighbourhood environment with physical activity, blood lipids and blood pressure.

CONCLUSIONS

Within a low-density and low-pollution context, denser, walkable neighbourhoods with good access to nature may benefit residents' cardiometabolic health by facilitating the adoption of an active lifestyle. Possible disadvantages of living in denser neighbourhoods for older populations are having limited opportunities for gardening, higher levels of noise and less healthy dietary patterns associated with eating out.

Association between exposure to outdoor artificial light at night and the risk of preterm birth

Background

This study aimed to investigate the association between outdoor artificial light at night (ALAN) exposure during pregnancy and the risk of preterm birth (PTB).

Methods

A retrospective case-control study was conducted, and data were collected from pregnant women residing in Beijing, China. The level of ALAN exposure during pregnancy was estimated using remote sensing satellite data. Propensity score matching was utilized to match the control group. Logistic and multivariate linear regression were used to analyze the association between ALAN and the risk of PTB. The odds ratio (OR) and partial regression coefficient (β) with 95% confidence interval (CI) were utilized to assess the association.

Results

A total of 2,850 pregnant women were enrolled in this study. ALAN (nW/cm2/sr) exposure was higher in the PTB group than in the control group during first trimester (mean ± standard deviation: 25.30 ± 17.91 vs. 17.56 ± 14.74, p < 0.001) and second trimester (27.07 ± 18.10 vs. 21.93 ± 16.08, p < 0.001). A negative association was found between ALAN exposure and gestation day in the first (β = -0.151, 95%CI: -0.217 to -0.085, p < 0.001) and second trimesters (β = -0.077, 95%CI: -0.139 to -0.015, p = 0.015). ALAN was identified as a risk factor for PTB during the first trimester (OR = 1.032, 95%CI: 1.025-1.040, p < 0.001) and the second trimester (OR = 1.018, 95%CI: 1.011-1.025, p < 0.001), while no significant association was observed in the third trimester.

Conclusion

Our study suggesting that exposure to outdoor ALAN, especially during first and second trimester, was associated with the risk of PTB. These findings highlight the potential impact of ALAN on pregnancy health and offer new insights into the risk of PTB.

Greenness and chronic respiratory health issues: a systematic review and meta-analysis

Introduction

The number of chronic respiratory disease (CRD) individuals worldwide has been continuously increasing. Numerous studies have shown that greenness can improve chronic respiratory health issues through different mechanisms, with inconsistent evidence. By quantitatively summarizing existing studies, our purpose is to determine the connection between greenness exposure and various chronic respiratory health.

Methods

We conducted a comprehensive search on PubMed, EMBASE, and Web of Science core databases to identify relevant studies on the correlation between greenness exposure and chronic respiratory health issues. Studies published up to January 2023 were included in the search. The study used the most frequent indicator (normalized difference vegetation index [NDVI]) as the definition of greenness exposure.

Results

We finally identified 35 studies for meta-analysis. We calculated pooled effects across studies using a random-effects model and conducted a subgroup analysis by age and buffer zones to discuss the effects on chronic respiratory health issues. This study showed that 0.1 increments in NDVI were significantly related to lower rates of asthma incidence, lung cancer incidence, and chronic obstructive pulmonary disease (COPD) mortality risk; the pooled RRs were 0.92 (95% CI: 0.85-0.98), 0.62 (95% CI: 0.40-0.95), and 0.95 (95% CI: 0.92- 0.99), respectively. For the age subgroup, the higher greenness exposure level was related to the incidence rate of asthma among teenagers aged 13-18years (RR: 0.91; 95% CI: 0.83-0.99). For the buffer subgroup, a positive relationship with greenness exposure and asthma incidence/prevalence at 200-300m and 800- 1000m buffers, as well as the COPD mortality at 800-1000m buffer, the pooled RRs were 0.92 (95% CI: 0.86-0.98), 0.87 (95% CI: 0.81-0.93), and 0.93 (95% CI: 0.88- 0.98), respectively. Evidence of publication bias was not detected in this study.

Discussion

Our study is the first global meta-analysis between greenness and various CRDs to report an inverse association. Further research is needed in order to determine the effect of greenness exposure on different CRDs. Therefore, when planning for green development, more consideration must be given to public health and green management as intervention measures.

https://www.crd.york.ac.uk/PROSPEROFILES/384029_STRATEGY_20230116.pdf.

The Green Heart Project: Objectives, Design, and Methods

The Green Heart Project is a community-based trial to evaluate the effects of increasing greenery on urban environment and community health. The study was initiated in 2018 in a low-to-middle-income mixed-race residential area of nearly 28,000 residents in Louisville, KY. The 4 square mile area was surveyed for land use, population characteristics, and greenness, and assigned to 8 paired clusters of demographically- and environmentally matched "target" (T) and adjacent "control" (C), clusters. Ambient levels of ultrafine particles, ozone, oxides of nitrogen, and environmental noise were measured in each cluster. Individual-level data were acquired during in-person exams of 735 participants in Wave 1 (2018-2019) and 545 participants in Wave 2 (2021) to evaluate sociodemographic and psychosocial factors. Blood, urine, nail, and hair samples were collected to evaluate standard cardiovascular risk factors, inflammation, stress, and pollutant exposure. Cardiovascular function was assessed by measuring arterial stiffness and flow-mediated dilation. After completion of Wave 2, more than 8,000 mature, mostly evergreen, trees and shrubs were planted in the T clusters in 2022. Post planting environmental and individual-level data were collected during Wave 3 (2022) from 561 participants. We plan to continue following changes in area characteristics and participant health to evaluate the long-term impact of increasing urban greenery.

A review of factors influencing sensitive skin: an emphasis on built environment characteristics

Background

Sensitive skin (SS) is a condition characterized by hyperreactivity. Impacting around 37 percent of the worldwide population and exerting an influence on the quality of life for affected individuals. Its prevalence rate has increased due to factors such as elevating stress levels and deteriorating environmental conditions. The exposome factors influencing SS have extended from demographic, biological attributes, and lifestyle to external environments. Built environments (BEs) have demonstrated as root drivers for changes in behaviors and environmental exposure which have the potential to trigger SS, but the review of the associations between BEs and SS is currently lacking.

Objective

This review aims to achieve two primary objectives: (1) Examine exposome factors that exert influence on SS at the individual and environmental levels. (2) Develop a theoretical framework that establishes a connection between BEs and SS, thereby offering valuable insights into the impact of the built environment on this condition.

Methods

An extensive literature search was carried out across multiple fields, including sociology, epidemiology, basic medicine, clinical medicine, and environmental research, with a focus on SS. To identify pertinent references, renowned databases such as PubMed, Web of Science, and CNKI were utilized.

Results

SS is the outcome of interactions between individual attributes and environmental factors. These influencing factors can be categorized into five distinct classes: (1) demographic and socioeconomic characteristics including age, gender, and race; (2) physiological and biological attributes such as emotional changes, skin types, sleep disorders, and menstrual cycles in women; (3) behavioral factors, such as spicy diet, cosmetic use, alcohol consumption, and physical exercise; (4) natural environmental features, including climate conditions and air pollution; (5) built environmental features such as population density, green space availability, road network density, and access to public transportation, also have the potential to affect the condition.

Conclusion

The importance of interdisciplinary integration lies in its ability to ascertain whether and how BEs are impacting SS. By elucidating the role of BEs in conjunction with other factors in the onset of SS, we can provide guidance for future research endeavors and the formulation of interventions aimed at mitigating the prevalence of SS.

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.

Air pollution, cardiovascular disease, and urban greening: an ecological blueprint

A number of studies and systematic reviews indicate that exposure to greenness reduces of all-cause, non accidental mortality, particularly from cardiopulmonary and cancer causes. There is also some evidence that green space residence may be associated with improved pregnancy and birth outcomes, and with better school performances in children. Furthermore, because at least one third of the premature deaths are globally attributable to exposure to air pollution due household agents, particularly in fragile populations living in low-income countries (i.e., children, older and deprived people, pregnant women), that houseplants are an effective and economic mean for cleaning indoor air and thus reducing volatile organic compounds such as formaldehyde, benzene, toluene and others. On the whole more prospective studies are needed to further elucidate the mechanisms linking air pollution, greenness and health outcomes, although the multiple and interacting mechanisms depicted in this article are all biologically plausible.

Independent and interactive associations between greenness and ambient pollutants on novel glycolipid metabolism biomarkers: A national repeated measurement study

This study aims to investigate the independent and interactive effects of greenness and ambient pollutants on novel glycolipid metabolism biomarkers. A repeated national cohort study was conducted among 5085 adults from 150 counties/districts across China, with levels of novel glycolipid metabolism biomarkers of TyG index, TG/HDL-c, TC/HDL-c, and non-HDL-c measured. Exposure levels of greenness and ambient pollutants (including PM1, PM2.5, PM10, and NO2) for each participant were determined based on their residential location. Linear mixed-effect and interactive models were used to evaluate the independent and interactive effects between greenness and ambient pollutants on the four novel glycolipid metabolism biomarkers. In the main models, the changes [β (95% CIs)] of TyG index, TG/HDL-c, TC/HDL-c, and non-HDL-c were -0.021 (-0.036, -0.007), -0.120 (-0.175, -0.066), -0.092 (-0.122, -0.062), and -0.445 (-1.370, 0.480) for every 0.1 increase in NDVI, and were 0.004 (0.003, 0.005), 0.014 (0.009, 0.019), 0.009 (0.006, 0.011), and 0.067 (-0.019, 0.154) for every 1 μg/m3 increase in PM1. Results of interactive analyses demonstrated that individuals living in low-polluted areas could get greater benefits from greenness than those living in highly-polluted areas. Additionally, the results of mediation analyses revealed that PM2.5 mediated 14.40% of the association between greenness and the TyG index. Further research is needed to validate our findings.

Effect of neighbourhood greenness on the association between air pollution and risk of stroke first onset: A case-crossover study in shandong province, China

BACKGROUND

Higher neighbourhood greenness is associated with beneficial health outcomes, and short-term exposure to air pollution is associated with an elevated risk of stroke onset. However, little is known about their interactions.

METHODS

Daily data on stroke first onset were collected from 20 counties in Shangdong Province, China, from 2013 to 2019. The enhanced vegetation index (EVI) and concentrations of fine particulate matter (PM2.5), nitrogen dioxide (NO2), ozone (O3), carbon monoxide (CO), and sulfur dioxide (SO2) were calculated for each individual at the village or community level based on their home address to measure their neighbourhood exposure to greenness and air pollution. EVI was categorised as low or high, and a time-stratified case-crossover design was used to estimate the percent excess risk (ER%) of stroke associated with short-term exposure to air pollution. We further stratified greenness on the basis of EVI values into quartiles and introduced interaction terms between air pollutant concentrations and the median EVI values of the quartiles to assess the effect of greenness on the associations between short-term exposure and stroke.

RESULTS

Individuals living in the high-greenness areas had weaker associations between total stroke risk and exposure to NO2 (low greenness: ER% = 1.765% [95% CI 1.205%-2.328%]; high greenness: ER% = 0.368% [95% CI -0.252% to 0.991%]; P = 0.001), O3 (low greenness: 0.476% [95% CI 0.246%-0.706%]; high greenness: ER% = 0.085% [95% CI -0.156% to 0.327%]; P = 0.011), and SO2 (low greenness: 0.632% [95% CI 0.138%-1.129%]; high greenness: ER% = -0.177% [95% CI -0.782% to 0.431%]; P = 0.035).

CONCLUSION

Residence in areas with higher greenness was related to weaker associations between air pollution and stroke risk, suggesting that effectively planning green spaces can improve public health.

Mixtures of long-term exposure to ambient air pollution, built environment and temperature and stroke incidence across Europe

INTRODUCTION

The complex interplay of multiple environmental factors and cardiovascular has scarcely been studied. Within the EXPANSE project, we evaluated the association between long-term exposure to multiple environmental indices and stroke incidence across Europe.

METHODS

Participants from three traditional adult cohorts (Germany, Netherlands and Sweden) and four administrative cohorts (Catalonia [region Spain], Rome [city-wide], Greece and Sweden [nationwide]) were followed until incident stroke, death, migration, loss of follow-up or study end. We estimated exposures at residential addresses from different exposure domains: air pollution (nitrogen dioxide (NO2), particulate matter < 2.5 μm (PM2.5), black carbon (BC), ozone), built environment (green/blue spaces, impervious surfaces) and meteorology (seasonal mean and standard deviation of temperatures). Associations between environmental exposures and stroke were estimated in single and multiple-exposure Cox proportional hazard models, and Principal Component (PC) Analyses derived prototypes for specific exposures domains. We carried out random effects meta-analyses by cohort type.

RESULTS

In over 15 million participants, increased levels of NO2 and BC were associated with increased higher stroke incidence in both cohort types. Increased Normalized Difference Vegetation Index (NDVI) was associated with a lower stroke incidence in both cohort types, whereas an increase in impervious surface was associated with an increase in stroke incidence. The first PC of the air pollution domain (PM2.5, NO2 and BC) was associated with an increase in stroke incidence. For the built environment, higher levels of NDVI and lower levels of impervious surfaces were associated with a protective effect [%change in HR per 1 unit = -2.0 (95 %CI, -5.9;2.0) and -1.1(95 %CI, -2.0; -0.3) for traditional adult and administrative cohorts, respectively]. No clear patterns were observed for distance to blue spaces or temperature parameters.

CONCLUSIONS

We observed increased HRs for stroke with exposure to PM2.5, NO2 and BC, lower levels of greenness and higher impervious surface in single and combined exposure models.

Who benefits from green spaces? Surrounding greenness and incidence of cardiovascular disease in a population-based electronic medical records cohort in Madrid

The objective was to study the association between surrounding greenness and the incidence of cardiovascular diseases (CVD) with a four years follow-up in almost half a million high CVD-risk women and men, as well as its differential effect by area-level deprivation in Madrid. We analyzed 2015-2018 primary healthcare electronic medical records for 437,513 high CVD risk individuals representing more than 95% of the population of that age range residing in Madrid. The outcome variable was any cardiovascular event. We measured surrounding residence greenness at 200 m, 300 m, 500 m, and 1000 m through the Normalized Difference Vegetation Index (NDVI). We assessed socioeconomic deprivation through a census-based deprivation index. We estimated the 4-year relative risk of CVD by an increase in 0.1 units of NDVI and then stratified the models by quintiles of deprivation (Q5 the most deprived). We found that for every increase in 0.1 units of NDVI at 1000 m there was a 16% decrease in CVD risk (RR = 0.84 95% CI 0.75-0.94). CVD risk for the remaining distance exposures (at 200 m, 300 m, and 500 m) were none statistically significant. In general, the protective effect of green spaces was present in medium-deprivation areas and males, but the associations were inconsistent across deprivation levels. This study highlights the relevance of evaluating the interaction between physical and social urban components to further understand possible population prevention approaches for cardiovascular diseases. Future studies should focus on the mechanisms of context-specific interactions between social inequalities and green spaces' effects on health.

Preferred reporting items in green space health research. Guiding principles for an interdisciplinary field

The relationship between green spaces and health is attracting more and more societal and research interest. The research field is however still suffering from its differing monodisciplinary origins. Now in a multidisciplinary environment on its way to a truly interdisciplinary field, there is a need for a common understanding, precision in green space indicators, and coherent assessment of the complexity of daily living environments. In several reviews, common protocols and open-source scripts are considered a high priority to advance the field. Realizing these issues, we developed PRIGSHARE (Preferred Reporting Items in Greenspace Health Research). It is accompanied by an open-source script that supports non-spatial disciplines in assessing greenness and green space on different scales and types. The PRIGSHARE checklist contains 21 items that have been identified as a risk of bias and are necessary for understanding and comparison of studies. The checklist is divided into the following topics: objectives (3 items), scope (3 items), spatial assessment (7 items), vegetation assessment (4 items), and context assessment (4 items). For each item, we include a pathway-specific (if relevant) rationale and explanation. The PRIGSHARE guiding principles should be helpful to support a high-quality assessment and synchronize the studies in the field while acknowledging the diversity of study designs.

Time in Nature: A Prescription for the Prevention or Management of Hypertension

Growing evidence suggests time in nature may positively influence a broad range of health outcomes including blood pressure. The mechanism(s) by which nature exerts this influence is not fully understood, but it has been proposed that nature or natural environments promote health due to opportunities for physical activity and stress reduction. Experimental and observational studies suggest that time in forests or other green spaces is associated with reduced blood pressure, lower prevalence of hypertension, and reduced odds of using antihypertensive medications. Therefore, prescribing time in nature for patients at risk or diagnosed with hypertension may have substantial benefits.

Inequalities in urban greenness and epigenetic aging: Different associations by race and neighborhood socioeconomic status

Slower epigenetic aging is associated with exposure to green space (greenness); however, the longitudinal relationship has not been well studied, particularly in minority groups. We investigated the association between 20-year exposure to greenness [Normalized Difference Vegetation Index (NDVI)] and epigenetic aging in a large, biracial (Black/white), U.S. urban cohort. Using generalized estimating equations adjusted for individual and neighborhood socioeconomic characteristics, greater greenness was associated with slower epigenetic aging. Black participants had less surrounding greenness and an attenuated association between greenness and epigenetic aging [βNDVI5km: -0.80, 95% confidence interval (CI): -4.75, 3.13 versus βNDVI5km: -3.03, 95% CI: -5.63, -0.43 in white participants]. Participants in disadvantaged neighborhoods showed a stronger association between greenness and epigenetic aging (βNDVI5km: -3.36, 95% CI: -6.65, -0.08 versus βNDVI5km: -1.57, 95% CI: -4.12, 0.96 in less disadvantaged). In conclusion, we found a relationship between greenness and slower epigenetic aging, and different associations by social determinants of health such as race and neighborhood socioeconomic status.

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.

Modification of low temperature-related hospital admissions for cardiovascular diseases by multiple green space indicators at multiple spatial scales: Evidence from Guangzhou, China

BACKGROUND

Extreme temperatures have an adverse effect on the occurrence of cardiovascular diseases (CVDs). Previous literatures tend to discuss the modification of CVDs occurrence by green space under high temperature. Relatively less attention is paid to the modification under low temperature. The variation of different attributes and spatial scales of green space in affecting CVDs occurrence are also overlooked.

METHODS

This study collected a total of 4364 first-time admission cases due to CVDs in a tertiary hospital in Guangzhou from 2012 to 2018, measured the scale of green space by greening rate (GR) and percentage of landscape (PLAND), the distribution of green space by patch density (PD), mean nearest neighbor distance (ENN_MN) and largest patch index (LPI), and the accessibility of green space by green patch accessibility index (GPAI). Using the time stratified case crossover design method, the modification of low temperature-related CVDs occurrence by the above green space indicators is evaluated in an area with a radius of 100-1000 m which is further divided at an interval of 100 m.

RESULTS

We found high GR, high PLAND, high PD, low ENN_MN, high LPI, and low GPAI corresponds to low risk of CVDs occurrence, the optimal modification scale of each green space indicator, which is radius corresponding to the maximum risk difference between high and low indicator subgroups, is around 800 m (GR), 600 m (PLAND and PD), 500 m (GPAI), and 300 m (LPI and ENN_MN), respectively. As the temperature decreases further, the health benefit from low GPAI at the optimal scale is weakened, whereas the benefits from the others are strengthened.

CONCLUSIONS

Low temperature related CVDs occurrence risk can be modified by multiple green space indicators, and these modifications have spatial scale effect. Our findings have important theoretical and practical significance for the formulation and implementation of local green space policies.

Pollution from fine particulate matter and atherosclerosis: A narrative review

According to the WHO, the entire global population is exposed to air pollution levels higher than recommended for health preservation. Air pollution is a complex mixture of nano- to micro-sized particles and gaseous components that poses a major global threat to public health. Among the most important air pollutants, causal associations have been established between particulate matter (PM), mainly < 2.5 μm, and cardiovascular diseases (CVD), i.e., hypertension, coronary artery disease, ischemic stroke, congestive heart failure, arrhythmias as well as total cardiovascular mortality. Aim of this narrative review is to describe and critically discuss the proatherogenic effects of PM_2.5 that have been attributed to many direct or indirect effects comprising endothelial dysfunction, a chronic low-grade inflammatory state, increased production of reactive oxygen species, mitochondrial dysfunction and activation of metalloproteases, all leading to unstable arterial plaques. Higher concentrations of air pollutants are associated with the presence of vulnerable plaques and plaque ruptures witnessing coronary artery instability. Air pollution is often disregarded as a CVD risk factor, in spite of the fact that it is one of the main modifiable factors relevant for prevention and management of CVD. Thus, not only structural actions should be taken in order to mitigate emissions, but health professionals should also take care to counsel patients on the risks of air pollution.

Air pollution and myocardial infarction; effect modification by sociodemographic and environmental factors. A cohort study from Denmark

Air pollution is associated with increased risk of myocardial infarction (MI), but it is unresolved to what extent the association is modified by factors such as socioeconomic status, comorbidities, financial stress, residential green space, or road traffic noise. We formed a cohort of all (n = 1,964,702) Danes, aged 50-85 years, with 65,311 cases of MI during the followed-up period 2005-2017. For all participants we established residential five-year running average exposure to particulate matter <2.5  μm (PM_2.5), ultrafine particles (UFP, <0.1  μm), elemental carbon (EC) and nitrogen dioxide (NO₂). We evaluated risk in population strata, using Aalen additive hazards models to estimate absolute risk and Cox proportional hazards models to estimate relative risk of MI with 95% confidence intervals (CI). PM_2.5 and the other pollutant were associated with MI. Lower education and lower income were associated with higher absolute risks of MI from air pollution, whereas no clear effect modification was apparent for relative risk estimates. For example, 5 μg/m³ higher PM_2.5 was associated with HR for MI of 1.16 (95% CI: 1.10-1.22) among those with only mandatory education and 1.13 (95% CI: 1.03-1.24) among those with long education. The corresponding rate differences per 100,000 person years were 243 (95% CI: 216-271) and 358 (95% CI: 338-379), respectively. Higher level of comorbidity was consistently across all four pollutants associated with both higher absolute and relative risk of MI. In conclusion, people with comorbid conditions or of lower SES appeared more vulnerable to long-term exposure to air pollution and more cases of MI may be prevented by focused interventions in these groups.

How do territorial characteristics affect spatial inequalities in the risk of coronary heart disease?

BACKGROUND

Cardiovascular diseases remain the leading cause of death and disabilities worldwide, with coronary heart diseases being the most frequently diagnosed. Their multifactorial etiology involves individual, behavioral and territorial determinants, and thus requires the implementation of multidimensional approaches to assess links between territorial characteristics and the incidence of coronary heart diseases.

CONTEXT AND OBJECTIVES

This study was carried out in a densely populated area located in the north of France with multiple sources of pollutants. The aim of this research was therefore to establish complex territorial profiles that have been characterized by the standardized incidence, thereby identifying the influences of determinants that can be related to a beneficial or a deleterious effect on cardiovascular health.

METHODS

Forty-four variables related to economic, social, health, environment and services dimensions with an established or suspected impact on cardiovascular health were used to describe the multidimensional characteristics involved in cardiovascular health.

RESULTS

Three complex territorial profiles have been highlighted and characterized by the standardized incidence rate (SIR) of coronary heart diseases after adjustment for age and gender. Profile 1 was characterized by an SIR of 0.895 (sd: 0.143) and a higher number of determinants that revealed favorable territorial conditions. Profiles 2 and 3 were characterized by SIRs of respectively 1.225 (sd: 0.242) and 1.119 (sd: 0.273). Territorial characteristics among these profiles of over-incidence were nevertheless dissimilar. Profile 2 revealed higher deprivation, lower vegetation and lower atmospheric pollution, while profile 3 displayed a rather privileged population with contrasted territorial conditions.

CONCLUSION

This methodology permitted the characterization of the multidimensional determinants involved in cardiovascular health, whether they have a negative or a positive impact, and could provide stakeholders with a diagnostic tool to implement contextualized public health policies to prevent coronary heart diseases.

Cross-sectional associations of different types of nature exposure with psychotropic, antihypertensive and asthma medication

BACKGROUND

Exposure to natural environments is thought to be beneficial for human health, but the evidence is inconsistent.

OBJECTIVE

To examine whether exposure to green and blue spaces in urban environments is associated with mental and physical health in Finland.

METHODS

The Helsinki Capital Region Environmental Health Survey was conducted in 2015-2016 in Helsinki, Espoo and Vantaa in Finland (n=7321). Cross-sectional associations of the amounts of residential green and blue spaces within 1 km radius around the respondent's home (based on the Urban Atlas 2012), green and blue views from home and green space visits with self-reported use of psychotropic (anxiolytics, hypnotics and antidepressants), antihypertensive and asthma medication were examined using logistic regression models. Indicators of health behaviour, traffic-related outdoor air pollution and noise and socioeconomic status (SES) were used as covariates, the last of these also as a potential effect modifier.

RESULTS

Amounts of residential green and blue spaces or green and blue views from home were not associated with medications. However, the frequency of green space visits was associated with lower odds of using psychotropic medication (OR=0.67, 95% CI 0.55 to 0.82 for 3-4 times/week; 0.78, 0.63 to 0.96 for ≥5 times/week) and antihypertensive (0.64, 0.52 to 0.78; 0.59, 0.48 to 0.74, respectively) and asthma (0.74, 0.58 to 0.94; 0.76, 0.59 to 0.99, respectively) medication use. The observed associations were attenuated by body mass index, but no consistent interactions with SES indicators were observed.

CONCLUSIONS

Frequent green space visits, but not the amounts of residential green or blue spaces, or green and blue views from home, were associated with less frequent use of psychotropic, antihypertensive and asthma medication in urban environments.

Associations Between Built Environment Factors and SARS-CoV-2 Infections at the Neighbourhood Level in a Metropolitan Area in Germany

COVID-19-related health outcomes displayed distinct geographical patterns within countries. The transmission of SARS-CoV-2 requires close spatial proximity of people, which can be influenced by the built environment. Only few studies have analysed SARS-CoV-2 infections related to the built environment within urban areas at a high spatial resolution. This study examined the association between built environment factors and SARS-CoV-2 infections in a metropolitan area in Germany. Polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infections of 7866 citizens of Essen between March 2020 and May 2021 were analysed, aggregated at the neighbourhood level. We performed spatial regression analyses to investigate associations between the cumulative number of SARS-CoV-2 infections per 1000 inhabitants (cum. SARS-CoV-2 infections) up to 31.05.2021 and built environment factors. The cum. SARS-CoV-2 infections in neighbourhoods (median: 11.5, IQR: 8.1-16.9) followed a marked socially determined north-south gradient. The effect estimates of the adjusted spatial regression models showed negative associations with urban greenness, i.e. normalized difference vegetation index (NDVI) (adjusted β =  - 35.36, 95% CI: - 57.68; - 13.04), rooms per person (- 10.40, - 13.79; - 7.01), living space per person (- 0.51, - 0.66; - 0.36), and residential (- 0.07, 0.16; 0.01) and commercial areas (- 0.15, - 0.25; - 0.05). Residential areas with multi-storey buildings (- 0.03, - 0.12; 0.06) and green space (0.03, - 0.05; 0.11) did not show a substantial association. Our results suggest that the built environment matters for the spread of SARS-CoV-2 infections, such as more spacious apartments or higher levels of urban greenness are associated with lower infection rates at the neighbourhood level. The unequal intra-urban distribution of these factors emphasizes prevailing environmental health inequalities regarding the COVID-19 pandemic.

Association between exposure to greenness and atopic march in children and adults-A systematic review and meta-analysis

Introduction

Allergic diseases are a global public health problem. Food allergy, atopic dermatitis (AD), allergic rhinoconjunctivitis, allergic rhinitis (AR) and asthma represent the natural course of allergic diseases, also known as the "atopic march". In recent years, a large number of studies have been published on the association between greenness exposure and allergic diseases. However, systematic reviews on the association between greenness exposure and multiple allergic diseases or atopic march are lacking.

Methods

In this study, PubMed, EMBASE, ISI Web of Science, and Scopus were systematically searched. Meta-analyses were performed if at least three studies reported risk estimates for the same outcome and exposure measures.

Results

Of 2355 records, 48 studies were included for qualitative review. Five birth cohort studies, five cross-sectional studies, and one case-control study were included for asthma meta-analysis, respectively. Four birth cohort studies were included for AR meta-analysis. Our results support that exposure to a greener environment at birth reduces the risk of asthma and AR in childhood. In addition, higher greenness exposure was associated with decreased odds of current asthma in children.

Discussion

There was a large heterogeneity among the included studies and most of them did not specify the vegetation type and causative allergens. Therefore the study results need to be further validated. In addition, a small number of studies evaluated the association between greenness and food allergy, AD and allergic rhinoconjunctivitis. More research is needed to strengthen our understanding of the association between greenness and allergic diseases.

Associations and pathways between residential greenness and metabolic syndromes in Fujian Province

Background

Greenness exposure is beneficial to human health, but its potential mechanisms through which the risk for metabolic syndrome (MetS) could be reduced have been poorly studied. We aimed to estimate the greenness-MetS association in southeast China and investigate the independent and joint mediation effects of physical activity (PA), body mass index (BMI), and air pollutants on the association.

Methods

A cross-sectional study was conducted among the 38,288 adults based on the Fujian Behavior and Disease Surveillance (FBDS), established in 2018. MetS was defined as the presence of three or more of the five components: abdominal obesity, elevated triglyceride, reduced high-density lipoprotein cholesterol (HDL-C), high blood pressure, and elevated fasting glucose. The residential greenness exposure was measured as the 3-year mean values of the normalized difference vegetation index (NDVI) and enhanced vegetation index (EVI) within the 250, 500, and 1,000 meters (m) buffer zones around the residential address of each participant. Logistic regression models were used to estimate the greenness-MetS association. The causal mediation analysis was used to estimate the independent and joint mediation effects of PA, BMI, particulate matter with an aerodynamic diameter of 2.5 μm (PM_2.5), particulate matter with an aerodynamic diameter ≤ 10 μm (PM₁₀), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂).

Results

Each interquartile range (IQR) increase in greenness was associated with a decrease of 13% (OR = 0.87 [95%CI: 0.83, 0.92] for NDVI_500m and OR = 0.87 [95%CI: 0.82, 0.91] for EVI_500m) in MetS risk after adjusting for covariates. This association was stronger in those aged < 60 years (e.g., OR = 0.86 [95%CI: 0.81, 0.92] for NDVI_500m), males (e.g., OR = 0.73 [95%CI: 0.67, 0.80] for NDVI_500m), having an educational level of primary school or above (OR = 0.81 [95%CI: 0.74, 0.89] for NDVI_500m), married/cohabitation (OR = 0.86 [95%CI: 0.81, 0.91] for NDVI_500m), businessman (OR = 0.82 [95%CI: 0.68, 0.99] for NDVI_500m), other laborers (OR = 0.77 [95%CI: 0.68, 0.88] for NDVI_500m), and non-smokers (OR = 0.77 [95%CI: 0.70, 0.85] for NDVI_500m). The joint effect of all six mediators mediated about 48.1% and 44.6% of the total effect of NDVI_500m and EVI_500m on the MetS risk, respectively. Among them, BMI showed the strongest independent mediation effect (25.0% for NDVI_500m), followed by NO₂ and PM₁₀.

Conclusion

Exposure to residential greenness was associated with a decreased risk for MetS. PA, BMI, and the four air pollutants jointly interpreted nearly half of the mediation effects on the greenness-MetS association.

Associations of ambient temperature with mortality for ischemic and hemorrhagic stroke and the modification effects of greenness in Shandong Province, China

BACKGROUND

Evidence is scant on the relative and attributable contributions of ambient temperature on stroke subtypes mortality. Few studies have examined modification effects of multiple greenness indicators on such contributions, especially in China. We quantified the associations between ambient temperature and overall, ischemic, and hemorrhagic stroke mortality; further examined whether the associations were modified by greenness.

METHODS

We conducted a multicenter time-series analysis from January 1, 2013 to December 31, 2019. we adopted a distributed lag non-linear model to evaluate county-specific temperature-stroke mortality associations. We then applied a random-effects meta-analysis to pool county-specific effects. Attributable mortality was calculated for cold and heat, defined as temperatures below and above the minimum mortality temperature (MMT). Finally, We conducted a multivariate meta-regression to determine associations between greenness and stroke mortality risks for cold and heat, using normalized difference vegetation index (NDVI), soil adjusted vegetation index (SAVI), and enhanced vegetation index (EVI) as quantitative indicators of greenness exposure.

RESULTS

In the study period, 138,749 deaths from total stroke were reported: 86,873 ischemic and 51,876 hemorrhagic stroke. We observed significant W-shaped relationships between temperature and stroke mortality, with substantial differences among counties and regions. With MMT as the temperature threshold, 17.16 % (95 % empirical CI, 13.38 %-19.75 %) of overall, 20.05 % (95 % eCI, 16.46 %-22.70 %) of ischemic, and 12.55 % (95 % eCI, 5.59 %-16.24 %) of hemorrhagic stroke mortality were attributable to non-optimum temperature (combining cold and heat), more mortality was caused by cold (14.94 %; 95 % eCI, 11.57 %-17.34 %) than by heat (2.22 %; 95 % eCI, 1.54 %-2.72 %). Higher levels of NDVI, SAVI and EVI were related to mitigated effects of non-optimum temperatures-especially heat.

CONCLUSIONS

Exposure to non-optimum temperatures aggravated stroke mortality risks; increasing greenness could alleviate that risks. This evidence has important implications for local communities in developing adaptive strategies to minimize the health consequences of adverse temperatures.

The impact of greenspace or nature-based interventions on cardiovascular health or cancer-related outcomes: A systematic review of experimental studies

SIGNIFICANCE

Globally, cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality. While having different etiologies, CVD and cancer are linked by multiple shared risk factors, the presence of which exacerbate adverse outcomes for individuals with either disease. For both pathologies, factors such as poverty, lack of physical activity (PA), poor dietary intake, and climate change increase risk of adverse outcomes. Prior research has shown that greenspaces and other nature-based interventions (NBIs) contribute to improved health outcomes and climate change resilience.

OBJECTIVE

To summarize evidence on the impact of greenspaces or NBIs on cardiovascular health and/or cancer-related outcomes and identify knowledge gaps to inform future research.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and Peer Review of Electronic Search Strategies (PRESS) guidelines, we searched five databases: Web of Science, Scopus, Medline, PsycINFO and GreenFile. Two blinded reviewers used Rayyan AI and a predefined criteria for article inclusion and exclusion. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). This review is registered with PROSPERO, ID # CRD42021231619.

RESULTS & DISCUSSION

Of 2565 articles retrieved, 31 articles met the inclusion criteria, and overall had a low risk of bias. 26 articles studied cardiovascular related outcomes and 5 studied cancer-related outcomes. Interventions were coded into 4 categories: forest bathing, green exercise, gardening, and nature viewing. Outcomes included blood pressure (BP), cancer-related quality of life (QoL) and (more infrequently) biomarkers of CVD risk. Descriptions of findings are presented as well as visual presentations of trends across the findings using RAW graphs. Overall studies included have a low risk of bias; and alluvial chart trends indicated that NBIs may have beneficial effects on CVD and cancer-related outcomes.

CONCLUSIONS & IMPLICATIONS

(1) Clinical implication: Healthcare providers should consider the promotion of nature-based programs to improve health outcomes. (2) Policy implication: There is a need for investment in equitable greenspaces to improve health outcomes and build climate resilient neighborhoods. (3) Research or academic implication: Research partnerships with community-based organizations for a comprehensive study of benefits associated with NBIs should be encouraged to reduce health disparities and ensure intergenerational health equity. There is a need for investigation of the mechanisms by which NBIs impact CVD and exploration of the role of CVD biological markers of inflammation among cancer survivors.

Exploring the impacts of street-level greenspace on stroke and cardiovascular diseases in Chinese adults

In recent years, cardiovascular diseases (CVDs) have become the primary cause of death in the world. Existing studies have found that greenspace is important for the prevention of CVDs and stroke. However, since they only focus on large green infrastructure (e.g., urban parks) or the general greenspace (usually being evaluated through normalized difference vegetation index), little information exists regarding the association between street-level greenspace and CVDs (stroke). In this study, the CVDs and stroke data of participants were retrieved from the 33 Chinese Community Health Study. We measured participants' exposure to street-level greenspace exposure using street view images and machine learning technique. Multilevel logistic regressions were applied. While controlling for confounders, we found that higher level of street-level greenspace exposure was associated with lower CVDs prevalence. However, street-level greenspace exposure was associated with stroke prevalence only for females. The associations were stronger among females, younger adults, participants with educational attainment above high school, physically active participants and participants who were not overweight. None of the mediators (air pollution, physical exercise, and BMI) can explain the associations between street-level greenspace exposure and CVDs (stroke) prevalence. Our findings suggest that street-level vegetation should be increased to cope with the rapid growth of the CVDs burdens. Also, the differences between the effect of street-level trees and grasses should be noted before formulating specific urban planning policies.

Effects of Self-Rated Health Status on Residents' Social-Benefit Perceptions of Urban Green Space

Urban green spaces (UGS) provide many social benefits and improves residents' wellbeing. Studying residents' perceptions of UGS's social benefits and driving factors could promote public health and environmental justice. A questionnaire survey of 432 Beijing residents and statistical tests assessed the impacts of residents' living environments and self-rated health status on UGS perceptions. The results showed: (1) perceptions of UGS' physical health benefits were subdued, with an inclination towards other social benefits. Respondents more highly perceived accelerating patient recovery and reducing morbidity and mortality rates. Perceptions of bearing larger-head babies with higher weight were relatively low. For other social benefits, perceptions of improving the environment and life quality were higher, but reducing anger outbursts and resolving conflicts were lower. (2) Childhood living environments did not affect perceptions of social benefits, but current living environments did. Suburb residents understood reducing pain-relief medication demands and bearing larger-head babies better than city residents. City residents understood UGS' investments considerable and sustained returns better than village residents. City residents agreed with accelerating patient recovery higher than village ones. (3) Respondents with "poor" self-rated health status had better perceptions of other social benefits. Those with "excellent" ratings did not fully understand UGS' physical health benefits. "Poor" ratings understood improving a city's image and making cities livable and sustainable better than "good" or "fair" ratings. "Excellent" ratings had less understanding of larger-head babies than "good" or "fair" ratings. The study could enhance appreciation of UGS' social benefits to facilitate planning and management to meet residents' expectations.

Perceived Qualities, Visitation and Felt Benefits of Preferred Nature Spaces during the COVID-19 Pandemic in Australia: A Nationally-Representative Cross-Sectional Study of 2940 Adults

We investigated how the perceived quality of natural spaces influenced levels of visitation and felt benefits during the COVID-19 pandemic in Australia via a nationally representative online and telephone survey conducted on 12–26 October (Social Research Centre’s Life in AustraliaTM panel aged > 18 years, 78.8% response, n = 3043). Our sample was restricted to those with complete information (n = 2940). Likert scale responses to 18 statements regarding the quality of local natural spaces that participants preferred to visit were classified into eight quality domains: access; aesthetics; amenities; facilities; incivilities; potential usage; safety; and social. These domains were then summed into an overall nature quality score (mean = 5.8, range = 0–16). Associations between these quality variables and a range of nature visitation and felt benefits were tested using weighted multilevel models, adjusted for demographic and socioeconomic confounders. Compared with participants in the lowest perceived nature quality quintile, those in the highest quality quintile had higher odds of spending at least 2 h in their preferred local nature space in the past week (Odds Ratio [OR] = 3.40; 95% Confidence Interval [95%CI] = 2.38–4.86), of visiting their preferred nature space almost every day in the past four weeks (OR = 3.90; 2.77–5.47), and of reporting increased levels of nature visitation in comparison with before the COVID-19 pandemic (OR = 3.90; 2.54–6.00). Participants in the highest versus lowest perceived nature quality quintile also reported higher odds of feeling their visits to nature enabled them to take solace and respite during the pandemic (OR = 9.49; 6.73–13.39), to keep connected with their communities (OR = 5.30; 3.46–8.11), and to exercise more often than they did before the pandemic (OR = 3.88; 2.57–5.86). Further analyses of each quality domain indicated time in and frequency of visiting nature spaces were most affected by potential usage and safety (time in nature was also influenced by the level of amenity). Feelings of connection and solace were most affected by potential usage and social domains. Exercise was most influenced by potential usage, social and access domains. In conclusion, evidence reported in this study indicates that visits to nature and various health-related benefits associated with it during the COVID-19 pandemic were highly contingent upon numerous qualities of green and blue spaces.