Residential neighbourhood greenspace is associated with reduced risk of cardiovascular disease: A prospective cohort study

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.

Engagement with nature and proinflammatory biology

BACKGROUND

Prior evidence indicates that contact with nature improves physical health, but data explicitly linking engagement with nature to biological processes are limited.

DESIGN

Leveraging survey and biomarker data from 1,244 adults (mean age = 54.50 years, range = 34-84 years) from the Midlife in the United States (MIDUS II) study, we examined associations between nature engagement, operationalized as the frequency of pleasant nature encounters, and systemic inflammation. Concentrations of interleukin-6 (IL-6), C-reactive protein (CRP), and fibrinogen were measured from fasting blood samples. Analyses adjusted for sociodemographic, health behavior, and psychological well-being covariates.

RESULTS

More frequent positive nature contact was independently associated with lower circulating levels of inflammation.

CONCLUSIONS

These findings add to a growing literature on the salubrious health effects of nature by demonstrating how such experiences are instantiated in downstream physiological systems, potentially informing future interventions and public health policies.

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.

Greenspaces And Cardiovascular Health

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

The Urban Environment and Cardiometabolic Health

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

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring associations of greenery, air pollution and walkability with cardiometabolic health in people at midlife and beyond

AIM

To examine associations of neighborhood greenery, air pollution and walkability with cardiometabolic disease in adults aged ≥45 years in the Frankston-Mornington Peninsula region, Victoria, Australia.

METHODS

A cross-sectional, ecological study design was used. We assessed mean annual neighborhood greenery using the Normalized Difference Vegetation Index; air pollution (fine particulate matter of diameter ≤2.5 μm [PM2.5] and NO2) using land-use regression models; and walkability using Walk Score (possible values 0-100). Medically diagnosed diabetes (~95% type-2), heart disease and stroke were self-reported in the Australian Census (2021). Multivariable regression was used to model associations between environmental exposures and area-level (neighborhood) cardiometabolic disease prevalence (age group ≥45 years), with socioeconomic status, age and sex as covariates. Air pollution was examined as a mediator of associations between greenery and disease prevalence.

RESULTS

Our sample comprised 699 neighborhoods with the following mean (SD) values: Normalized Difference Vegetation Index 0.47 (0.09), PM2.5, 8.5 (0.6) μg/m3 and NO2, 5.2 (1.6) ppb. Disease prevalences were: heart disease, mean 8.9% (4.5%); diabetes, mean 10.3% (4.7%); and stroke, median 1.2% (range 0-10.9%). Greenery was negatively associated with diabetes (β = -5.85, 95% CI -9.53, -2.17) and stroke prevalence (β = -1.26, 95% CI -2.11, -0.42). PM2.5 and NO2 were positively associated with diabetes (β = 1.59, 95% CI 1.00, 2.18; β = 0.42, 95% CI 0.22, 0.62) and stroke prevalence (β = 0.15, 95% CI 0.01, 0.29; β = 0.06, 95% CI 0.01, 0.10). The association between greenery and diabetes was partially mediated by PM2.5 (mediated effect -5.38, 95% CI -7.84, -3.03).

CONCLUSIONS

Greenery and air pollutants were associated with lower and higher prevalence, respectively, of self-reported diabetes and, to a lesser extent, stroke. These ecological findings require further exploration with stronger, longitudinal study designs to inform public health policy and directions. Geriatr Gerontol Int 2024; 24: 208-214.

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.

Associations of Urban Built Environment with Cardiovascular Risks and Mortality: a Systematic Review

With rapid urbanization, built environment has emerged as a set of modifiable factors of cardiovascular disease (CVD) risks. We conducted a systematic review to synthesize evidence on the associations of attributes of urban built environment (e.g. residential density, land use mix, greenness and walkability) with cardiovascular risk factors (e.g. hypertension and arterial stiffness) and major CVD events including mortality. A total of 63 studies, including 31 of cross-sectional design and 32 of longitudinal design conducted across 21 geographical locations and published between 2012 and 2023 were extracted for review. Overall, we report moderately consistent evidence of protective associations of greenness with cardiovascular risks and major CVD events (cross-sectional studies: 12 of 15 on hypertension/blood pressure (BP) and 2 of 3 on arterial stiffness; and longitudinal studies: 6 of 8 on hypertension/BP, 7 of 8 on CVD mortality, 3 of 3 on ischemic heart disease mortality and 5 of 8 studies on stroke hospitalization or mortality reporting significant inverse associations). Consistently, walkability was associated with lower risks of hypertension, arterial stiffness and major CVD events (cross-sectional studies: 11 of 12 on hypertension/BP and 1 of 1 on arterial stiffness; and longitudinal studies: 3 of 6 on hypertension/BP and 1 of 2 studies on CVD events being protective). Sixty-seven percent of the studies were rated as "probably high" risk of confounding bias because of inability to adjust for underlying comorbidities/family history of diseases in their statistical models. Forty-six percent and 14% of the studies were rated as "probably high" risk of bias for exposure and outcome measurements, respectively. Future studies with robust design will further help elucidate the linkages between urban built environment and cardiovascular health, thereby informing planning policies for creating healthy cities.

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.

Green space exposure and type 2 diabetes mellitus incidence: A systematic review

INTRODUCTION

Epidemiological studies have suggested that exposure to green spaces is associated with a lower prevalence of diabetes. The aim of this systematic review was to summarize the evidence on green spaces and diabetes mellitus II (T2DM) in longitudinal studies.

METHODS

We searched PubMed, SCOPUS, Web of Science (WoS)/Core Collection, WoS/MEDLINE, and EMBASE until February 2023. We included cohort studies that assessed the incidence of T2DM according to the level of exposure to green spaces. Two authors independently performed study selection, data extraction, and analysis of risk of bias. No meta-analysis was performed due to clinical heterogeneity between studies.

RESULTS

We included 13 cohort studies with a sample size ranging from 1700 to 1 922 545 participants. Studies presented different ways of defining (quartiles, percentages) and measuring (tools, buffers) green spaces. Similarly, the definition of T2DM was heterogeneous (self-reports, medical records, clinical criteria). Twelve studies showed that individuals with higher exposure to green spaces had a decreased incidence of T2DM. Out of these 12 studies, 10 revealed statistically significant differences. All studies were of high methodological quality, except for one.

CONCLUSION

Our findings suggest that exposure to green space could be a protective factor for the development of T2DM. Promoting policies to preserve and increase green space could help to reduce T2DM at the community level. More standardization of green space exposure definition is needed in studies on green space and T2DM.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The Weight of Place: Built Environment Correlates of Obesity and Diabetes

In recent decades, the prevalence of obesity and diabetes has risen substantially in North America and worldwide. To address these dual epidemics, researchers and policymakers alike have been searching for effective means to promote healthy lifestyles at a population level. As a consequence, there has been a proliferation of research examining how the "built" environment in which we live influences physical activity levels, by promoting active forms of transportation, such as walking and cycling, over passive ones, such as car use. Shifting the transportation choices of local residents may mean that more members of the population can participate in physical activity during their daily routine without structured exercise programs. Increasingly, this line of research has considered the downstream metabolic consequences of the environment in which we live, raising the possibility that "healthier" community designs could help mitigate the rise in obesity and diabetes prevalence. This review discusses the evidence examining the relationship between the built environment, physical activity, and obesity-related diseases. We also consider how other environmental factors may interact with the built environment to influence metabolic health, highlighting challenges in understanding causal relationships in this area of research.

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.

Associations of parks, greenness, and blue space with cardiovascular and respiratory disease hospitalization in the US Medicare cohort

Natural environments have been linked to decreased risk of cardiovascular disease (CVD) and respiratory disease (RSD) mortality. However, few cohort studies have looked at associations of natural environments with CVD or RSD hospitalization. The aim of this study was to evaluate these associations in a cohort of U.S. Medicare beneficiaries (∼63 million individuals). Our open cohort included all fee-for-service Medicare beneficiaries (2000-2016), aged ≥65, living in the contiguous U.S. We assessed zip code-level park cover based on the United States Geological Survey Protected Areas Database, average greenness (Normalized Difference Vegetation Index, NDVI), and percent blue space cover based on Landsat satellite images. Cox-equivalent Poisson models were used to estimate associations of the exposures with first CVD and RSD hospitalization in the full cohort and among those living in urban zip codes (≥1000 persons/mile2). NDVI was weakly negatively correlated with percent park cover (Spearman ρ = -0.23) and not correlated with percent blue space (Spearman ρ = 0.00). After adjustment for potential confounders, percent park cover was not associated with CVD or RSD hospitalization in the full or urban population. An IQR (0.27) increase in NDVI was negatively associated with CVD (HR: 0.97, 95%CI: 0.96, 0.97), but not with RSD hospitalization (HR: 0.99, 95%CI: 0.98, 1.00). In urban zip codes, an IQR increase in NDVI was positively associated with RSD hospitalization (HR: 1.02, 95%CI: 1.00, 1.03). In stratified analyses, percent park cover was negatively associated with CVD and RSD hospitalization for Medicaid eligible individuals and individuals living in low socioeconomic status neighborhoods in the urban population. We observed no associations of percent blue space cover with CVD or RSD hospitalization. This study suggests that natural environments may benefit cardiorespiratory health; however, benefits may be limited to certain contexts and certain health outcomes.

Neighbourhood natural space and the narrowing of socioeconomic inequality in years of life lost: a cross-sectional ecological analysis of the Scottish Burden of Disease

BACKGROUND

Natural space is associated with reduced risk of, and narrower socioeconomic inequalities in, diseases that affect older populations, and some contributors to premature mortality in younger individuals. Burden of disease measures such as years of life lost (YLL) are influenced by premature poor health and death. We hypothesised some association between natural space and both rates of and inequalities in YLL might be present.

METHODS

The outcome data were the YLL component from Scottish Burden of Disease 2016, provided at small-area level (datazone) for males and females under 65 years of age in Scotland, UK. Exposure variables were the percentages of land cover within each datazone defined as 'natural space' (NS), and 'natural space and private gardens' (NSG). Together with a measure of area income deprivation, these were fitted in a multilevel Poisson model accounting for intra-datazone level variation, and spatial autocorrelation between datazones.

RESULTS

An increased percentage cover of NSG was associated with lower YLL in males (incident rate ratio (IRR) 0.993, 95% credible interval (CrI) 0.989 to 0.997) and females (IRR 0.993, CrI 0.987 to 0.998); each 10% increase of natural space cover was associated with a 7% decrease in the incidence rate. An increased amount of natural space within local areas was associated with reduced disparity in YLL between the most and least income deprived areas.

CONCLUSIONS

The health benefits of natural space also apply when indicators sensitive to health events at younger ages are used. An increased amount of natural space within local areas has the potential to reduce the disparity in YLL between the most and least income deprived areas-the 'equigenic' effect.

Holistic approach to assess the association between the synergistic effect of physical activity, exposure to greenspace, and fruits and vegetable intake on health and wellbeing: Cross-sectional analysis of UK Biobank

Background

Urban agriculture has been shown to contribute to healthy lifestyle behaviors, such as increased fruit and vegetable intake and greater exposure to greenspaces and there is plenty of evidence linking these lifestyle behaviors to better health and wellbeing. However, most evidence relates to assessing one behavior at a time despite available epidemiological research showing how the combined effects of multiple behaviors are associated with health and wellbeing. This research aims to examine the association of the interactions between various lifestyle behaviors and exposures related to urban agriculture and health and wellbeing.

Methods

We used data from the UK Biobank baseline questionnaire (N~500, 000) to assess the association of two lifestyle behaviors (fruit and vegetable intake and physical activity) and greenspace exposure, with four health and wellbeing markers (blood pressure, BMI, self-health assessment, and self-reported loneliness) independently, and in combination. Associations between lifestyle behaviors, greenspace exposure, and the possible interactions with health and wellbeing were explored using general linear models (GLMs), adjusted for socio-demographic confounders including age, sex, educational qualifications, index of multiple deprivation, and ethnicity, and a lifestyle confounder: smoking status.

Results

After removing missing data, as well as participants who did not meet the inclusion criteria, the final study sample was n = 204,478. The results indicate that meeting recommended levels of the World Health Organization (WHO) for fruits and vegetable intake, and the advice from the UK Chief Medical Officer for physical activity, is linked to better health and wellbeing markers. We found that UK Biobank participants who lived in greener areas and were physically active were more likely to feel alone and think their health was poor. Participants who were physically active and met the recommended intake of fruits and vegetables were more likely to have healthy blood pressure, feel less lonely, and rate their health as good. Evidence of three-way interactions was weak, and mostly was not associated with the health and wellbeing markers assessed here.

Conclusion

Taken in combination, healthy diets, physical activity and exposure to greenspaces are associated with health and wellbeing. In some cases, these effects are synergistic, indicating associations above and beyond the mere additive effect of the behaviors considered independently. Promoting such behaviors together, for example, through urban agriculture, is therefore more likely to generate greater public health changes than if they are promoted through independent policies and programs. Inter-relationships between these pathways and different health and wellbeing markers, however, are complex, and require further investigation to understand optimal environments and conditions for urban health promotion.

Exposure to transportation noise and risk for cardiovascular disease in a nationwide cohort study from Denmark

BACKGROUND

Transportation noise increases the risk of ischemic heart disease (IHD), but few studies have investigated subtypes of IHD, such as myocardial infarction (MI), angina pectoris, or heart failure. We aimed to study whether exposure to road, railway and aircraft noise increased risk for ischemic heart disease (IHD), IHD subtypes, and heart failure in the entire adult Danish population, investigating exposures at both maximum exposed and silent façades of each residence.

METHODS

We modelled road, railway, and aircraft noise at the most and least exposed façades for the period 1995-2017 for all addresses in Denmark and calculated 10-year time-weighted running means for 2.5 million individuals age ≥50 years, of whom 122,523 developed IHD and 79,358 developed heart failure during follow-up (2005-2017). Data were analyzed using Cox proportional hazards models, adjusted for individual and area-level sociodemographic covariates and air pollution.

RESULTS

We found road traffic noise at the most exposed façade (L_den) to be associated with higher risk of IHD, myocardial infarction (MI), angina pectoris, and heart failure, with hazard ratios (HRs) (95% confidence intervals (CI)) of 1.052 (1.044-1.059), 1.041 (1.032-1.051), 1.095 (1.071-1.119), and 1.039 (1.033-1.045) per 10 dB higher 10-year mean exposure, respectively. These associations followed a near-linear exposure-response relationship and were robust to adjustment for air pollution with PM_2.5. Railway noise at the least exposed façade was associated with heart failure (HR 1.28; 95% CI: 1.004-1.053), but not the other outcomes. Exposure to aircraft noise (>45 dB) seemed associated with increased risk for MI and heart failure.

CONCLUSIONS

We found road traffic noise and potentially railway and aircraft noise to increase risk of various major cardiovascular outcomes, highlighting the importance of preventive actions towards transportation noise.

Impacts of changes in environmental exposures and health behaviours due to the COVID-19 pandemic on cardiovascular and mental health: A comparison of Barcelona, Vienna, and Stockholm

Responses to COVID-19 altered environmental exposures and health behaviours associated with non-communicable diseases. We aimed to (1) quantify changes in nitrogen dioxide (NO₂), noise, physical activity, and greenspace visits associated with COVID-19 policies in the spring of 2020 in Barcelona (Spain), Vienna (Austria), and Stockholm (Sweden), and (2) estimated the number of additional and prevented diagnoses of myocardial infarction (MI), stroke, depression, and anxiety based on these changes. We calculated differences in NO₂, noise, physical activity, and greenspace visits between pre-pandemic (baseline) and pandemic (counterfactual) levels. With two counterfactual scenarios, we distinguished between Acute Period (March 15th - April 26th, 2020) and Deconfinement Period (May 2nd - June 30th^, 2020) assuming counterfactual scenarios were extended for 12 months. Relative risks for each exposure difference were estimated with exposure-risk functions. In the Acute Period, reductions in NO₂ (range of change from -16.9 μg/m³ to -1.1 μg/m³), noise (from -5 dB(A) to -2 dB(A)), physical activity (from -659 MET*min/wk to -183 MET*min/wk) and greenspace visits (from -20.2 h/m to 1.1 h/m) were largest in Barcelona and smallest in Stockholm. In the Deconfinement Period, NO₂ (from -13.9 μg/m³ to -3.1 μg/m³), noise (from -3 dB(A) to -1 dB(A)), and physical activity levels (from -524 MET*min/wk to -83 MET*min/wk) remained below pre-pandemic levels in all cities. Greatest impacts were caused by physical activity reductions. If physical activity levels in Barcelona remained at Acute Period levels, increases in annual diagnoses for MI (mean: 572 (95% CI: 224, 943)), stroke (585 (6, 1156)), depression (7903 (5202, 10,936)), and anxiety (16,677 (926, 27,002)) would be anticipated. To decrease cardiovascular and mental health impacts, reductions in NO₂ and noise from the first COVID-19 surge should be sustained, but without reducing physical activity. Focusing on cities' connectivity that promotes active transportation and reduces motor vehicle use assists in achieving this goal.

Perceived green space quality, child biomarkers and health-related outcomes: A longitudinal study

Accumulating exposure to quality green space over time is posited to influence child health, yet longitudinal studies are scarce. This study aimed to examine the associations between trajectories of perceived green space quality and child health-related outcomes. We used data from 1874 childrenin the B-cohort of the Longitudinal Study of Australian Children who participated in the Child Health Checkpoint module at 11-12 years. Data on caregiver perceived green space quality measured biennially was assessed using discrete trajectory mixture models to group children by contrasting distributions in green space quality over time. Examination of associations between trajectory groups of perceived green space quality and child biomarkers (i.e., albumin-to-creatinine ratio, total, cholesterol, total triglycerides, and glucose), physical health and behavioural assessments (i.e., anthropometric measurements, blood pressure, sedentary behaviour, physical activity, sleep, aerobic work capacity, and general wellbeing), and health care use were assessed using multilevel models, adjusted for sociodemographic variables. Four perceived green space quality trajectories were identified: "decreasing quality from high to moderate"; "increasing quality from low to high"; "consistently high quality"; "consistently low quality". Compared with consistently low levels of quality green space, adjusted models indicated consistently high-quality green space was associated with lower total triglycerides (β -0.13; 95%CI -0.25, -0.01). Lower odds of hospital admission was observed among children who accumulated quality green space over time (OR 0.45; 95%CI 0.23, 0.87). These associations were observed in boys only in sex-stratified analyses. Moreover, boys accumulating quality green space through time tended to have lower diastolic blood pressure (β -2.76; 95%CI -5.17, -0.35) and girls who experienced loss in quality green space tended to have a higher percentage of body fat (β 2.81; 95%CI 0.43, 5.20). Accumulating quality green space over time is important for various aspects of child health, with contrasting benefits by sex.

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

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

Multi-use physical activity trails in an urban setting and cardiovascular disease: a difference-in-differences analysis of a natural experiment in Winnipeg, Manitoba, Canada

Objective

To determine if expansion of multi-use physical activity trails in an urban centre is associated with reduced rates of cardiovascular disease (CVD).

Methods

This was a natural experiment with a difference in differences analysis using administrative health records and trail-based cycling data in Winnipeg, Canada. Prior to the intervention, each year, 314,595 (IQR: 309,044 to 319,860) persons over 30 years without CVD were in the comparison group and 37,901 residents (IQR: 37,213 to 38,488) were in the intervention group. Following the intervention, each year, 303,853 (IQR: 302,843 to 304,465) persons were in the comparison group and 35,778 (IQR: 35,551 to 36,053) in the intervention group. The natural experiment was the construction of four multi-use trails, 4-7 km in length, between 2010 and 2012. Intervention and comparison areas were based on buffers of 400 m, 800 m and 1200 m from a new multi-use trail. Bicycle counts were obtained from electromagnetic counters embedded in the trail. The primary outcome was a composite of incident CVD events: CVD-related mortality, ischemic heart disease, cerebrovascular events and congestive heart failure. The secondary outcome was a composite of incident CVD risk factors: hypertension, diabetes and dyslipidemia.

Results

Between 2014 and 2018, 1,681,125 cyclists were recorded on the trails, which varied ~ 2.0-fold across the four trails (2358 vs 4264 counts/week in summer months). Between 2000 and 2018, there were 82,632 CVD events and 201,058 CVD risk events. In propensity score matched Poisson regression models, the incident rate ratio (IRR) was 1.06 (95% CI: 0.90 to 1.24) for CVD events and 0.95 (95%CI: 0.88 to 1.02) for CVD risk factors for areas within 400 m of a trail, relative to comparison areas. Sensitivity analyses indicated this effect was greatest among households adjacent to the trail with highest cycling counts (IRR = 0.85; 95% CI: 0.75 to 0.96).

Conclusions

The addition of multi-use trails was not associated with differences in CVD events or CVD risk factors, however the differences in CVD risk may depend on the level of trail use.

Trial registration

Trial registration number: NCT04057417.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01279-z.

Greenspace, Inflammation, Cardiovascular Health, and Cancer: A Review and Conceptual Framework for Greenspace in Cardio-Oncology Research

Cardiovascular disease (CVD) is a leading cause of global morbidity and mortality. Cancer survivors have significantly elevated risk of poor cardiovascular (CV) health outcomes due to close co-morbid linkages and shared risk factors between CVD and cancer, as well as adverse effects of cancer treatment-related cardiotoxicity. CVD and cancer-related outcomes are exacerbated by increased risk of inflammation. Results from different pharmacological interventions aimed at reducing inflammation and risk of major adverse cardiovascular events (MACEs) have been largely mixed to date. Greenspaces have been shown to reduce inflammation and have been associated with CV health benefits, including reduced CVD behavioral risk factors and overall improvement in CV outcomes. Greenspace may, thus, serve to alleviate the CVD burden among cancer survivors. To understand pathways through which greenspace can prevent or reduce adverse CV outcomes among cancer survivors, we review the state of knowledge on associations among inflammation, CVD, cancer, and existing pharmacological interventions. We then discuss greenspace benefits for CV health from ecological to multilevel studies and a few existing experimental studies. Furthermore, we review the relationship between greenspace and inflammation, and we highlight forest bathing in Asian-based studies while presenting existing research gaps in the US literature. Then, we use the socioecological model of health to present an expanded conceptual framework to help fill this US literature gap. Lastly, we present a way forward, including implications for translational science and a brief discussion on necessities for virtual nature and/or exposure to nature images due to the increasing human-nature disconnect; we also offer guidance for greenspace research in cardio-oncology to improve CV health outcomes among cancer survivors.

Urban forest biodiversity and cardiovascular disease: Potential health benefits from California's street trees

Enhanced immune functioning in response to biodiversity may explain potential health benefits from exposure to green space. Using unique data on urban forest biodiversity at the zip code level for California measured from 2014 to 2019 we test whether greater diversity of street trees is associated with reduced death from cardiovascular disease. We find that urban forests with greater biodiversity measured via the Shannon Index at the genus level are associated with a lower mortality rate for heart disease and stroke. Our estimates imply that increasing the Shannon Index by one standard deviation (0.64) is associated with a decrease in the mortality rate of 21.4 per 100,000 individuals for heart disease or 13% and 7.7 per 100,000 individuals for stroke or 16%. Our estimates remain robust across several sensitivity checks. A policy simulation for tree planting in Los Angeles based on our estimates suggests that if these relationships were causal, investment in planting for a more biodiverse set of street trees would be a cost-effective way to reduce mortality related to cardiovascular disease in urban areas.

Piloting the Use of Concept Mapping to Engage Geographic Communities for Stress and Resilience Planning in Toronto, Ontario, Canada

The physical and social characteristics of urban neighborhoods engender unique stressors and assets, contributing to community-level variation in health over the lifecourse. Actors such as city planners and community organizations can help strengthen resilience in places where chronic stress is endemic, by learning about perceived stressors and assets from neighborhood users themselves (residents, workers, business owners). This study piloted a methodology to identify Toronto neighborhoods experiencing chronic stress and to engage them to identify neighborhood stressors, assets, and solutions. Crescent Town was identified as one neighborhood of interest based on relatively high levels of emotional stress in Twitter Tweets produced over two one-year periods (2013–2014 and 2017–2018) and triangulation using other neighborhood-level data. Using concept mapping, community members (n = 23) created a ten-cluster concept map describing neighborhood stressors and assets, and identified two potential strategies, a Crescent Town Residents’ Association and a community fair to promote neighborhood resources and build social networks. We discuss how this knowledge has circulated through the City of Toronto and community-level organizations to date, and lessons for improving this methodology.

Contextual influences on chronic illness: A multi-level analysis in the twin cities of Ramallah and Al Bireh in the occupied Palestinian Territory

The features of the urban environment can support human health as well as harm it, but less is known about such influences in the context of middle eastern countries. The association between green space and the political classifications of the urban environment and the risk of chronic illness was investigated in a novel setting, the twin cities of Ramallah and Albireh in the occupied Palestinian territory. We used a generalised multi-level regression analysis to link the 2017 census data with Geographic Information System data. We modelled individuals at level one (n = 54693) and areas of residence at level two (n = 228), adjusting for individual demographic and socio-economic characteristics.

The proportions of ‘mixed’ trees in residential areas had a significant inverse association with the risk of chronic illness. On the political dimension, only living in a refugee camp had a significant positive association with chronic illness; however, this was largely explained and rendered non-significant when green space variables were entered into the models. Our ability to differentiate between several types of green space was important, as findings demonstrated that not all types were associated with reduced risk of chronic illness. Our results from a middle eastern setting add to the largely Western existing evidence, that trees in urban settings are important and beneficial to human health. Researchers and policymakers should pay more attention to the health consequences of refugee camps but also the role of trees in benefiting individuals' health in such a disadvantaged context.

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The study explored the urban political and environmental impacts on health in the Palestinian context.

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Living in a refugee camp is positively associated with the risk of chronic illness, over and above individual characteristics.

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Residential areas mixed trees are inversely associated with chronic illness, and explained the association with refugee camps.

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Not all types of green space are associated with a reduced risk of chronic illness.

Impact of social determinants of health on cardiovascular disease prevention

PURPOSE OF REVIEW

Social determinants of health (SDOH) describe conditions in one's environment that have an impact on health, quality-of-life, outcomes, and risks. These include income, education, employment, culture, language, healthcare access, social support, race, ethnicity, structural racism, discrimination, social support, neighborhood characteristics, and others. SDOH manifest as persistent inequalities in cardiovascular risk factors and disease, and, therefore, contribute to cardiovascular disease (CVD)-related morbidity and mortality. This article reviews how SDOH affect CVD risk and the role they play in CVD prevention.

RECENT FINDINGS

The 2019 American College of Cardiology/American Heart Association (AHA) guideline on the primary prevention of CVD recommends that clinicians evaluate SDOH on an individual basis to inform treatment decisions for CVD prevention efforts. Recent evidence shows that low socioeconomic status, adverse childhood experiences, less social support, reduced health literacy, and limited healthcare access are associated with higher CVD risk and poorer health outcomes. A 2020 AHA statement emphasized the role of structural racism as a fundamental driver of health disparities. The AHA 2030 Impact Goals state a desire to achieve health equity by identifying and removing barriers to healthcare access and quality.

SUMMARY

SDOH affect CVD prevention efforts. The SDOH that affect cardiovascular risk factors, diseases, and outcomes are complex and intersect. Addressing them can be challenging and will require a multilevel and multidisciplinary approach, involving public health measures, changes in health systems, team-based care, and dismantling of structural racism. More studies are needed to investigate the effect of interventions that improve SDOH and prevent CVD or lower CVD risk.

Active use and perceptions of parks as urban assets for physical activity: A mixed-methods study

Parks are potential key urban assets for improved population health; however, their use is not equal among all social groups. Individual and contextual factors could influence residents' perceptions of parks and how they interact with and, eventually, benefit from them. The use of complementary methodologies provides a deeper understanding of the relationship between park use, physical activity (PA), and residents' perceptions. Thus, we designed a mixed-methods study to analyze differences in park use and PA, and the perceptions of parks as urban assets for PA. We selected six parks from three neighborhoods in Madrid (Spain) with different neighborhood socioeconomic status (NSES) for systematic social observation. We registered park users by age, PA level (low, medium, and high), gender, and NSES using the System for Observing Play and Recreation in Communities (SOPARC) audit tool adapted for iOS software (iSOPARC). We also conducted 37 semi-structured interviews and 29 focus groups to analyze residents' perceptions of parks as urban assets for PA in the same neighborhoods. We adopted a convergent-parallel design to analyze both quantitative and qualitative data, and to describe the convergence and divergence areas between them. Parks within the high-NSES were more visited, showing a higher proportion of people performing high PA (11.9%) as compared to residents of the middle (9.3%) and low-NSES (3.2%). Female visitors showed lower PA levels compared to men, especially for parks within high-NSES. The following issues were reported as influence urban park use and perceptions: park maintenance and area perception, works constraints, insecurity and crime, differential perceptions by age, and the availability of organized activities in the parks. Residents from high-NSES reported fewer barriers to park use compared to residents from the other areas, who reported limitations such as less leisure time due to job constrains or perceived insecurity in parks. Senior participants reported that having parks with organized activities and a design oriented towards different age-groups are valuable. Our study shows consistency between the fewer and less intense use of parks registered in the middle and low-NSES neighborhoods, and the more barriers for PA reported in this areas during the qualitative analysis. Mixed-methods provided an insight of the potential causes leading to the differences in park use and PA within cities, which is essential in terms of environmental justice and health equity. Thus, a mixed-methods comprehensive approach to public health problems can help designing public policies addressing relevant factors related to urban health inequities.

Relationship between Green and Blue Spaces with Mental and Physical Health: A Systematic Review of Longitudinal Observational Studies

There is growing interest in the ways natural environments influence the development and progression of long-term health conditions. Vegetation and water bodies, also known as green and blue spaces, have the potential to affect health and behaviour through the provision of aesthetic spaces for relaxation, socialisation and physical activity. While research has previously assessed how green and blue spaces affect mental and physical wellbeing, little is known about the relationship between these exposures and health outcomes over time. This systematic review summarised the published evidence from longitudinal observational studies on the relationship between exposure to green and blue space with mental and physical health in adults. Included health outcomes were common mental health conditions, severe mental health conditions and noncommunicable diseases (NCDs). An online bibliographic search of six databases was completed in July 2020. After title, abstract and full-text screening, 44 eligible studies were included in the analysis. Depression, diabetes and obesity were the health conditions most frequently studied in longitudinal relationships. The majority of exposures included indicators of green space availability and urban green space accessibility. Few studies addressed the relationship between blue space and health. The narrative synthesis pointed towards mixed evidence of a protective relationship between exposure to green space and health. There was high heterogeneity in exposure measures and adjustment for confounding between studies. Future policy and research should seek a standardised approach towards measuring green and blue space exposures and employ theoretical grounds for confounder adjustment.

Resilience and Equity in a Time of Crises: Investing in Public Urban Greenspace Is Now More Essential Than Ever in the US and Beyond

The intersecting negative effects of structural racism, COVID-19, climate change, and chronic diseases disproportionately affect racial and ethnic minorities in the US and around the world. Urban populations of color are concentrated in historically redlined, segregated, disinvested, and marginalized neighborhoods with inadequate quality housing and limited access to resources, including quality greenspaces designed to support natural ecosystems and healthy outdoor activities while mitigating urban environmental challenges such as air pollution, heat island effects, combined sewer overflows and poor water quality. Disinvested urban environments thus contribute to health inequity via physical and social environmental exposures, resulting in disparities across numerous health outcomes, including COVID-19 and chronic diseases such as cancer and cardiovascular diseases (CVD). In this paper, we build off an existing conceptual framework and propose another conceptual framework for the role of greenspace in contributing to resilience and health equity in the US and beyond. We argue that strategic investments in public greenspaces in urban neighborhoods impacted by long term economic disinvestment are critically needed to adapt and build resilience in communities of color, with urgency due to immediate health threats of climate change, COVID-19, and endemic disparities in chronic diseases. We suggest that equity-focused investments in public urban greenspaces are needed to reduce social inequalities, expand economic opportunities with diversity in workforce initiatives, build resilient urban ecosystems, and improve health equity. We recommend key strategies and considerations to guide this investment, drawing upon a robust compilation of scientific literature along with decades of community-based work, using strategic partnerships from multiple efforts in Milwaukee Wisconsin as examples of success.

Time spent outdoors and risk of myocardial infarction and stroke in middle and old aged adults: Results from the UK Biobank prospective cohort

BACKGROUND

Time spent outdoors has been previously related to several cardiovascular risk factors, implying that it may confer either beneficial or harmful effects on cardiovascular health. However, no large population-based studies have examined the relation between time spent outdoors and myocardial infarction and stroke.

OBJECTIVES

We aimed to investigate the longitudinal relation between time spent outdoors and myocardial infarction and stroke in large UK population-based cohort.

METHODS

A total of 446,648 participants from UK Biobank were included in the study of which 431,146 participants (56% females and 44% males with a mean age of 56.4 ± 8.1 years) were followed for a median time of 7 years. Time spent outdoors was self-reported and participants were stratified into quantiles (less than 1.5 [reference group]; 1.5 to 2.4; 2.5 to 3.5 and more than 3.5 h per day outdoors). Myocardial infarction and stroke events were either collected from hospital records and death registries or were self-reported by the participants. Cox proportional hazard regression was used for the analysis. In addition to age and sex, analyses were adjusted for potential demographic (TDI, ethnic background, current employment status), lifestyle (alcohol intake frequency, current tobacco use, sedentary time and moderate-to-vigorous physical activity), health related factors (BMI, systolic and diastolic blood pressure) and environmental indicators (NO₂, NO_x, PM₁₀, PM_2.5-10, PM_2,5, noise pollution, % greenspace, % natural environment and % water).

RESULTS

A 20% increased risk for myocardial infarction incidence was observed among participants who reported spending more than 3.5 h/day outdoors (HR: 1.20, 95% CI: 1.06-1.36) compared to the reference group. A trend was also observed for stroke (HR: 1.14, 95% CI: 0.97-1.34).

CONCLUSION

Findings from the present study indicate that spending more than 3.5 h/day outdoors is a risk factor for myocardial infarction and stroke. Future research is needed to further understand the relation between time spent outdoors and cardiovascular disease.

Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity

PURPOSE OF REVIEW

We sought to examine the role of social and environmental conditions that determine an individual's behaviors and risk of disease-collectively known as social determinants of health (SDOH)-in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US).

RECENT FINDINGS

Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework. We examined existing evidence of the association between SDOH-organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context-and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.

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

BACKGROUND

With the launch of the "Global Age-Friendly Cities project", increasing emphasis has been placed on the effects of green spaces on health in the elderly. The previous literature has shown that green spaces are beneficial to a range of health-related outcomes in adults. However, associations of greenness with mortality and cardiovascular outcomes are less certain, which may differ depending on the age class. This review aimed to synthesize current evidence from observational studies to assess relationships of green space exposure with mortality and cardiovascular outcomes in older individuals.

METHODS

Five databases were searched. Qualitative evaluation and meta-analyses of included studies were conducted. This review is registered with PROSPERO, CRD42020160366.

RESULTS

Of the 8,143 records identified, we finally included 22 studies. In a narrative systematic review, we observed that the majority of studies showed reductions in the risk of all-cause mortality and total cardiovascular disease. Further meta-analyses which included eight cohort studies, indicated that greater greenness exposure (per 0.1 unit increase of normalized difference vegetation index (NDVI)) was associated with a reduced risk of all-cause mortality (pooled hazard ratios (HR) (95% confidence interval (CI) = 0.99 (0.97, 1.00)) and stroke mortality (pooled HR (95% CI) = 0.77 (0.59, 1.00)) in older individuals.

CONCLUSIONS

This review supports increasing green space exposure in terms of the prevention of death and cardiovascular outcomes in older individuals. Effective measures to increase or preserve greenspaces should therefore be considered as important public health interventions.

Green-Blue Spaces and Population Density versus COVID-19 Cases and Deaths in Poland

In the last year, in connection with the COVID-19 pandemic caused by the SARS-CoV-2 coronavirus, scientific papers have appeared in which the authors are trying to identify factors (including environmental) favoring the spread of this disease. This paper presents the spatial differentiation in the total number of COVID-19 cases and deaths during the full year (March 2020-March 2021) of the SARS-CoV-2 pandemic in Poland versus green-blue spaces (green-i.a. forests, orchards, meadows and pastures, recreational and rest areas, biologically active arable land; blue-lakes and artificial water reservoirs, rivers, ecological areas and internal waters) and population density. The analysis covers 380 counties, including 66 cities. This study used daily reports on the progress of the pandemic in Poland published by the Ministry of Health of the Republic of Poland and unique, detailed data on 24 types of land use available in the Statistics Poland database. Statistical relationships were determined between the above-mentioned environmental variables and the variables characterizing COVID-19 (cases and deaths). Various basic types of regression models were analysed. The optimal model was selected, and the determination coefficient, significance level and the values of the parameters of these relationships, together with the estimation error, were calculated. The obtained results indicated that the higher the number of green-blue spaces in individual counties, the lower the total number of COVID-19 infections and deaths. These relationships were described by logarithmic and homographic models. In turn, an increase in the population density caused an increase in COVID-19 cases and deaths, according to the power model. These results can be used in the current analysis of the spread of the pandemic, including the location of potential outbreaks. In turn, the developed models can be used as a tool in forecasting the development of the pandemic and making decisions about the implementation of preventive measures.

Outdoor artificial light at night: A forgotten factor in green space and health research

Exposure to green space has been associated with a range of human health benefits, largely in spatial epidemiological studies. Green space and artificial light at night are both associated with breast and prostate cancer, depressive symptoms, obesity, and sleep problems, and are both influenced by the built environment and urbanisation. We identified a negative correlation between green space diversity and outdoor artificial light at night for Australian major cities. Outdoor artificial light at night is therefore a potential, but overlooked, confounder in spatial epidemiological studies of green space exposure and human health, and should be incorporated into future models.

Green space and cardiovascular health in people with type 2 diabetes

Associations between green space type and 9-year risk of incident cardiovascular disease (CVD) hospitalisations and deaths were analysed in 4166 people with type 2 diabetes in the Sax Institute's 45 and Up Study. Incidence of all-cause mortality, cardiovascular mortality, fatal or non-fatal CVD events and acute myocardial infarctions (AMI) were 14.67%, 7.23%, 47.36%, and 4.51%, respectively. After full adjustment, more tree canopy was associated with lower CVD mortality, lower fatal or non-fatal CVD events, and lower AMI risk. More open grass was associated with lower all-cause mortality, lower CVD mortality and lower fatal or non-fatal CVD events, but higher AMI risk.

Device-Measured and Self-Reported Active Travel Associations with Cardiovascular Disease Risk Factors in an Ethnically Diverse Sample of Adults

Active travel (AT) provides an opportunity to alleviate the physical inactivity and climate crises contributing to the global chronic disease burden, including cardiovascular diseases (CVD). Though AT shows promising links to reduced CVD risk, prior studies relied on self-reported AT assessment. In the present study, device-measured and self-reported AT were compared across population subgroups and relationships with CVD risk biomarkers were evaluated for both measures. The study recruited an ethnically diverse sample (N = 602, mean age 59 years, 42% Hispanic/Latino ethnicity) from neighborhoods that varied by walkability and food access. AT was assessed using concurrently collected accelerometer and GPS data and self-report data from a validated survey. Relationships with body mass index (BMI), triglycerides, high-density lipoprotein (HDL) cholesterol, blood pressure (BP), and moderate-to-vigorous physical activity (MVPA) were modeled using multivariable linear regression. Devices captured more AT than did self-report. We found differences in AT measures by population subgroups, including race, ethnicity, education, income, vehicle access, and walkability. Men had more accelerometer-measured MVPA, though women self-reported more daily minutes. Both device and survey AT measures were positively associated with total accelerometer-measured MVPA, though the relationship was stronger with device-measured AT. Device-measured AT was associated with lower BMI. No other CVD risk biomarker was associated with either AT measure. No effect modification by Hispanic/Latino ethnicity was detected. Further studies with device-based measures are warranted to better understand the relationship between AT and cardiovascular health.

Socioeconomic status as an effect modifier of the association between built environment and mortality in elderly Hong Kong Chinese: A latent profile analysis

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.

Relationship between Urban Green Spaces and Cancer: A Scoping Review

This scoping study aims to explore the relationships between urban green spaces (UGSs) and the onset, remission and recovery of cancer. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (protocol published in 2018). Eligibility criteria for papers were: (1) to be concerned with UGSs, (2) reporting effects of UGSs on cancer-related outcomes including direct or indirect measures, (3) reporting randomized controlled trials, prospective cohort studies, case studies, observational studies, non-comparative studies, (4) in English or French. The search covered primary studies in the published and unpublished (grey) literatures searching by hand and electronic databases (MEDLINE, Green File, Cumulative Index to Nursing and Allied Health Literature and ScienceDirect). Among 1703 records screened by two reviewers independently, 29 were included for qualitative synthesis. We classify the cancers concerned and the effects reported i.e., protective effect, risk or without association. The most investigated cancers are bladder, breast and lung cancer. Our study also identified contributing factors and their mediating effects between UGSs and cancer. Even though the strength of the evidence of the associations between UGSs and cancer is still weak due to the low number of studies and their design, results highlight the wide variety of possible mediating factors between the use of green spaces and cancer occurrence, remission and/or prevention. Knowledge gaps and future research perspectives should be oriented to qualitative research on protective factors with an attention to equity in UGS access and use.

Analytical approaches to testing pathways linking greenspace to health: A scoping review of the empirical literature

BACKGROUND

Inadequate translation from theoretical to statistical models of the greenspace - health relationship may lead to incorrect conclusions about the importance of some pathways, which in turn may reduce the effectiveness of public health interventions involving urban greening. In this scoping review we aimed to: (1) summarize the general characteristics of approaches to intervening variable inference (mediation analysis) employed in epidemiological research in the field; (2) identify potential threats to the validity of findings; and (3) propose recommendations for planning, conducting, and reporting mediation analyses.

METHODS

We conducted a scoping review, searching PubMed, Scopus, and Web of Science for peer-reviewed epidemiological studies published by December 31, 2019. The list of potential studies was continuously updated through other sources until March 2020. Narrative presentation of the results was coupled with descriptive summary of study characteristics.

RESULTS

We found 106 studies, most of which were cross-sectional in design. Most studies only had a spatial measure of greenspace. Mental health/well-being was the most commonly studied outcome, and physical activity and air pollution were the most commonly tested intervening variables. Most studies only conducted single mediation analysis, even when multiple potentially intertwined mediators were measured. The analytical approaches used were causal steps, difference-of-coefficients, product-of-coefficients, counterfactual framework, and structural equation modelling (SEM). Bootstrapping was the most commonly used method to construct the 95% CI of the indirect effect. The product-of-coefficients method and SEM as used to investigate serial mediation components were more likely to yield findings of indirect effect. In some cases, the causal steps approach thwarted tests of indirect effect, even though both links in an indirect effect were supported. In most studies, sensitivity analyses and proper methodological discussion of the modelling approach were missing.

CONCLUSIONS

We found a persistent pattern of suboptimal conduct and reporting of mediation analysis in epidemiological studies investigating pathways linking greenspace to health; however, recent years have seen improvements in these respects. Better planning, conduct, and reporting of mediation analyses are warranted.