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

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

Effects of residential greenness on attention in a longitudinal study at 8 and 11-13 years

In an urbanizing world, with 55% of the population living in cities, it is essential to design friendly and healthy ones. An emerging body of evidence has associated greenspace exposure with improved cognitive development, including attentional function; however, the longitudinal studies looking at the association with attentional function are still scarce. Therefore, the objective of this study was to analyze the association of the exposure to greenspace and attention in school children. This study was based on 751 participants at 8 years and 598 at 11-13 years of two sub-cohorts of the INMA cohort study in Gipuzkoa and Asturias, Spain. Greenspace exposure at home was characterized using four indicators: (i) average of Normalized Difference Vegetation Index (NDVI) and (ii) Vegetation Continuous Field (VCF) in buffers of 100 m, 300 m, and 500 m around the residential address, (ii) availability of a green space within 300 m from the residential address, and (iv) residential distance to green spaces. Participants' attention was characterized twice at ages of 8 and 11 years, using the computerized Attentional Network Test (ANT). General linear models were used for the cross-sectional analyses and linear mixed effects model for the longitudinal analyses. Our cross-sectional analyses showed a statistical significant protective association between average NDVI at 300 m and inattentiveness (-7.20, CI 95%: 13.74; -0.67). In our longitudinal analyses, although we generally observed beneficial associations between greenspace exposure and attention, none attained statistical significance. No statistically significant indirect effect were seen for NO₂. Our findings add to the emerging body of evidence on the role of green spaces in neurodevelopment, which can provide the evidence base for implementing intervention aimed at promoting neurodevelopment in urban children.

Does exposure to greenness improve children's neuropsychological development and mental health? A Navigation Guide systematic review of observational evidence for associations

BACKGROUND

Contact with nature may have a key role in child brain development. Recent observational studies have reported improvements in children's neuropsychological development and mental health associated with greenness exposure. In a rapidly urbanizing word, researchers, policymakers, healthcare workers and urban planners need to work together to elaborate evidence-based policies and interventions to increase the availability of quality green space with the potential to enhance childhood development.

OBJECTIVE

To review the observational evidence assessing the effect of exposure to greenness on children's neuropsychological development and mental health.

METHODS

The protocol for the review was preregistered at PROSPERO (CRD42020213838). The Navigation Guide systematic review methodology was followed. Search strategies were formulated and adapted to each database. Searches were performed in PubMed, Scopus, Web of Science and EBSCO's GreenFILE on October 5, 2021. Additional articles were further identified by hand-searching reference lists of included papers.

RESULTS

A systematic search of 4 databases identified 621 studies, of which 34 were included in the review. The studies included investigated diverse domains within neuropsychological development and mental health, such as attention, working memory, intelligence, cognitive development, academic performance, well-being, attention-deficit/hyperactivity disorder symptoms, and behavior. Most of the studies were rated as having high or probably high risk of bias in the assessment.

DISCUSSION

Although nearly all studies showed a positive association between greenness exposure and the outcomes studied, the heterogeneity in the methods used to assess exposure and the diversity of domains within each main outcome has made it difficult to draw clear conclusions. Future studies should adopt a longitudinal design to confirm the causality of the associations and include measures to determine which characteristics of greenness have the greatest influence on each domain. Researchers should also try to explore pathways linking exposure to greenness with the neuropsychological development and mental health, by implementing mechanistic studies.

Manganese levels in newborns' hair by maternal sociodemographic, dietary and environmental factors

Exposure to manganese (Mn) has been associated with neurodevelopmental problems in children. Mn exposure begins in utero, and maternal sociodemographic, dietary and environmental factors may affect Mn levels in newborns' hair. This study aimed to characterize in utero Mn exposure using Mn levels in newborns' hair as a biomarker of prenatal exposure, and to analyze its relationship with sociodemographic, dietary and environmental factors in the Spanish INMA-Gipuzkoa cohort. Overall, 638 pregnant women were recruited in the first trimester of pregnancy and a hair sample was obtained from 473 newborns. Sociodemographic, dietary and environmental data were recorded through two questionnaires administered in the first and third trimesters of pregnancy. The median Mn concentration in newborns´ hair was 0.31 µg/g (P5 = 0.02; P95 = 1.23). Mn levels in newborns´ hair were associated with smoking during pregnancy (β = 0.222; 95% CI = 0.065-0.379) and with maternal PM_2.5 exposure (β = 0.025; 95% CI = 0.004; 0.047), as well as with cereal and pasta intake in the first trimester of pregnancy (β = 0.002; 95% CI = 0.0004; 0.003). In conclusion, fetal exposure to Mn was associated with smoking and exposure to atmospheric pollution during pregnancy.

Air Polycyclic Aromatic Hydrocarbons (PAHs) associated with PM2.5 in a North Cantabric coast urban environment

Health studies and more specifically epidemiological studies require an extended analysis of the physical and chemical characteristics of the environment in which are held. The aim of this study is to evaluate the concentration of six Polycyclic Aromatic Hydrocarbons (PAHs) in PM2.5 fraction of air in a peri-urban environment in the province of Gipuzkoa (Basque Country, Spain) where residential areas are surrounded by industrial activity. The six studied PAH are as follows: Fluoranthene, Benzo(b)fluoranthene, Benzo(k)fluoranthene, (Benzo(a)pyrene, Indene(123-cd)pyrene and Benzo(ghi)perylene. Our six-year study shows a decrease in PAH concentrations between 2006 and 2011, especially since 2008 due to the fall in industrial activity and related traffic. Overall, 801 data were obtained. Total PAH concentration ranged between 0.3 and 8.29ngm(-3) and Benzo(a)pyrene (BaP) from 0.05 to 0.88ngm(-3). The mean value for BaP in PM2.5 was 0.15ngm(-3) and the target value established by European legislation in PM10 was only exceeded in occasional days. Contribution percentages of each PAH in the monitoring sites were very similar, indicating common sources. The results of this study suggest that emission from industry play an important role although we also have to consider the contribution of traffic. PAH seasonal variations are similar as those reported in many previous studies. BaP and PAH concentration values in our region of study were in the range of other Spanish cities.

Influence of fetal glutathione S-transferase copy number variants on adverse reproductive outcomes

A nested case-control association study was designed to investigate the influence of maternal and fetal copy number variants (CNVs) on reproductive outcomes. Genotypes of ten CNVs encompassing GST and CYP genes were assessed. Significant associations were only found for child CNV genotypes. In particular, the child GSTM1 insertion allele was associated with prematurity protection (odds ratio, 95% CI: 0.67, 0.51-0.89; P < 0.01), whereas the child GSTT2B insertion allele was associated with an increased risk of being small for gestational age (odds ratio, 95% CI: 1.33, 1.07-1.67; P = 0.01). The study highlights the role of the fetal genome in prenatal development and also the need to analyse CNVs in a systematic manner.

Prenatal mercury exposure in a multicenter cohort study in Spain

BACKGROUND

Mercury is a ubiquitous heavy metal that may negatively affect human health. It is desirable to investigate mercury exposure in vulnerable populations.

OBJECTIVE

To determine the concentrations of total mercury (T-Hg) in cord blood and to evaluate the role of maternal fish consumption in a Spanish mother and child cohort.

METHODS

A total of 1883 mother and child pairs from a population-based cohort were included between 2004 and 2008. T-Hg concentrations were measured in whole cord blood and maternal seafood consumption was ascertained by means of a food-frequency questionnaire. Linear regression was used in stratified analyses, while a joint model was adjusted using a mixed-effects linear model.

RESULTS

Maternal daily seafood consumption was 78g/d and the geometric mean for T-Hg was 8.2μg/L. Maternal fish intake during pregnancy, mother's age, country of origin, educational level, employment status and parity, as well as area of study and season of delivery, were associated with cord blood T-Hg levels. A doubling in consumption of large oily fish was associated with an increase of 11.4% (95%CI: 3.8 to 19.6%) in cord blood T-Hg levels, followed by an increase of 8.4% (95%CI: 5.7 to 11.2%) in the case of canned tuna and 8.3% (95%CI: 5.5 to 11.1%) in that of lean fish.

CONCLUSION

A high proportion of newborns had elevated concentrations of cord blood T-Hg according to the current US-EPA reference dose (5.8μg/L for methylmercury). Mercury concentrations were related to maternal fish consumption, with large oily fish being the main contributor.

Sociodemographic, reproductive and dietary predictors of organochlorine compounds levels in pregnant women in Spain

Organochlorine pesticides and polychlorinated biphenyls (PCBs) are consistently found in human tissues. Serum levels of organochlorine compounds (OC) in pregnant women in particular have raised concern about possible harm to humans in the early phases of physical and behavioural development. The objective of the present study was to evaluate the association between concentration of OCs in serum of two cohorts of pregnant women from Gipuzkoa and Sabadell in Spain and socioeconomic, reproductive and dietary variables. Concentration of polychlorinated biphenyls (PCBs: 28, 52, 101, 118, 138, 153 and 180), hexachlorobenzene (HCB), beta and gamma-hexachlorocyclohexane (β-HCH and γ-HCH), heptachlor epoxide, dichlorodiphenyl dichloroethylene (p,p'-DDE) and dichlorodiphenyl trichloroethane (p,p'-DDT) were measured in the serum of 1259 pregnant women. Associations between OCs and potential predictor variables were assessed using linear regression models adjusted for potential confounders. The compounds most commonly found in the serum were p,p'-DDE (99% of the samples) and PCB-153 (95% of the samples). Geometric means of serum concentrations (ng g⁻¹ lipid) of organochlorine pesticides were 110.0, 19.1, and 33.5 for p,p'-DDE, β-HCH, and HCB respectively, while the geometric means of PCBs were 21.8, 38.9 and 26.9 for PCB 138, 153, and 180 respectively. The levels of all OCs increased with age. BMI was positively associated with the concentration of organochlorine pesticides but inversely related to PCB concentrations. The serum levels of OCs fell only after a cumulative period of breastfeeding of over a year. Levels of PCBs were related to fish intake, but in general dietary factors did not improve the explained variability of the concentrations of OCs. Overall, the levels of OCs found in the study are at the lower end of the range reported in Spain and other countries.

Urinary 1-hydroxypyrene and PAH exposure in 4-year-old Spanish children

AIMS

Exposure to polycyclic aromatic hydrocarbons (PAH), among the main compounds present in polluted urban air, is of concern for children's health. Childhood exposure to PAH was assessed by urinary monitoring of 1-hydroxypyrene (1-OHP), a pyrene metabolite, investigating its association with exposure to air pollution and other factors related to PAH in air.

METHODS

A group of 174 4-year-old children were recruited and a questionnaire on their indoor and outdoor residential environment was completed by parents. At the same time, environmental measurements of traffic-related air pollution (NO2) were carried out. A urine sample was collected from each child in order to analyze 1-OHP using HPLC with fluorescence detection, correcting for creatinine concentrations. Non-parametric tests and regression analyses were used to identify environmental factors that influence 1-OHP excretion.

RESULTS

Mean urinary 1-OHP concentration was 0.061 micromol/mol creatinine, ranging from 0.004 to 0.314 micromol/mol. Non-parametric tests and regression analysis showed positive and significant associations (P<or=0.05) between 1-OHP and predicted residential exposure to NO2 (which was based on outdoor environmental measurements and geo-statistical analysis), self-reported residential vehicle traffic, passive smoking and cooking appliance. 1-OHP levels tended to be higher among children living in urban areas (0.062 micromol/mol vs. 0.058 micromol/mol for children living in rural areas) but differences were not significant (P=0.20).

CONCLUSION

In Southern Spain, concentrations of urinary 1-OHP were in the lower range of those generally reported for children living in non-polluted areas in Western Europe and the USA. Traffic-related air pollution, passive smoking and cooking appliance influenced urinary 1-OHP level in the children, which should be prevented due to the health consequences of the inadvertent exposure to PAH during development.

Environmental and lifestyle factors for organochlorine exposure among women living in Southern Spain

Southern Spain has the largest area of intensive greenhouse agriculture in Europe, and may constitute a special case of occupational and female exposure, because this type of farming requires considerable pesticide use and employs many women. We measured adipose tissue levels of 14 organochlorine pesticides in 458 women living in this area and analyzed the relationship between pesticide level/presence and sociodemographic characteristics, reproductive history or life-style factors that may influence this exposure. Pesticide presence was determined by gas chromatography with electron-capture detector. All fat samples were positive for 1 residue. DDT or metabolites were found in 98.25%, with mean value of 660 ngg(-1) of lipid. p,p'-DDE level was higher in women who were older, with lower educational level or obese. Almost 70% had measurable levels of endosulfan and/or metabolites, with a mean total value of 38.8 ngg(-1) of lipid. Endosulfan-I exposure was higher in women with shorter residence in rural settings and more frequent in women with 3 children. 52.62% were exposed to 1 of aldrin-dieldrin-endrin group. Endrin was more frequent in women who were younger, with higher educational level or no agricultural working experience; dieldrin was more frequent in women who were older, with lower educational level or more children. Finally, lindane residues were found in 39.30%. Lindane levels were higher in women who breastfed longer or had more children. Research is required on women occupationally exposed to a selected group of organochlorine pesticides, especially those of reproductive age, as a basis for preventive action.

Human exposure to endocrine disrupters: standardisation of a marker of estrogenic exposure in adipose tissue

In many epidemiological studies based on the direct measurement of exposure to organochlorines, the chemicals of concern are determined directly from adipose tissue samples. Although the measurement of all possible organochlorines, their metabolites, isomers and congeners may be desirable, it is expensive and time-consuming and many chemicals with hormonal activity may not yet have been identified. Testing systems are therefore required to screen for estrogenicity and to identify appropriate biomarkers of human exposure. To address this issue, we developed and standardised a method to assess the total estrogenic xenobiotic burden in human adipose tissue. The method extracts and separates the more lipophilic xenoestrogens from ovarian estrogens, with a subsequent bioassay determination of the cumulative effect of the xenoestrogens. It was applied to 400 women, using 200 mg of adipose tissue: 65% of samples showed measurable estrogenicity in the fraction where most non-polar xenoestrogens eluted, and 76% of fractions where ovarian estrogens eluted were positive for estrogenicity. Residues of 16 organochlorine pesticides were determined. No correlation was found between pesticide content and estrogenicity of the samples. The high percentage of positive samples suggests that the method is sensitive enough to be used as a biomarker of human exposure to estrogenic xenobiotics and can be applied in epidemiological studies.

[Impact of 3 years of contract implementation on the quality of cataract surgery]

OBJECTIVE

To assess the adequacy to clinical practice of cataract procedures contracted in the Gipuzkoa Health Area (in public as well as concerted hospitals) from 1995. A second aim is to identify the achievements obtained three years after its implementation comparing the data with those of 1994, a year before.

METHODS

Before its implementation a multidisciplinar team established the number of surgical procedures to be contracted each year by age and sex, as well as the technical and quality conditions (out-patient surgery, loco-regional anaesthetic, facoemulsification, etc.). Data used for the assessment: Cataracts Registry of the Ophthalmologic Unit, Patient Management Categories and surgical waiting lists.

RESULTS

During the period studied, 8,073 cataract operations were performed, 9% higher than expected. The distribution by age and sex was as estimated. Technical and quality standards were fulfilled, except for the surgical waiting list, in at least 75% of the procedures. The surgical technique mainly used was facoenmulsification, increasing from 15% in 1994 to 76.5% in 1997.

CONCLUSION

The contracting of cataract surgery has allowed the assessment, reordering, and establishment of standards of care for all the professionals involved in the process. There were improvements in clinical practice during the period studied. This has given raise to the homogenisation of care in all the units following technical and quality standards, meaning better equity for the patients in need of the procedure.