Built environment and cardiovascular risk

Abstract

This thesis has described the current evidence of the association between the built environment and cardiovascular risk, and has originally investigated this long-term association and its underlying mechanisms. Chapter 1 introduces the epidemiology of cardiovascular disease (CVD), determinants of CVD, and gaps in current evidence. To sum up, it introduces the outline of the current thesis. Chapter 2 provides a comprehensive overview of the current evidence on objectively measured neighbourhood built environment exposures in relation to CVD events in adults. We searched seven databases for systematic reviews between 2000 and 2021. From the 3,304 initial hits, 51 systematic reviews were included. There was strong evidence of the associations between increased air pollutants (especially PM2.5 exposure) and increased residential noise with greater risk of CVD. Highly suggestive evidence was found for an association between increased ambient temperature and greater risk of CVD. Systematic reviews on physical activity environment, food environment, light pollution and urbanisation in relation to CVD were scarce or lacking. Chapter 3 maps the spatial distribution of green space by all vegetation, trees, shrubs, low vegetation, grass field, and agriculture in the Netherlands in 2017. Furthermore, it assesses socio-demographic and socio-economic differences in the availability of green space in the Netherlands. Data from 16,440,620 individuals aged one and above of the Netherlands on January 1, 2017, were analyzed. Ethnic Dutch and Indonesian had more green space coverage around residence than Turkish and Moroccan. People with higher household SES had gradually more green space coverage. Chapter 4 originally investigates the longitudinal associations of air pollution and green space with cardiometabolic risk among children in the Netherlands. Three Dutch prospective cohorts with a total of 13,822 participants aged 5 to 17 years were included. More green space exposure at residence was associated with decreased cardiometabolic risk over time. Exposure to higher concentrations of NO2 and elemental carbon was associated with increased cardiometabolic risk in the Lifelines cohort. No evidence was found for PM2.5 and PM10, probably due to the small variations in exposures. Chapter 5 presents findings from a nationwide cohort study that investigates the relationship between changes in residential neighbourhood walkability and CVD incidence in adults. Three million Dutch adults aged 40 and above were followed for 24 years. The growth mixture model identified four distinct trajectories of changes in neighbourhood walkability from 1996 to 2008. In the subsequent years till 2019, a total of 644,785 individuals (21.0%) developed CVD. As compared to the stable but relatively higher walkability group, residing in stable low and increasing walkability areas was associated with a higher CVD risk. Chapter 6 explores the underlying mechanism of the association between exposure to green space and blood pressure (BP) levels based on a theoretical framework. Both shorter distance to green space and more green space coverage around residence and workplace were associated with lower SBP, lower DBP and lower risk of hypertension. The observed inverse associations of green space exposures with BP and hypertension were partly explained by better mental health.