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Mori Y, Tsuji T, Watanabe R, Hanazato M, Miyazawa T, Kondo K. Built environments and frailty in older adults: A three-year longitudinal JAGES study. Arch Gerontol Geriatr 2022; 103:104773. [PMID: 35849975 DOI: 10.1016/j.archger.2022.104773] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study investigated the relationship between built environments and the onset of frailty after 3 years. METHODS This was a longitudinal study using prospective cohort data from the 2013 Japan Gerontological Evaluation Study on 38,829 older adults nested in 562 comunnities who were not frail. The dependent variable, frailty, was assessed using the Kihon checklist. The explanatory variables were eight items for the built environment at the individual and community levels. To consider each level of built environment simultaneously, multilevel Poisson regression analysis was used to calculate risk ratios and 95% confidence intervals. RESULTS After 3 years of follow-up, the onset of frailty was 2740 (7.1%) in 2016. At the individual level, there was an increased risk of developing frailty in negative built environments, such as locations with graffiti or garbage (incidence rate ratio (IRR), 1.15; confidence interval (CI), 1.05-1.25). Positive built environments, such as areas with access to parks and sidewalks (IRR, 0.78; CI, 0.70-0.88), lowered the risk of developing frailty. At the community level, the risk of developing frailty was lower only in areas with locations difficult for walking (hills or steps) (IRR, 0.97; CI, 0.94-0.99). CONCLUSIONS At the individual level, frailty onset was associated with all built environments. However, irrespective of their answers, there was a lower risk of developing frailty among older adults living in areas where walking was difficult. It would be desirable to verify whether the risk of developing frailty can be reduced by changing the built environment.
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Affiliation(s)
- Yuta Mori
- Department of Rehabilitation, Hananooka Hospital, 707-3, Yamamurocho, Matsusaka, Mie 515-0052, Japan; Department of Public Health, Graduate School of Medicine, University of Chiba, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba 260-8670, Japan.
| | - Taishi Tsuji
- Faculty of Health and Sport Sciences, University of Tsukuba, 3-29-1, Otsuka, Bunkyo-ku, Tokyo 112-0012, Japan; Center for Preventive Medical Sciences, University of Chiba, 1-33, Yayoicho, Inage-ku, Chiba, Chiba 263-8522, Japan
| | - Ryota Watanabe
- Center for Preventive Medical Sciences, University of Chiba, 1-33, Yayoicho, Inage-ku, Chiba, Chiba 263-8522, Japan; Center for Gerontology and Social Science, Research Institute, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu, Aichi 474-8511, Japan
| | - Masamichi Hanazato
- Center for Preventive Medical Sciences, University of Chiba, 1-33, Yayoicho, Inage-ku, Chiba, Chiba 263-8522, Japan
| | - Takuto Miyazawa
- Chiba Rehabilitation Center, 1-45-2, Hondacho, Midori-ku, Chiba, Chiba 266-0005, Japan
| | - Katsunori Kondo
- Department of Public Health, Graduate School of Medicine, University of Chiba, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba 260-8670, Japan; Center for Preventive Medical Sciences, University of Chiba, 1-33, Yayoicho, Inage-ku, Chiba, Chiba 263-8522, Japan; Center for Gerontology and Social Science, Research Institute, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu, Aichi 474-8511, Japan
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Effect of Urban Green Space in the Hilly Environment on Physical Activity and Health Outcomes: Mediation Analysis on Multiple Greenery Measures. LAND 2022. [DOI: 10.3390/land11050612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Background: Green spaces reduce the risk of multiple adverse health outcomes by encouraging physical activity. This study examined correlations between urban green space and residents’ health outcomes in hilly neighborhoods: if they are mediated by social cohesion, visual aesthetics, and safety. Methods: We used multiple green space indicators, including normalized difference vegetation index (NDVI) extracted from satellite imagery, green view index (GVI) obtained from street view data using deep learning methods, park availability, and perceived level of greenery. Hilly terrain was assessed by the standard deviation of the elevation to represent variations in slope. Resident health outcomes were quantified by their psychological and physiological health as well as physical activity. Communities were grouped by quartiles of slopes. Then a mediation model was applied, controlling for socio-demographic factors. Results: Residents who perceived higher quality greenery experienced stronger social cohesion, spent more time on physical activity and had better mental health outcomes. The objective greenery indicators were not always associated with physical activity and might have a negative influence with certain terrain. Conclusions: Perceived green space offers an alternative explanation of the effects on physical activity and mental health in hilly neighborhoods. In some circumstances, geographical environment features should be accounted for to determine the association of green space and resident health outcomes.
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Rotenberg DK, Stewart-Freedman B, Søgaard J, Vinker S, Lahad A, Søndergaard J. Similarities and differences between two well-performing healthcare systems: a comparison between the Israeli and the Danish healthcare systems. Isr J Health Policy Res 2022; 11:14. [PMID: 35227304 PMCID: PMC8883018 DOI: 10.1186/s13584-022-00524-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 02/16/2022] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Denmark and Israel both have highly rated and well-performing healthcare systems with marked differences in funding and organization of primary healthcare. Although better population health outcomes are seen in Israel, Denmark has a substantially higher healthcare expenditure. This has caused Danish policy makers to take an interest in Israeli community care organization. Consequently, we aim to provide a more detailed insight into differences between the two countries’ healthcare organization and cost, as well as health outcomes.
Methods
A comparative analysis combining data from OECD, WHO, and official sources. World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD) statistics were used, and national official sources were procured from the two healthcare systems. Literature searches were performed in areas relevant to expenditure and outcome. Data were compared on health care expenditure and selected outcome measures. Expenditure was presented as purchasing power parity and as percentage of gross domestic product, both with and without adjustment for population age, and both including and excluding long-term care expenditure.
Results
Denmark’s healthcare expenditure is higher than Israel’s. However, corrected for age and long-term care the difference diminishes. Life expectancy is lower in Denmark than in Israel, and Israel has a significantly better outcome regarding cancer as well as a lower number of Years of Potential Life Lost. Israelis have a healthier lifestyle, in particular a much lower alcohol consumption.
Conclusion
Attempting to correct for what we deemed to be the most important influencing factors, age and different inclusions of long-term care costs, the Israeli healthcare system still seems to be 25% less expensive, compared to the Danish one, and with better health outcomes. This is not necessarily a function of the Israeli healthcare system but may to a great extent be explained by cultural factors, mainly a much lower Israeli alcohol consumption.
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Abe T, Okuyama K, Hamano T, Kamada M, Isomura M, Nabika T, Miyazaki R. Association between hilliness and walking speed in community-dwelling older Japanese adults: A cross-sectional study. Arch Gerontol Geriatr 2021; 97:104510. [PMID: 34487955 DOI: 10.1016/j.archger.2021.104510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/18/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE This cross-sectional study investigated the association between hilliness and walking speed in community-dwelling older adults, and whether it varied according to their car-driving status. METHODS Data were collected from 590 participants aged 65 and older living in Okinoshima Town, Shimane prefecture, Japan, in 2018. Comfortable walking speed (m/s) was objectively assessed. Hilliness was measured by the mean land slope (degree) within a 500-m or 1000-m network buffer around each participant's home using a geographic information system. A multiple linear regression examined whether the land slope was associated with walking speed, adjusted for sex, age, body mass index, smoking habits, alcohol consumption habits, exercise habits, chronic disease, and living arrangements. A stratified analysis by car-driving status was also conducted. RESULTS After adjusting for all confounders, the land slope within the 500-m or 1000-m network buffer was negatively associated with walking speed (B = -0.007, 95% CI [-0.011, -0.002]; B = -0.007, 95% CI [-0.011, -0.003], respectively). The stratified analysis by car-driving status showed that living in a hilly area was negatively associated with walking speed among non-drivers in the 500-m or 1000-m network buffer (B = -0.011, 95% CI [-0.017, -0.004]; B = -0.012, 95% CI [-0.019, -0.006]), though there were no associations among drivers. CONCLUSIONS A hilly environment is positively associated with slow walking speed in community-dwelling older adults in Japan. Moreover, car-driving status potentially modifies the relationship between living in a hilly environment and slow walking speed.
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Affiliation(s)
- Takafumi Abe
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, 223-8 Enya-cho, Izumo-shi, Shimane 693-8501, Japan.
| | - Kenta Okuyama
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, 223-8 Enya-cho, Izumo-shi, Shimane 693-8501, Japan; Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Jan Waldenströms gata 35, Malmö 20502, Sweden
| | - Tsuyoshi Hamano
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, 223-8 Enya-cho, Izumo-shi, Shimane 693-8501, Japan; Department of Sports Sociology and Health Sciences, Faculty of Sociology, Kyoto Sangyo University, Motoyama, Kamigamo, Kita-ku, Kyoto 603-8555, Japan
| | - Masamitsu Kamada
- Department of Health Education and Health Sociology, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Minoru Isomura
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, 223-8 Enya-cho, Izumo-shi, Shimane 693-8501, Japan; Faculty of Human Sciences, Shimane University, 1060 Nishikawatsu-cho, Matsue-shi, Shimane 690-8504, Japan
| | - Toru Nabika
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, 223-8 Enya-cho, Izumo-shi, Shimane 693-8501, Japan; Department of Functional Pathology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo-shi, Shimane 693-8501, Japan
| | - Ryo Miyazaki
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, 223-8 Enya-cho, Izumo-shi, Shimane 693-8501, Japan; Faculty of Human Sciences, Shimane University, 1060 Nishikawatsu-cho, Matsue-shi, Shimane 690-8504, Japan
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Abe T, Okuyama K, Hamano T, Takeda M, Yamasaki M, Isomura M, Nakano K, Sundquist K, Nabika T. Assessing the Impact of a Hilly Environment on Depressive Symptoms among Community-Dwelling Older Adults in Japan: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094520. [PMID: 33923194 PMCID: PMC8123156 DOI: 10.3390/ijerph18094520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022]
Abstract
Although some neighborhood environmental factors have been found to affect depressive symptoms, few studies have focused on the impact of living in a hilly environment, i.e., land slope, on depressive symptoms among rural older adults. This cross-sectional study aimed to investigate whether a land slope is associated with depressive symptoms among older adults living in rural areas. Data were collected from 935 participants, aged 65 years and older, who lived in Shimane prefecture, Japan. Depressive symptoms were assessed using the Zung Self-Rating Depression Scale (SDS) and defined on the basis of an SDS score ≥ 40. Land slopes within a 400 m network buffer were assessed using geographic information systems. Odds ratios (ORs) with 95% confidence intervals (CIs) of depressive symptoms were estimated using logistic regression. A total of 215 (23.0%) participants reported depressive symptoms. The land slope was positively associated with depressive symptoms (OR = 1.04; 95% CI = 1.01-1.08) after adjusting for all confounders. In a rural setting, living in a hillier environment was associated with depressive symptoms among community-dwelling older adults in Japan.
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Affiliation(s)
- Takafumi Abe
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
- Correspondence: ; Tel.: +81-853-20-2586
| | - Kenta Okuyama
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, 20502 Malmö, Sweden
| | - Tsuyoshi Hamano
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
- Department of Sports Sociology and Health Sciences, Faculty of Sociology, Kyoto Sangyo University, Kyoto 603-8555, Japan
| | - Miwako Takeda
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
| | - Masayuki Yamasaki
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
- Faculty of Human Sciences, Shimane University, Shimane 690-8504, Japan
| | - Minoru Isomura
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
- Faculty of Human Sciences, Shimane University, Shimane 690-8504, Japan
| | - Kunihiko Nakano
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
| | - Kristina Sundquist
- Center for Community-Based Healthcare Research and Education (CoHRE), Head Office for Research and Academic Information, Shimane University, Shimane 693-8501, Japan; (K.O.); (T.H.); (M.T.); (M.Y.); (M.I.); (K.N.); (K.S.)
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, 20502 Malmö, Sweden
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029-5674, USA
| | - Toru Nabika
- Department of Functional Pathology, Faculty of Medicine, Shimane University, Shimane 693-8501, Japan;
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Lin J, Leung J, Yu B, Woo J, Kwok T, Ka-Lun Lau K. Socioeconomic status as an effect modifier of the association between built environment and mortality in elderly Hong Kong Chinese: A latent profile analysis. ENVIRONMENTAL RESEARCH 2021; 195:110830. [PMID: 33548297 DOI: 10.1016/j.envres.2021.110830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Previous studies have focused on associations between individual built environment (BE) characteristics and mortality, and found the BE-mortality associations differed by socioeconomic status (SES). Different individual BE characteristics may have different impacts on health and thus could interact. Combinations of BE characteristics may be a better approach to explore the BE-mortality associations. OBJECTIVES This study aimed to investigate the associations of BE pattern with mortality in a prospective cohort of elderly Hong Kong Chinese (Mr. OS and Ms. OS Study), and assess whether the BE-mortality association differed by SES. METHODS Between 2001 and 2003, 3944 participants aged 65-98 years at baseline were included in the present analysis. BE characteristics were assessed via Geographic Information System. Data on all-cause and cause-specific mortality were obtained from the Hong Kong Government Death Registry. Latent profile analysis was used to derive BE class, and the Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS Three BE classes were identified. During a total of 53276 person-years of follow-up, 1632 deaths were observed. There were no significant associations of BE class with all-cause and cause-specific mortality. However, we found the associations of BE class with all-cause mortality were modified by SES. In comparison with Class 3 (characterized by greater green space), HRs (95%CIs) were 0.72 (0.54, 0.97) for Class 1 (characterized by greater commercial land use) and 0.77 (0.64, 0.94) for Class 2 (characterized by greater residential land use) among low-SES participants. The associations were stronger among high-SES participants, with 0.55 (0.33, 0.89) for Class 1 and 0.68 (0.48, 0.97) for Class 2. In contrast, Class 2 (HR 1.18, 95%CI 1.01-1.39) had a higher mortality risk compared with Class 3 among middle-SES participants. CONCLUSIONS Our findings provide new evidence on the role of SES as an effect modifier of BE pattern and mortality. BE pattern has a varied effect on mortality risk for different SES groups.
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Affiliation(s)
- Jiesheng Lin
- Institute of Future Cities, The Chinese University of Hong Kong, Hong Kong.
| | - Jason Leung
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong
| | - Blanche Yu
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Jean Woo
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Timothy Kwok
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Kevin Ka-Lun Lau
- Institute of Future Cities, The Chinese University of Hong Kong, Hong Kong; CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong.
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Inconvenience of Living Place Affects Individual HbA1c Level in a Rural Area in Japan: Shimane CoHRE Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031147. [PMID: 33525428 PMCID: PMC7908499 DOI: 10.3390/ijerph18031147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/17/2021] [Accepted: 01/26/2021] [Indexed: 12/13/2022]
Abstract
Background: It has been shown that the socio-geographical environment of residential areas, such as altitude, affects the health status and health-maintenance behavior of residents. Here, we examined a hypothesis that altitude of residence would influence glycemic control in a general elderly population living in a rural area. Methods: A thousand and sixteen participants living in a mountainous region in Japan were recruited at health examinations. Hemoglobin A1c (HbA1c) was measured in serum as a parameter of glycemic control. The altitude of residence, distance to grocery stores and to medical facilities were estimated using a geographic information system. Results: Linear regression analysis confirmed a significant effect of the altitude on log HbA1c even after adjustment of other demographic and biochemical factors. When the distance to grocery stores or medical facilities were used instead of the altitude in a linear regression analysis, distance to secondary medical facilities alone showed a significant effect on HbA1c. Conclusions: We found a positive correlation between HbA1c level and residential altitude in a rural area of Japan. The altitude seemed to be a parameter substituting the inconvenicence of residential areas. Socio-geographical factors of living place, such as inconvenience, may influence glycemic control of the residents.
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Abe T, Okuyama K, Hamano T, Takeda M, Isomura M, Nabika T. Hilly environment and physical activity among community-dwelling older adults in Japan: a cross-sectional study. BMJ Open 2020; 10:e033338. [PMID: 32220911 PMCID: PMC7170569 DOI: 10.1136/bmjopen-2019-033338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES We investigated whether a moderate-to-vigorous physical activity (MVPA) level and walking time were associated with a hilly environment in rural Japanese older adults. DESIGN Cross-sectional study. SETTING Unnan city, Ohnan and Okinoshima towns in Shimane, Japan. PARTICIPANTS Data were collected from 1115 adults from the Shimane CoHRE study, who were aged 60 years and older and living in rural Japan in 2012. MEASURES We measured the total time spent on MVPA and walking using a Japanese short version of the International Physical Activity Questionnaire. The land slope in 400 or 800 m network buffers was assessed using the geographic information system. A multivariable Poisson regression model examined the prevalence ratios (PR) and 95% CIs of walking time or MVPA levels meeting the WHO guideline (>150 min/week) in the land slope categories (low, middle and high), adjusted for confounders. RESULTS Engaging in the recommended level of MVPA was significantly associated with middle land slope (PR=1.07; p=0.03) and high land slope (PR=1.06; p=0.07) compared with low land slope in the 400 m network buffer, as well as with middle land slope (PR=1.02; p=0.48) and high land slope (PR=1.04; p=0.25) compared with the low land slope in the 800 m network buffer. Walking time was significantly associated with middle land slope (PR=1.13; p=0.04) and high land slope (PR=1.17; p=0.01) compared with low land slope in the 400 m network buffer, and with middle land slope (PR=1.09; p=0.16) and high land slope (PR=1.17; p<0.01) compared with low land slope in the 800 m network buffer. The sensitivity analysis found only a positive association between walking time and land slope in the 400 and 800 m network buffers. CONCLUSIONS This study showed that a hilly environment was positively associated with walking time among older adults living in rural Japan.
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Affiliation(s)
- Takafumi Abe
- Center for Community-Based Healthcare Research and Education (CoHRE), Organization for Research and Academic Information, Shimane University, Izumo, Shimane, Japan
| | - Kenta Okuyama
- Center for Community-Based Healthcare Research and Education (CoHRE), Organization for Research and Academic Information, Shimane University, Izumo, Shimane, Japan
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Tsuyoshi Hamano
- Center for Community-Based Healthcare Research and Education (CoHRE), Organization for Research and Academic Information, Shimane University, Izumo, Shimane, Japan
- Department of Sports Sociology and Health Sciences, Faculty of Sociology, Kyoto Sangyo University, Kita-ku, Kyoto, Japan
| | - Miwako Takeda
- Center for Community-Based Healthcare Research and Education (CoHRE), Organization for Research and Academic Information, Shimane University, Izumo, Shimane, Japan
| | - Minoru Isomura
- Center for Community-Based Healthcare Research and Education (CoHRE), Organization for Research and Academic Information, Shimane University, Izumo, Shimane, Japan
- Faculty of Human Sciences, Shimane University, Matsue, Shimane, Japan
| | - Toru Nabika
- Center for Community-Based Healthcare Research and Education (CoHRE), Organization for Research and Academic Information, Shimane University, Izumo, Shimane, Japan
- Department of Functional Pathology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
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Dzhambov AM, Markevych I, Lercher P. Associations of residential greenness, traffic noise, and air pollution with birth outcomes across Alpine areas. THE SCIENCE OF THE TOTAL ENVIRONMENT 2019; 678:399-408. [PMID: 31077918 DOI: 10.1016/j.scitotenv.2019.05.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 05/25/2023]
Abstract
UNLABELLED Aim This explorative study aimed to investigate the association of residential greenness, traffic noise, and air pollution with birth outcomes in several Alpine areas with unique topography. METHODS We used data from two cross-sectional studies (UIT, n = 573 and BBT, n = 518) in the Tyrol Region (Austria/Italy). Only mothers who had lived in their current residence during the whole pregnancy were included. They completed a questionnaire, and medical records were used to draw data on birth weight, low birth weight (LBW), preterm birth, and small for gestational age (SGA). Normalized Difference Vegetation Index (NDVI) in the year of birth was assigned at the residential address as a measure of greenness. Road/railway traffic noise (Ldn) and air pollution (NO2) were calculated about 10 years after birth and used as surrogates for exposure levels during pregnancy. RESULTS In the UIT survey, higher NDVI500-m was consistently associated with lower odds for LBW and SGA, while an increase of Ldn was associated with higher odds for LBW. Other effect estimates were in the expected direction albeit non-significant. In the BBT survey, most findings were inconclusive (for NDVI) or present only in subgroups (for Ldn and NO2). CONCLUSION This study provides inconclusive evidence that the surrounding environment might be associated with birth outcomes in mountainous areas. Given the disparate associations across the study areas, further research in larger representative samples is warranted.
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Affiliation(s)
- Angel M Dzhambov
- Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria.
| | - Iana Markevych
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany; Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany; Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children's Hospital, Munich, Ludwig Maximilian University of Munich, Munich, Germany
| | - Peter Lercher
- Institute for Highway Engineering and Transport Planning, Graz University of Technology, Graz, Austria
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Keskinen KE, Rantakokko M, Suomi K, Rantanen T, Portegijs E. Hilliness and the Development of Walking Difficulties Among Community-Dwelling Older People. J Aging Health 2018; 32:278-284. [DOI: 10.1177/0898264318820448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: The objective of this study is to study the associations of objectively defined hilliness with the prevalence and incidence of walking difficulties among community-dwelling older adults, and to explore whether behavioral, health, or socioeconomic factors would fully or partially explain these associations. Method: Baseline interviews ( n = 848, 75-90 years) on difficulties in walking 500 m, frequency of moving through the neighborhood, and perceived hilliness as a barrier to outdoor mobility were conducted. Two-year follow-up interviews ( n = 551) on difficulties in walking 500 m were conducted among participants without baseline walking difficulties. Hilliness objectively defined as the mean slope in 500-m road network. Results: Logistic regression showed that hilliness was associated with incident walking difficulties at the 2-year follow-up (odds ratio [OR] = 1.66, 95% confidence interval [CI] = [1.09, 2.51]) but not with the prevalence of walking difficulties at baseline. Adding behavioral, health, or socioeconomic factors to the models did not markedly change the results. Discussion: Greater hilliness should be considered a risk factor for developing walking difficulties among older adults.
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Affiliation(s)
- Kirsi E. Keskinen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Finland
- Gerontology Research Center, University of Jyväskylä, Finland
| | - Merja Rantakokko
- Faculty of Sport and Health Sciences, University of Jyväskylä, Finland
- Gerontology Research Center, University of Jyväskylä, Finland
- JAMK University of Applied Sciences, Jyväskylä, Finland
| | - Kimmo Suomi
- Faculty of Sport and Health Sciences, University of Jyväskylä, Finland
| | - Taina Rantanen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Finland
- Gerontology Research Center, University of Jyväskylä, Finland
| | - Erja Portegijs
- Faculty of Sport and Health Sciences, University of Jyväskylä, Finland
- Gerontology Research Center, University of Jyväskylä, Finland
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11
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Dzhambov AM, Markevych I, Lercher P. Greenspace seems protective of both high and low blood pressure among residents of an Alpine valley. ENVIRONMENT INTERNATIONAL 2018; 121:443-452. [PMID: 30273867 DOI: 10.1016/j.envint.2018.09.044] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND There is some data suggesting that residential greenspace may protect against high blood pressure in urbanized areas, but there is no evidence of effects on hypotension, in less urbanized areas, and in idiosyncratic geographic contexts such as mountain valleys. OBJECTIVES The current study aimed to investigate the associations between residential greenspace and blood pressure in an alpine valley in Austria. METHODS We conducted a cross-sectional survey of a representative sample of 555 adults living in the Lower Inn Valley, Austria. Several definitions of blood pressure were employed: continuously-measured systolic (SBP) and diastolic blood pressure (DBP), doctor-diagnosed hyper- and hypotension, and high- and low blood pressure medication use. Greenspace metrics considered were: Normalized Difference Vegetation Index (NDVI), Soil Adjusted Vegetation Index (SAVI), and tree cover as measures of surrounding greenness in circular buffers of 100 m, 300 m, 500 m, and 1000 m around the home; distance to different types of structured green space; and having a domestic garden and a balcony. Relationships were examined across different definitions of blood pressure and greenspace and evaluated for potential effect modification by demographic factors, presence of a domestic garden/balcony, adiposity, and traffic sensitivity. RESULTS Higher overall greenness was associated with 30-40% lower odds of hyper/hypotension and 2-3 mm Hg lower SBP. Similar pattern was revealed for tree cover, however, associations with hypertension were less consistent across buffers, and SBP and DBP were lower only in association with greenness in the 100-m buffer. Having a domestic garden also seemed protective of high DBP. Residing near to forests, agricultural land, or urban green spaces was not related to blood pressure. Higher NDVI500-m was stronger associated with lower SBP in those having a domestic garden, while the effect on DBP was stronger in overweight/obese participants. CONCLUSION These findings support the idea that greenspace should be considered as protective of both high and low blood pressure, however, underlying mechanisms remain insufficiently understood.
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Affiliation(s)
- Angel M Dzhambov
- Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria.
| | - Iana Markevych
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany; Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany; Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children's Hospital, Munich, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Peter Lercher
- Division of Social Medicine, Medical University Innsbruck, Innsbruck, Austria
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12
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Koohsari MJ, Nakaya T, Oka K. Activity-Friendly Built Environments in a Super-Aged Society, Japan: Current Challenges and toward a Research Agenda. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15092054. [PMID: 30235862 PMCID: PMC6163734 DOI: 10.3390/ijerph15092054] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 11/17/2022]
Abstract
There is a growing recognition of the role of built environment attributes, such as streets, shops, greenways, parks, and public transportation stations, in supporting people’s active behaviors. In particular, surrounding built environments may have an important role in supporting healthy active aging. Nevertheless, little is known about how built environments may influence active lifestyles in “super-aged societies”. More robust evidence-based research is needed to identify how where people live influences their active behaviors, and how to build beneficial space in the context of super-aged societies. This evidence will also be informative for the broader international context, where having an aging society will be the inevitable future. This commentary sought to move this research agenda forward by identifying key research issues and challenges in examining the role of built environment attributes on active behaviors in Japan, which is experiencing the longest healthy life expectancy, but rapid “super-aging”, with the highest proportion of old adults among its population in the world.
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Affiliation(s)
- Mohammad Javad Koohsari
- Faculty of Sport Sciences, Waseda University, Saitama 359-1192, Japan.
- Behavioural Epidemiology Laboratory, Baker Heart and Diabetes Institute, Melbourne 3004, Australia.
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne 3000, Australia.
| | - Tomoki Nakaya
- Graduate School of Environmental Studies, Tohoku University, Sendai City 980-0845, Japan.
| | - Koichiro Oka
- Faculty of Sport Sciences, Waseda University, Saitama 359-1192, Japan.
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13
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Environmental Risk Factors for Developing Type 2 Diabetes Mellitus: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15010078. [PMID: 29304014 PMCID: PMC5800177 DOI: 10.3390/ijerph15010078] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/19/2017] [Accepted: 12/23/2017] [Indexed: 12/12/2022]
Abstract
Different elements of the environment have been posited to influence type 2 diabetes mellitus (T2DM). This systematic review summarizes evidence on the environmental determinants of T2DM identified in four databases. It proposes a theoretical framework illustrating the link between environment and T2DM, and briefly discusses some methodological challenges and potential solutions, and opportunities for future research. Walkability, air pollution, food and physical activity environment and roadways proximity were the most common environmental characteristics studied. Of the more than 200 reported and extracted relationships assessed in 60 studies, 82 showed significant association in the expected direction. In general, higher levels of walkability and green space were associated with lower T2DM risk, while increased levels of noise and air pollution were associated with greater risk. Current evidence is limited in terms of volume and study quality prohibiting causal inferences. However, the evidence suggests that environmental characteristics may influence T2DM prevention, and also provides a reasonable basis for further investigation with better quality data and longitudinal studies with policy-relevant environmental measures. This pursuit of better evidence is critical to support health-orientated urban design and city planning.
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Fujiwara T, Takamoto I, Amemiya A, Hanazato M, Suzuki N, Nagamine Y, Sasaki Y, Tani Y, Yazawa A, Inoue Y, Shirai K, Shobugawa Y, Kondo N, Kondo K. Is a hilly neighborhood environment associated with diabetes mellitus among older people? Results from the JAGES 2010 study. Soc Sci Med 2017; 182:45-51. [PMID: 28412640 DOI: 10.1016/j.socscimed.2017.04.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 04/01/2017] [Accepted: 04/07/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although living in a hilly environment may promote muscular activity in the daily lives of residents, and such activity may prevent diabetes mellitus, few studies have focused on the impact of living in a hilly environment on diabetes mellitus. The purpose of this study was to investigate the impact of a hilly neighborhood environment on DM in older people. METHODS We used data from the Japan Gerontological Evaluation Study, a population-based, cross-sectional study of individuals aged 65 or older without long-term care needs in Japan, which was conducted in 2010. A total of 8904 participants in 46 neighborhoods had responded to the questionnaire and undergone a health check. Diabetes mellitus was diagnosed as HbA1c ≥ 6.5% and those undergoing treatment for diabetes mellitus. Poorly controlled diabetes mellitus was diagnosed in those without other chronic diseases who had an HbA1c > 7.5%, and in those with other chronic diseases if their HbA1c was >8.0%. Neighborhood environment was evaluated based on the percentage of positive responses in the questionnaire and geographical information system data. A multilevel analysis was performed, adjusted for individual-level risk factors. Furthermore, sensitivity analysis was conducted for those who were undergoing treatment for diabetes mellitus (n = 1007). RESULTS After adjustment for other physical environmental and individual covariates, a 1 interquartile range increase (1.48°) in slope in the neighborhood decreased the risk of poorly controlled diabetes mellitus by 18% (odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.70-0.97). Sensitivity analysis confirmed that larger slopes in the neighborhood showed a significant protective effect against diabetes mellitus among those who were undergoing treatment for diabetes mellitus (OR: 0.73, 95% CI: 0.59-0.90). CONCLUSION A hilly neighborhood environment was not associated with diabetes mellitus, but was protective against poorly controlled diabetes mellitus.
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Affiliation(s)
- Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Iseki Takamoto
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Airi Amemiya
- Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Masamichi Hanazato
- Center for Preventive Medical Sciences, Chiba University, Chiba City, Chiba, Japan
| | - Norimichi Suzuki
- Center for Preventive Medical Sciences, Chiba University, Chiba City, Chiba, Japan
| | - Yuiko Nagamine
- Center for Preventive Medical Sciences, Chiba University, Chiba City, Chiba, Japan
| | - Yuri Sasaki
- Center for Preventive Medical Sciences, Chiba University, Chiba City, Chiba, Japan
| | - Yukako Tani
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Aki Yazawa
- Department of Human Ecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yosuke Inoue
- Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Kokoro Shirai
- Department of Human Sciences, School of Law and Letters, University of the Ryukyus, Okinawa, Japan
| | - Yugo Shobugawa
- Division of International Health, Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Naoki Kondo
- Department of Health Education and Health Sociology, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Katsunori Kondo
- Center for Well-being and Society, Nihon Fukushi University, Aichi, Japan; Department of Gerontology and Evaluation Study, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Aichi, Japan
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15
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Nguyen QC, Li D, Meng HW, Kath S, Nsoesie E, Li F, Wen M. Building a National Neighborhood Dataset From Geotagged Twitter Data for Indicators of Happiness, Diet, and Physical Activity. JMIR Public Health Surveill 2016; 2:e158. [PMID: 27751984 PMCID: PMC5088343 DOI: 10.2196/publichealth.5869] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 08/29/2016] [Accepted: 09/15/2016] [Indexed: 01/09/2023] Open
Abstract
Background Studies suggest that where people live, play, and work can influence health and well-being. However, the dearth of neighborhood data, especially data that is timely and consistent across geographies, hinders understanding of the effects of neighborhoods on health. Social media data represents a possible new data resource for neighborhood research. Objective The aim of this study was to build, from geotagged Twitter data, a national neighborhood database with area-level indicators of well-being and health behaviors. Methods We utilized Twitter’s streaming application programming interface to continuously collect a random 1% subset of publicly available geolocated tweets for 1 year (April 2015 to March 2016). We collected 80 million geotagged tweets from 603,363 unique Twitter users across the contiguous United States. We validated our machine learning algorithms for constructing indicators of happiness, food, and physical activity by comparing predicted values to those generated by human labelers. Geotagged tweets were spatially mapped to the 2010 census tract and zip code areas they fall within, which enabled further assessment of the associations between Twitter-derived neighborhood variables and neighborhood demographic, economic, business, and health characteristics. Results Machine labeled and manually labeled tweets had a high level of accuracy: 78% for happiness, 83% for food, and 85% for physical activity for dichotomized labels with the F scores 0.54, 0.86, and 0.90, respectively. About 20% of tweets were classified as happy. Relatively few terms (less than 25) were necessary to characterize the majority of tweets on food and physical activity. Data from over 70,000 census tracts from the United States suggest that census tract factors like percentage African American and economic disadvantage were associated with lower census tract happiness. Urbanicity was related to higher frequency of fast food tweets. Greater numbers of fast food restaurants predicted higher frequency of fast food mentions. Surprisingly, fitness centers and nature parks were only modestly associated with higher frequency of physical activity tweets. Greater state-level happiness, positivity toward physical activity, and positivity toward healthy foods, assessed via tweets, were associated with lower all-cause mortality and prevalence of chronic conditions such as obesity and diabetes and lower physical inactivity and smoking, controlling for state median income, median age, and percentage white non-Hispanic. Conclusions Machine learning algorithms can be built with relatively high accuracy to characterize sentiment, food, and physical activity mentions on social media. Such data can be utilized to construct neighborhood indicators consistently and cost effectively. Access to neighborhood data, in turn, can be leveraged to better understand neighborhood effects and address social determinants of health. We found that neighborhoods with social and economic disadvantage, high urbanicity, and more fast food restaurants may exhibit lower happiness and fewer healthy behaviors.
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Affiliation(s)
- Quynh C Nguyen
- Department of Health, Kinesiology, and Recreation, University of Utah College of Health, Salt Lake City, UT, United States.
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Inoue Y, Stickley A, Yazawa A, Shirai K, Amemiya A, Kondo N, Kondo K, Ojima T, Hanazato M, Suzuki N, Fujiwara T. Neighborhood Characteristics and Cardiovascular Risk among Older People in Japan: Findings from the JAGES Project. PLoS One 2016; 11:e0164525. [PMID: 27716825 PMCID: PMC5055291 DOI: 10.1371/journal.pone.0164525] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 09/27/2016] [Indexed: 11/18/2022] Open
Abstract
Previous studies have found an association between neighborhood characteristics (i.e., aspects of the physical and social environment) and the incidence of cardiovascular disease (CVD) and elevated CVD risk. This study investigated the relationship between neighborhood characteristics and CVD risk among older people in Japan where research on this association is scarce. Data came from the Japan Gerontological Evaluation Study project; questionnaire data collected from 3,810 people aged 65 years or older living in 20 primary school districts in Aichi prefecture, Japan, was linked to a computed composite CVD risk score based on biomarker data (i.e., hemoglobin A1c, systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and estimated glomerular filtration rate). A sex-stratified multilevel linear regression analysis revealed that for male participants, living in neighborhoods with a higher perceived occurrence of traffic accidents and reduced personal safety was associated with an elevated CVD risk (coefficient = 1.08 per interquartile range increase, 95% confidence interval [CI] = 0.30 to 1.86) whereas males living in neighborhoods with a higher perceived proximity of exercise facilities had a lower risk (coefficient = −1.00, 95% CI = −1.78 to −0.21). For females, there was no statistically significant association between neighborhood characteristics and CVD risk. This study suggests that aspects of the neighborhood environment might be important for CVD morbidity and mortality in Japan, particularly among men.
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Affiliation(s)
- Yosuke Inoue
- Department of Human Ecology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- * E-mail:
| | - Andrew Stickley
- Department of Human Ecology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Stockholm Center for Health and Social Change (Scohost), Södertörn University, Huddinge, Sweden
| | - Aki Yazawa
- Department of Human Ecology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kokoro Shirai
- Department of Human Sciences, School of Law and Letters, University of the Ryukyus, Nakagami-gun, Okinawa, Japan
| | - Airi Amemiya
- Department of Social Medicine, National Research Institute for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Naoki Kondo
- Department of Health and Social Behavior, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Health Education and Health Sociology, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Katsunori Kondo
- Center for Preventive Medical Sciences, Chiba University, Chiba City, Chiba, Japan
- Center for Well-being and Society, Nihon Fukushi University, Nagoya City, Aichi, Japan
- Department of Gerontological Evaluation, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu City, Aichi, Japan
| | - Toshiyuki Ojima
- School of Medicine, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Masamichi Hanazato
- Center for Preventive Medical Sciences, Chiba University, Chiba City, Chiba, Japan
| | - Norimichi Suzuki
- Center for Preventive Medical Sciences, Chiba University, Chiba City, Chiba, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
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