Chronic disease and where you live: Built and natural environment relationships with physical activity, obesity, and diabetes

Is walkability healthy for all? Using the National Environmental Database to examine equity in the environmental health characteristics of pedestrian-supportive neighborhoods in the U.S

BACKGROUND

Marginalized populations in the U.S. often live in dense urban areas, which could promote active travel and health. However, while compactness can support walkability, it can also create exposure to pollution, noise, injury risk, and urban heat islands. These exposures may be higher for marginalized groups, creating systematic "walkability-related" risks.

OBJECTIVES

We evaluated relationships between walkability, health-related environmental exposures, and social vulnerability, asking: (1) How are sociodemographic groups sorted across space with respect to walkability? (2) Do the environmental health correlates of walkability vary by social vulnerability?

METHODS

We compiled block group-level data for the 30 largest U.S. metropolitan areas. We measured walkability using the National Walkability Index; social vulnerability using indicators of race/ethnicity and socioeconomic status; and environmental exposures using PM2.5, pedestrian fatalities, noise, and tree coverage. We used multilevel mixed-effects regressions to predict (1) walkability as a function of vulnerability and (2) each environmental exposure as a function of the cross-tabulation between walkability and vulnerability.

RESULTS

Higher walkability was associated with higher vulnerability. Compared to highly walkable block groups with low vulnerability, those with high vulnerability had higher PM2.5 and noise levels and lower tree coverage. These differences were even more pronounced among block groups with low walkability, suggesting pervasive inequities.

DISCUSSION

While marginalized groups often live in more walkable places, the "high" walkability to which they are exposed carries greater environmental risks than for privileged populations. Our findings illustrate the importance of mitigating environmental burdens that could dampen the health benefits of walkability in marginalized communities.

What is the cross-sectional association of geospatially derived walkability with walking for leisure and transport?

BACKGROUND

Built environments have been shown to shape active living behaviours, including walking. However, this literature is drawn predominantly from Europe and North America. This study aimed to create a geospatially derived city-wide walkability index and further investigate the association with walking in Belo Horizonte, Brazil.

METHODOLOGY

A cross-sectional analysis was conducted using data from participants in the 2014-15 MOVE-SE study in Belo Horizonte. A walkability index was created at the census tract level, which included net residential density, land use mix, and street connectivity, using ArcGIS software. Walking for leisure and transportation was self-reported via the International Physical Activity Questionnaire. Covariates such as sociodemographic characteristics, health indicators, and neighbourhood context were measured. A multilevel negative binomial regression was employed, incorporating confounders across five combined models with sequential addition of covariate groups. All statistical analyses were conducted in R software with a significance threshold of 5%.

RESULTS

The study included 1,372 adults aged 18 years and older, with a female majority of 60.5%, a median age of 41, and 45.9% completed at most primary schooling. The family income for 63.7% ranged between one to three times the minimum wage. Self-rated health was considered good by 64.7% of participants, and the median Body Mass Index (BMI) was 26.2 kg/m2. Regarding neighbourhood context, the median length of residence was 15 years, per capita monthly income was US$175, and the average land slope was 8.2%. Participants reported a median of 180 minutes per week (interquartile range: 120 - 250) for walking for leisure and transportation. The median walkability index was -0.51 (interquartile range: -1.40 - 1.21). After adjusting for confounders, the final model indicated a positive association between the walkability index and walking for leisure (IRR: 1.33; CI95%:1.32-1.35; p < 0.001) and transportation (IRR: 1.22; CI95%:1.20-1.24; p < 0.001).

DISCUSSION

The findings demonstrate a positive association between higher levels of walkability and increased walking behaviours in various contexts. It underscores the importance of urban planning, design, and policy interventions tailored to local environments to promote walkability, reduce car dependency, and facilitate healthier lifestyles as part of everyday living.

Pathogenic built environment? Reflections on modeling spatial determinants of health in urban settings considering the example of COVID-19 studies

The triad of host, agent, and environment has become a widely accepted framework for understanding infectious diseases and human health. While modern medicine has traditionally focused on the individual, there is a renewed interest in the role of the environment. Recent studies have shifted from an early-twentieth-century emphasis on individual factors to a broader consideration of contextual factors, including environmental, climatic, and social settings as spatial determinants of health. This shifted focus has been particularly relevant in the context of the COVID-19 pandemic, where the built environment in urban settings is increasingly recognized as a crucial factor influencing disease transmission. However, operationalizing the complexity of associations between the built environment and health for empirical analyses presents significant challenges. This study aims to identify key caveats in the operationalization of spatial determinants of health for empirical analysis and proposes guiding principles for future research. We focus on how the built environment in urban settings was studied in recent literature on COVID-19. Based on a set of criteria, we analyze 23 studies and identify explicit and implicit assumptions regarding the health-related dimensions of the built environment. Our findings highlight the complexities and potential pitfalls, referred to as the 'spatial trap,' in the current approaches to spatial epidemiology concerning COVID-19. We conclude with recommendations and guiding questions for future studies to avoid falsely attributing a built environment impact on health outcomes and to clarify explicit and implicit assumptions regarding the health-related dimensions.

Elucidating the Impact of Community-Level Social Determinants of Health on Pre-Operative Frailty: A Data-Driven Study in Florida

Frailty, an age-related syndrome, is associated with poor post-operative outcomes. The impact of community-level social determinants of health (SDoH) on pre-operative frailty has not been investigated yet. We developed a machine learning model to predict pre-operative frailty using an institutional dataset and applied it to a more geographically diverse population from the OneFlorida+ Clinical Research Consortium. Computable phenotyping for SDoH stratification using unsupervised learning was employed to identify distinct patient profiles based on zip code-level SDoH characteristics. We applied multivariate logistic regression to examine the association between SDoH profiles and pre-operative frailty risk. Adverse community-level SDoH profiles are independently associated with higher pre-operative frailty risk; patients from the disadvantaged SDoH profile had 1.21 times higher odds (95% CI 1.16-1.26) of being frail compared to the advantaged SDoH cluster after adjusting for potential confounders. Considering patients' social context could improve pre-operative care and surgical outcomes, informing clinical practice and policies.

The Role of Behavioral Factors on Chronic Diseases-Practice and Knowledge Gaps

Background: Behavioral factors, such as smoking, alcohol consumption, stress, poor diet, and physical inactivity, but also sleep deprivation and negative social connections, play a critical role in the development and progression of major chronic diseases. These include cardiovascular diseases, diabetes, chronic respiratory conditions, and cancers. Methods: The objective of this review is to explore the influence of these modifiable risk factors on the global burden of chronic diseases and assess the potential impact of public health interventions and policy changes. Results: The evidence highlights a significant association between behavioral risk factors and increased morbidity and mortality from chronic diseases. Public health interventions and policy changes targeting these modifiable behaviors have shown substantial potential in reducing the prevalence and impact of chronic conditions. Strategies such as smoking cessation programs, dietary improvements, physical activity promotion, and stress reduction are critical in mitigating these risks. Conclusions: Addressing modifiable behavioral factors is essential for the prevention and control of chronic diseases. Bridging the gap between current knowledge and effective implementation of interventions is crucial for improving population health outcomes. Public health strategies focused on modifying key behavioral risks can significantly reduce the burden of chronic diseases, thereby improving overall health and reducing healthcare costs.

Using photovoice to investigate patient experiences of lupus nephritis in Canada

OBJECTIVE

Lupus nephritis (LN) is a major cause of morbidity and mortality, affecting up to 60% of patients with systemic lupus erythematosus (SLE). The perspectives of patients with SLE have been explored; however, little is known of the lived experiences of patients with LN.

METHODS

Patients aged ≥18 years with biopsy-proven pure or mixed International Society of Nephrology/Renal Pathology Society Class III, IV or V LN were purposefully recruited from a Canadian lupus cohort to participate in a photovoice (visual-narrative participatory research method) exercise. Participants took photos of what LN means to them, impacts on daily life and factors impacting LN management. Photos were shared and discussed in focus groups.

RESULTS

13 individuals with LN participated (92.3% were female; mean (SD) age was 41.7 (14.0) years). The mean (SD) number of photos shared per participant was 4.2 (0.9). Photos (n=54) depicted activities/settings that contribute to well-being (n=15), the participants themselves (n=13), healthcare experiences (n=10), home (n=4), community (n=2), friends (n=2), work (n=2) and other challenges (n=6). All participants described physical and psychosocial impacts of living with LN. Although 12 mentioned activities/settings that contribute to well-being (eg, time in natural environments), participants were consistently reminded of limitations imposed by LN due to physical symptoms, challenges presented by the physical environment and the altered life trajectories experienced. Participants discussed the dual burden of LN and the associated medication journey; side effects and medication-related financial challenges were highlighted by ten and five participants, respectively.

CONCLUSIONS

Participants reported a substantial psychosocial burden associated with altered life trajectories, the dual burden of LN and the associated medication journey, and the conflicting role of the physical environment. The need for flexibility (ie, from employers, themselves) is an essential component of navigating altered life trajectories.

Social Determinants of Health and Diabetes in Pregnancy

Social determinants of health (SDOH) are the conditions in which people are born, grow, work, live, and age. SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes for different populations and can be measured at both an individual and neighborhood or community level (iSDOH, nSDOH). In pregnancy, increasing evidence shows that adverse iSDOH and/or nSDOH are associated with a greater likelihood that diabetes develops, and that when it develops, there is worse glycemic control and a greater frequency of adverse pregnancy outcomes. Future research should not only continue to examine the relationships between SDOH and adverse pregnancy outcomes with diabetes but should determine whether multi-level interventions that seek to mitigate adverse SDOH result in equitable maternal care and improved patient health outcomes for pregnant individuals living with diabetes. KEY POINTS: · SDOH are conditions in which people are born, grow, work, live, and age.. · SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes.. · SDOH can be measured at the individual and neighborhood level.. · Adverse SDOH are associated with worse outcomes for pregnant individuals living with diabetes.. · Interventions that mitigate adverse SDOH to improve maternal health equity and outcomes are needed..

Exploring the impact of the environment on physical activity in patients with chronic obstructive pulmonary disease (EPCOT)-A comparative analysis between suggested and free walking: Protocol study

BACKGROUND

Individuals with chronic obstructive pulmonary disease (COPD) exhibit reduced levels of physical activity, which are associated with poorer outcomes. The number of clinical trials aiming to promote behavioral changes to increase physical activity in this population has grown; therefore, these trials have yet to produce satisfactory results. An ecological model encompassing individual, social, environmental, and political factors represent a potentially more effective approach to promoting physical activity. While favorable urban environments can positively impact physical activity, specifically tailored environmental interventions for individuals with COPD could enhance their engagement in physical activity. Therefore, the aim of this randomized controlled trial (RCT) study was to analyze the effects of walking in a suggested environment and free walking on physical activity levels in individuals with COPD.

METHODS

The environment on physical activity for chronic obstructive disease (EPCOT) is a randomized controlled clinical trial protocol approved by our institution's Ethics Committee and registered with The Brazilian Registry of Clinical Trials (ReBEC) (https://ensaiosclinicos.gov.br, number RBR-4tfwdhp). This protocol will involve 38 volunteers diagnosed with COPD recruited from the pulmonary physiotherapy and rehabilitation service. The volunteers were randomly divided into two walking groups: an experimental group (ERG) with guidance for walking in a suggested environment and an active control group (ACG) instructed to choose their own routes. The intervention consisted of eight consecutive weeks, with progressive walks carried out 3 to 5 times weekly. The primary outcome will be assessing participants' physical activity levels. Secondary outcomes will include exercise capacity, quality of life, dyspnea levels, motivation, anxiety, depression, and perceptions of the environment. All assessments will occur before and after the intervention period, aiming to fill a literature gap by investigating the impact of urban environments on COPD-related physical activity. The results may shed light on the importance of environmental factors in promoting physical activity among individuals with COPD, helping to develop more effective interventions.

Validation of the physical activity neighborhood environment scale using geographic information systems among urban men and women in regional China

Aims

To examine the concurrent validity of the Chinese version of Physical Activity Neighborhood Environment Scale (PANES-CHN) among urban adults in regional China.

Methods

With multistage sampling approaches, 801 eligible urban adults aged 35-74 years were recruited from Nanjing municipality of China between July and September of 2019. The neighbourhood built environment features were measured subjectively with PANES-CHN and objectively with geographic information system. The concurrent validity of PANES was assessed using Spearman's correlations (rs).

Results

Among the total 801 participants, the mean age was 54.4 (standard deviation = 11.5), while 48.7 % were men. Overall, of all the five objectively-measurable built environment characteristics, the Spearman correlations were examined significant between subjective and objective measurements for commercial facilities (item 2) (rs = 0.19, 95CI%=0.12, 0.25), recreational facilities (item 6) (rs = 0.10, 95CI%=0.02, 0.16), traffic junctions (item 12) (rs = 0.15, 95CI%=0.07, 0.22), medical/education facilities (item 17) (rs = 0.22, 95CI%=0.15, 0.29), but not for public transport stops. Similar scenarios were observed for participants aged 35-60 years, with sufficient physical activity, men or women. The rs value for medical/education facilities (item 17) was significantly higher in participants aged 35-59 years (0.28 vs. 0.13; p = 0.04) than those aged 60 + years.

Conclusions

PANES-CHN generally has an acceptable validity for assessing built environment characteristics among urban adults in China, which implies that PANES-CHN can be used to measure built environment attributes in health-related population studies.

Neighborhood built environment, obesity, and diabetes: A Utah siblings study

Background

This study utilizes innovative computer vision methods alongside Google Street View images to characterize neighborhood built environments across Utah.

Methods

Convolutional Neural Networks were used to create indicators of street greenness, crosswalks, and building type on 1.4 million Google Street View images. The demographic and medical profiles of Utah residents came from the Utah Population Database (UPDB). We implemented hierarchical linear models with individuals nested within zip codes to estimate associations between neighborhood built environment features and individual-level obesity and diabetes, controlling for individual- and zip code-level characteristics (n = 1,899,175 adults living in Utah in 2015). Sibling random effects models were implemented to account for shared family attributes among siblings (n = 972,150) and twins (n = 14,122).

Results

Consistent with prior neighborhood research, the variance partition coefficients (VPC) of our unadjusted models nesting individuals within zip codes were relatively small (0.5%-5.3%), except for HbA1c (VPC = 23%), suggesting a small percentage of the outcome variance is at the zip code-level. However, proportional change in variance (PCV) attributable to zip codes after the inclusion of neighborhood built environment variables and covariates ranged between 11% and 67%, suggesting that these characteristics account for a substantial portion of the zip code-level effects. Non-single-family homes (indicator of mixed land use), sidewalks (indicator of walkability), and green streets (indicator of neighborhood aesthetics) were associated with reduced diabetes and obesity. Zip codes in the third tertile for non-single-family homes were associated with a 15% reduction (PR: 0.85; 95% CI: 0.79, 0.91) in obesity and a 20% reduction (PR: 0.80; 95% CI: 0.70, 0.91) in diabetes. This tertile was also associated with a BMI reduction of -0.68 kg/m2 (95% CI: -0.95, -0.40).

Conclusion

We observe associations between neighborhood characteristics and chronic diseases, accounting for biological, social, and cultural factors shared among siblings in this large population-based study.

The clinical complexity among patients with systemic, chronic diseases

OBJECTIVES

This study aimed to assess the clinical complexity of patients with chronic systemic diseases (systemic lupus erythematosus [SLE] and ANCA-associated vasculitis [AAV]) using the INTERMED Self-Assessment questionnaire (IMSA) to determine the most important factors responsible for this phenomenon in these patients.

METHODS

This was a cross-sectional, observational study. Questionnaires were used to evaluate biopsychosocial complexity (IMSA), quality of life (Short Form Survey [SF-36]), mental state (General Health Questionnaire - 28 [GHQ-28] and Hospital Anxiety and Depression Scale [HADS]), and acceptance of illness (Acceptance of Illness Scale [AIS]).

RESULTS

The final analysis included 81 patients. There was a moderate correlation between clinical complexity (total IMSA score) and quality of life related to mental health (SF-36) and mental state (GHQ-28) in patients with SLE. However, in patients with AAV, clinical complexity had a strong relationship with physical health-related quality of life and a moderate relationship with mental health-related quality of life. Stepwise regression analysis showed that low mental health-related quality of life is a predictor of higher complexity in SLE. The predictors of high clinical complexity in AAV were low physical and mental health-related quality of life and aggravated depressive symptoms (HADS). Other principal factors of clinical complexity were employment status, place of residence, social functioning, and illness duration.

CONCLUSION

This study confirmed the importance of holistic attitudes and complex healthcare among patients with chronic diseases.

Discriminant analysis of ecological factors influencing sarcopenia in older people in South Korea

This study aimed to investigate the ecological system factors that influence discrimination of sarcopenia among older individuals living in contemporary society. Data analysis included information from 618 older adults individuals aged 65 years or older residing in South Korea. To assess variations in ecological system factors related to SARC-F scores, we conducted correlation analysis and t-tests. Discriminant analysis was used to identify factors contributing to group discrimination. The key findings are summarized as follows. First, significant differences at the p < 0.001 level were observed between the SARC-F score groups in various aspects, including attitudes toward life, wisdom in life, health management, social support, media availability, sports environment, collectivist values, and values associated with death. Further, service environment differences were significant at p < 0.01 level, while social belonging and social activities exhibited significance at p < 0.05. Second, factors influencing group discrimination based on the SARC-F scores were ranked in the following order: health management, attitudes toward life, fear of own death, wisdom in life, physical environment, sports environment, media availability, social support, fear of the own dying, collectivist values, service environment, social activities, and social belonging. Notably, the SARC-F tool, which is used for sarcopenia discrimination, primarily concentrates on physical functioning and demonstrates relatively low sensitivity. Therefore, to enhance the precision of sarcopenia discrimination within a score-based group discrimination process, it is imperative to incorporate ecological system factors that exert a significant influence. These modifications aimed to enhance the clarity and precision of the text in an academic context.

A qualitative exploration of facilitators and barriers to adopting a healthy lifestyle among Black, Hispanic, and American Indian males with diabetes or at risk for type 2 diabetes

OBJECTIVES

Higher prevalence of several chronic diseases occurs in men in the United States, including diabetes and prediabetes. Of the 34 million adults with diabetes and 88 million with prediabetes there is a higher prevalence of both conditions in men compared to women. Black, Hispanic, and American Indian men have some of the highest rates of diabetes and diabetes complications. Adopting a healthy lifestyle including healthy eating and physical activity, is important in preventing type 2 diabetes and diabetes complications.

DESIGN

This study included six focus groups that explored facilitators and barriers to adopting a healthy lifestyle in Black, Hispanic, and American Indian men with diabetes or at risk for type 2 diabetes. Thematic analysis was used to identify facilitators and barriers to adopting a healthy lifestyle.

RESULTS

Participants included males 18 years of age and older identifying as Black, Hispanic, or American Indian and diagnosed with prediabetes, diabetes, hypertension, or otherwise at risk for type 2 diabetes. Thirty-seven men participated, 19 diagnosed with diabetes and 18 at risk for type 2 diabetes. Fourteen Black, 14 Hispanic, and 9 American Indian men participated. The themes of facilitators to a healthy lifestyle included: family and the social network; psychosocial factors; health status, health priorities and beliefs about aging; knowledge about health and healthy behavior; and healthy community resources. Themes of barriers to a healthy lifestyle also included: mistrust of the health care system, cost, and low socioeconomic status.

CONCLUSIONS

This study underscores the complexity of factors involved in adopting a healthy lifestyle for some racial and ethnic minority men with diabetes or at risk for type 2 diabetes.

Association between area-level walkability and glycated haemoglobin: a Portuguese population-based study

Diabetes poses a substantial disease burden, prompting preventive interventions. Physical inactivity, a major risk factor for type 2 diabetes, can potentially be mitigated by enhancing area-level walkability. Despite this, limited population-based studies have investigated the link between walkability and objective diabetes measures. Our study aims to estimate the association between area-level walkability and individual glycated haemoglobin levels in the Portuguese adult population without the diagnosis of diabetes. Data from the 2011 census and an updated street map were obtained to construct a walkability index based on residential density, land-use mix, and street connectivity. Individual health data were sourced from The National Health Examination Survey (INSEF) 2015, a representative survey of the Portuguese adult population. Gamma regression was employed for estimation of the main associations, revealing that residing in moderately walkable areas significantly reduced average glycated haemoglobin levels (Exp(β) = 0.906; 95% CI: 0.821, 0.999) compared to the least walkable areas. The association was less pronounced and not statistically significant for the third tertile of walkability (Exp(β) = 0.919; 95% CI: 0.822, 1.028). Our findings highlight a nonlinear protective association between walkability and glycated haemoglobin, emphasizing the potential policy implications for urban planning, diabetes prevention, and health promotion.

Food deserts exposure, density of fast-food restaurants, and park access: Exploring the association of food and recreation environments with obesity and diabetes using global and local regression models

To prevent obesity and diabetes environmental interventions such as eliminating food deserts, restricting proliferation of food swamps, and improving park access are essential. In the United States, however, studies that examine the food and park access relationship with obesity and diabetes using both global and local regression are lacking. To guide county, state, and federal policy in combating obesity and diabetes, there is a need for cross-scale analyses to identify that relationship at national and local levels. This study applied spatial regression and geographically weighted regression to the 3,108 counties in the contiguous United States. Global regression show food deserts exposure and density of fast-food restaurants have non-significant association with obesity and diabetes while park access has a significant inverse association with both diseases. Geographically weighted regression that takes into account spatial heterogeneity shows that, among southern states that show high prevalence of obesity and diabetes, Alabama and Mississippi stand out as having opportunity to improve park access. Results suggest food deserts exposure are positively associated with obesity and diabetes in counties close to Alabama, Georgia, and Tennessee while density of fast-food restaurants show positive association with two diseases in counties of western New York and northwestern Pennsylvania. These findings will help policymakers and public health agencies in determining which geographic areas need to be prioritized when implementing public interventions such as promoting healthy food access, limiting unhealthy food options, and increasing park access.

Neighborhood built and food environment in relation to glycemic control in people with type 2 diabetes in the moving to health study

OBJECTIVE

To examine whether built environment and food metrics are associated with glycemic control in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We included 14,985 patients with type 2 diabetes using electronic health records from Kaiser Permanente Washington. Patient addresses were geocoded with ArcGIS using King County and Esri reference data. Built environment exposures estimated from geocoded locations included residential unit density, transit threshold residential unit density, park access, and having supermarkets and fast food restaurants within 1600-m Euclidean buffers. Linear mixed effects models compared mean changes of HbA1c from baseline at 1, 3 (primary) and 5 years by each built environment variable.

RESULTS

Patients (mean age = 59.4 SD = 13.2, 49.5% female, 16.6% Asian, 9.8% Black, 5.5% Latino/Hispanic, 57.1% White, 20% insulin dependent, mean BMI = 32.7±7.7) had an average of 6 HbA1c measures available. Participants in the 1st tertile of residential density (lowest) had a greater decline in HbA1c (-0.42, -0.43, and -0.44 in years 1, 3, and 5 respectively) than those in the 3rd tertile (HbA1c = -0.37 at 1- and 3-years and -0.36 at 5-years; all p-values <0.05). Having any supermarkets within 1600 m of home was associated with a greater decrease in HbA1c at 1-year and 3-years compared to having none (all p-values <0.05).

CONCLUSIONS

Lower residential density and better proximity to supermarkets may benefit HbA1c control in people with people with type 2 diabetes. However, effects were small and indicate limited clinical significance.

Association of residential land cover and wheezing among children and adolescents: A cross-sectional study in five provinces of China

The association between residential land cover (RLC) and wheezing remains poorly understood. This study aimed to investigate the association between RLC and wheezing in childhood and adolescence. A cross-sectional survey was conducted among children and adolescents in five provinces of China. Land cover data were obtained from the Cross-Resolution Land-Cover mapping framework based on noisy label learning, classifying land cover into five categories: cropland, forest, grass/shrubland, wetland, and impervious. Generalized linear mixed models were employed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of wheezing. Mediation analysis was employed to investigate whether ambient particulate matter (PM2.5) acts as a mediator in the association between RLC and wheezing. A total of 12,875 participants were included in the study, comprising 318 patients and 12,557 controls. Cropland500m was significantly associated with decreased odds of wheezing (OR: 0.929, 95% CI: 0.879-0.982), while impervious surfaces500m significantly was associated with increased odds of wheezing (OR: 1.056, 95% CI: 1.019-1.096) in all participants. In the stratified analysis, significant differences were found in the main outcomes between the adolescence group (age ≥10 years) and the childhood group (age <10 years) (Pinteraction < 0.05), while no significant differences were observed between the southern and northern regions, or between male and female respondents. Mediation analysis revealed that PM2.5 partially mediated the association between cropland500m and impervious surfaces500m with wheezing. RLC plays a significant role in wheezing during childhood and adolescence, with cropland offering protection and impervious surfaces posing a heightened risk.

Exploring the provision, efficiency and improvements of urban green spaces on accessibility at the metropolitan scale

Accurately assessing urban green space (UGS) accessibility and proposing effective and specific proposals for UGS provision improvement accordingly is vital to urban development. Taking the metropolitan of Shanghai, China as the study site, this study first assessed its UGS provision by improved multiple step floating catchment area methods and multiple indexes, including UGS accessibility, theoretical capacity, potential demand, and traffic supply. Second, it investigated the impacts on citywide UGS accessibility justice for each UGS by comparing Gini index differences of citywide UGS accessibility between the conditions when exist and non-exist for each UGS. Third, it used ternary plots to explore the influence mechanism of the factors of UGS theoretical capacity, potential demand, and traffic supply on accessibility, and introduced an RGB color triangle to spatially and simultaneously display the effects of these three factors on accessibility for each UGS in Shanghai. Fourth, it assessed and classified the UGS provision efficiency for accessibility according to the relationships among the theoretical capacity, potential demand, and traffic supply factors by 3D scatter plot. Fifth, it proposed specific types and priorities of requirement for UGS improvement according to its impact on citywide UGS accessibility justice and the effect of its theoretical capacity factor on UGS accessibility. The findings showed that UGS accessibility and its three factors in Shanghai were correlative and had a spatial clustering trend in central city areas. The majority of UGSs showed positive impact on citywide accessibility justice, which went up with the values of accessibility and the three factors. Most UGSs were dominated by theoretical capacity power. The UGS provision efficiency was relatively good for most UGSs, which had relatively well-matched conditions and demands. The improvement requirements for UGSs on accessibility investigated in this study will improve UGS provision.

Community-level social determinants of health and pregestational and gestational diabetes

BACKGROUND

Individual adverse social determinants of health are associated with increased risk of diabetes in pregnancy, but the relative influence of neighborhood or community-level social determinants of health is unknown.

OBJECTIVE

This study aimed to determine whether living in neighborhoods with greater socioeconomic disadvantage, food deserts, or less walkability was associated with having pregestational diabetes and developing gestational diabetes.

STUDY DESIGN

We conducted a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be. Home addresses in the first trimester were geocoded at the census tract level. The exposures (modeled separately) were the following 3 neighborhood-level measures of adverse social determinants of health: (1) socioeconomic disadvantage, defined by the Area Deprivation Index and measured in tertiles from the lowest tertile (ie, least disadvantage [T1]) to the highest (ie, most disadvantage [T3]); (2) food desert, defined by the United States Department of Agriculture Food Access Research Atlas (yes/no by low income and low access criteria); and (3) less walkability, defined by the Environmental Protection Agency National Walkability Index (most walkable score [15.26-20.0] vs less walkable score [<15.26]). Multinomial logistic regression was used to model the odds of gestational diabetes or pregestational diabetes relative to no diabetes as the reference, adjusted for age at delivery, chronic hypertension, Medicaid insurance status, and low household income (<130% of the US poverty level).

RESULTS

Among the 9155 assessed individuals, the mean Area Deprivation Index score was 39.0 (interquartile range, 19.0-71.0), 37.0% lived in a food desert, and 41.0% lived in a less walkable neighborhood. The frequency of pregestational and gestational diabetes diagnosis was 1.5% and 4.2%, respectively. Individuals living in a community in the highest tertile of socioeconomic disadvantage had increased odds of entering pregnancy with pregestational diabetes compared with those in the lowest tertile (T3 vs T1: 2.6% vs 0.8%; adjusted odds ratio, 2.52; 95% confidence interval, 1.41-4.48). Individuals living in a food desert (4.8% vs 4.0%; adjusted odds ratio, 1.37; 95% confidence interval, 1.06-1.77) and in a less walkable neighborhood (4.4% vs 3.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.04-1.71) had increased odds of gestational diabetes. There was no significant association between living in a food desert or a less walkable neighborhood and pregestational diabetes, or between socioeconomic disadvantage and gestational diabetes.

CONCLUSION

Nulliparous individuals living in a neighborhood with higher socioeconomic disadvantage were at increased odds of entering pregnancy with pregestational diabetes, and those living in a food desert or a less walkable neighborhood were at increased odds of developing gestational diabetes, after controlling for known covariates.

Self-regulation of effort for a better health-related quality of life: a multidimensional activity pacing model for chronic pain and fatigue management

PURPOSE

To propose a comprehensive multidimensional model of activity pacing that improves health-related quality of life and promotes sustained physical activity engagement among adults with chronic conditions.

MATERIALS AND METHODS

A narrative review was conducted to examine the existing literature on activity pacing, health-related quality of life, pain and fatigue management, and physical activity promotion in chronic conditions.

RESULTS

The literature revealed a lack of a cohesive approach towards a multidimensional model for using activity pacing to improve health-related quality of life. A comprehensive multidimensional model of activity pacing was proposed, emphasizing the importance of considering all aspects of pacing for sustained physical activity engagement and improved health-related quality of life. The model incorporates elements such as rest breaks, self-regulatory skills, environmental factors, and effective coping strategies for depression/anxiety. It takes into account physical, psychological, and environmental factors, all of which contribute significantly to the enhancement of health-related quality of life, physical function, and overall well-being, reflecting a holistic approach.

CONCLUSIONS

The model offers guidance to researchers and clinicians in effectively educating patients on activity pacing acquisition and in developing effective interventions to enhance physical activity engagement and health outcomes among adults with chronic conditions. Additionally, it serves as a tool towards facilitating discussions on sustained physical activity and a healthy lifestyle for patients, which can eventually lead to improved quality of life.

The association of work physical activity and recreational physical activity with periodontitis in the NHANES (2009-2014)

BACKGROUND

The aim of this study was to investigate the association between different types and intensity of physical activities (PA) and periodontitis in a nationally representative sample of adults in the United States.

METHODS

The data of periodontal condition and PA of 10,714 individuals were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014 and the Global Physical Activity Questionnaire (GPAQ). The association between the prevalence of periodontitis and two PAs (work PA and recreational PA) was respectively analyzed and adjusted by uni- and multi-variable logistic regression models. The odd ratios (ORs), adjusted odd ratios (ORad ), and 95% confidence interval (95% CI) were calculated as the main outcome indicators.

RESULTS

After adjusted by age, sex, race, poverty-income ratio (PIR), diabetes, smoking status, alcohol use, and floss frequency, moderate and vigorous work PAs were significantly correlated with higher odds of periodontitis (ORad  = 1.22, 95% CI = 1.02-1.46; ORad  = 1.40, 95% CI = 1.04-1.89, respectively) while moderate and vigorous recreational PAs were correlated with lower odds of periodontitis (ORad  = 0.81, 95% CI = 0.69-0.95; ORad  = 0.55, 95% CI = 0.43-0.71, respectively).

CONCLUSIONS

Work PAs and recreational PAs have opposite associations on the prevalence of developing periodontitis and their aggravating or protective associations enhance with the increase of intensity.

Effects of Community Environment, Leisure, and Social Activities on Health Status of Older Adults with Diabetes in South Korea

This study investigates the effects of community environment, leisure, and social activities on the health status of older adults with diabetes, a serious disease in modern society. Data from the 2020 National Survey of Older Koreans were analyzed. Descriptive statistics were used to assess participants' characteristics, and regression analyses were conducted to assess the effects of community environment, leisure, and social activities. Mediating effects were tested using hierarchical regression analysis and bootstrapping. The key results are as follows. (a) Community environmental satisfaction affected participation in leisure and social activities. (b) Community accessibility had a negative effect on subjective health, while community environmental satisfaction had a positive effect on subjective health, cognitive function, and chronic diseases. (c) Leisure activities had a positive effect on cognitive health, while social activities influenced subjective health, cognitive function, and chronic diseases. (d) Analysis of the mediating effect of leisure and social activities on the relationship between the community environment and health status of older adults with diabetes confirmed a partial mediating effect. To improve older adults' mental and physical health, mere quantitative increases in the community environment will not be sufficient. It is necessary to cultivate and manage professionals to increase opportunities for participation by increasing social exchanges and systematically managing older adults' health.

Premature mortality attributable to NO2 exposure in cities and the role of built environment: A global analysis

BACKGROUND

Environmental risks accumulate in cities, including polluted air and health disparities, but these risks can be reduced through scientific city planning. The purpose of this study was to investigate the global burden of premature mortality attributable to NO₂ exposure in urban areas and the role of the built environment in this regard.

METHODS

An approach based on health impact assessment was used to estimate the premature mortality burdens associated with NO₂ exposure in 13,169 urban areas around the world using globally gridded NO₂ and population estimates, baseline mortality, and epidemiologically derived exposure-response functions. We used the most recent WHO recommended value (i.e.,10 μg/m³) as a counterfactual concentration. Finally, the relationship between the characteristics of the built environment at the city level and the burden of NO₂-related mortality was evaluated.

RESULTS

Worldwide, 549,715(95%CI: 276204-815,023) cases of death attributable to NO₂ exposure in urban areas could be prevented if compliance with the latest WHO guideline, accounting for 2.7 % (95%CI:1.4 %-4.0 %) of total mortalities in 2019. Across cities around the world, the age-standardized mortality rate (per 100,000 people) attributable to NO₂ exposure ranged from 51.3 (95%CI:25.8-76.0) in Central Asia to 3.4(95%CI: 1.7-5.1) in Oceania. Although there was a significant decrease in premature mortality attributable to NO₂ exposure globally, considerable regional heterogeneity exists, with cities in Central Asia and Andean Latin America in particular exhibiting an upward trend. Further, we discovered a positive association between population density and street connectivity with mortality attributable to NO₂. While the increase in green and blue space were significantly associated with a lower NO₂-associated mortality.

CONCLUSION

The findings of this study provided a comprehensive understanding of the premature mortality burden due to NO₂ in cities throughout the world and the role that urban planning policies can play in reducing the health burden associated with air pollution.

Association of community walkability and glycemic control among pregnant individuals with pregestational diabetes mellitus

BACKGROUND

Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined.

OBJECTIVE

This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes.

STUDY DESIGN

This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type.

RESULTS

Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability.

CONCLUSION

Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.

The relationship between physical activity and diabetes in middle-aged and elderly people

To investigate the association between diabetes symptoms and physical activity (PA) levels among middle-aged and older Chinese adults. Data for this study were obtained from 2018 Charles data. Z test, logistic regression analysis, and linear hierarchical regression analysis were performed in 5352 individuals aged ≥50 years with complete information. In terms of diabetes, 6.8% of the middle-aged and elderly people with diabetes were detected, and 93.2% of the middle-aged and elderly people without diabetes symptoms. The proportion of middle-aged and elderly people with high PA levels was 50.5%, and the proportion of middle-aged and elderly people with low PA was 49.5%. There was a significant positive correlation between low PA and diabetes (P < .05). After adjusting demographic characteristics (gender, registered permanent residence type, education level, age, widowhood) and health status characteristics (poor mood, asthma, hyperlipidemia, disability, memory disease, self-assessment of health status, hypertension, smoking, stroke, depression), there was still a statistical significance between PA level and diabetes (P < .05). The risk of diabetes of middle-aged and elderly people in China increases with age, while the risk of diabetes of middle-aged and elderly people with low level of PA is higher. The risk of diabetes is high among middle-aged and elderly people who are old, have poor self-evaluation health, suffer from hyperlipidemia, memory disease, and asthma. The middle-aged and old people should increase their PA levels to prevent and improve diabetes.

Higher walkability associated with increased physical activity and reduced obesity among United States adults

OBJECTIVE

This study examined associations among perceived neighborhood walkability, physical activity (PA), and obesity among United States adults.

METHODS

Data from the 2020 National Health Interview Survey were analyzed. Walkability was assessed using a summative scale and was categorized as low, medium, or high. PA was categorized as insufficient (0-149 min/wk) or sufficient (150+ min/wk). Multivariable regressions estimated an association between obesity and BMI and PA/walkability. Mediation analysis was used to partition contribution of PA as a mediator. Effect modification by race and ethnicity in the association between walkability and BMI was explored.

RESULTS

The sample included N = 31,568 adults. Compared with those in low-walkability neighborhoods, participants in high-walkability neighborhoods had increased odds of sufficient PA (odds ratio [OR] = 1.48; 95% CI: 1.30-1.69) and decreased obesity odds (OR = 0.76; 95% CI: 0.66-0.87). PA partially mediated the association between walkability and BMI (23.4%; 95% CI: 14.6%-62.7%). The association between walkability and BMI was modified by race and ethnicity (F[5,567]  = 2.75; p = 0.018). Among White, Black, Hispanic, and Asian adults, BMI decreased with increasing walkability; among American Indian/Alaska Native and multiracial/other adults, BMI increased with increasing walkability.

CONCLUSIONS

The findings highlight the importance of investing in the built environment to improve perceptions of walkability and promote PA and healthy weight, as well as developing interventions to target racial and ethnic disparities in these outcomes.

Exploring the understanding of how parenting influences the children's nutritional status, physical activity, and BMI

Aim

Parental behaviors and the home environment are two of the most effective ways to adopt healthy eating and active lifestyles. For this reason, it is crucial to understand children's nutritional habits, analyze the dynamics related to parental factors, diagnose and treat childhood obesity in the early period, and prevent adulthood obesity. This study aimed to explore how parenting influences children's nutritional status, physical activity, and BMI.

Methods

The study involved 596 children with their parents. The data were collected through face-to-face interviews using the survey method. The survey consists of descriptive information (age, gender, educational status), anthropometric measurements, nutritional habits, Family Nutrition and Physical Activity Scale (FNPA), International Physical Activity Questionnaire, and 24-h dietary recall. The Mean Adequacy Ratio (MAR) was applied to assess dietary adequacy.

Results

Most mothers and fathers were overweight or obese (61.6 and 68.7%, respectively). 38.6% of boys and 23.1% of girls were overweight or obese. The FNPA score was positively correlated with MAR (p < 0.05). Multiple linear regression analysis revealed that children's BMI was negatively correlated with FNPA score, while maternal BMI and father's BMI were positively correlated (p < 0.05). Furthermore, dietary energy was not associated with the child's BMI but with dietary adequacy (p < 0.05). There was no evidence that family impacted children's physical activity.

Conclusion

This study supports that parenting influences children's dietary intake and BMI. Adequate and balanced nutrition, regardless of dietary energy, may affect children's body weight. Family plays a significant role in influencing and forming children's lifestyle-related behaviors. Children's healthy eating and physical exercise habits can be encouraged through school-based programs involving families.

Relationship between Built-Up Environment, Air Pollution, Activity Frequency and Prevalence of Hypertension-An Empirical Analysis from the Main City of Lanzhou

In the process of promoting the strategy of a healthy China, the built environment, as a carrier of human activities, can effectively influence the health level of residents in the light of its functional types. Based on the POI data of four main urban areas in Lanzhou, this paper classifies the built environment in terms of function into four types. The association between different types of built environments and the prevalence of hypertension was investigated by using the community as the study scale, and activity frequency, air pollution and green space were used as mediating variables to investigate whether they could mediate the relationship between built environments and hypertension. The results indicate that communities with a high concentration of commercial service facilities, road and traffic facilities and industrial facilities have a relatively high prevalence of hypertension. By determining the direct, indirect and overall effects of different functional types of built environment on the prevalence of hypertension, it was learned that the construction of public management and service facilities can effectively mitigate the negative effects of hypertension in the surrounding residents. The results of the study contribute to the rational planning of the structure of the built environment, which is beneficial for optimizing the urban structure and preventing and controlling chronic diseases such as hypertension.

The Canadian Environmental Quality Index (Can-EQI): Development and calculation of an index to assess spatial variation of environmental quality in Canada's 30 largest cities

BACKGROUND

Multiple characteristics of the urban environment have been shown to influence population health and health-related behaviours, though the distribution and combined effects of these characteristics on health is less understood. A composite measure of multiple environmental conditions would allow for comparisons among different urban areas; however, this measure is not available in Canada.

OBJECTIVES

To develop an index of environmental quality for Canada's largest urban areas and to assess the influence of population size on index values.

METHODS

We conducted a systematic search of potential datasets and consulted with experts to refine and select datasets for inclusion. We identified and selected nine datasets across five domains (outdoor air pollution, natural environments, built environments, radiation, and climate/weather). Datasets were chosen based on known impacts on human health across the life course, complete geographic coverage of the cities of interest, and temporal alignment with the 2016 Canadian census. Each dataset was then summarized into dissemination areas (DAs). The Canadian Environmental Quality Index (Can-EQI) was created by summing decile ranks of each variable based on hypothesized relationships to health outcomes.

RESULTS

We selected 30 cities with a population of more than 100,000 people which included 28,026 DAs and captured approximately 55% of the total Canadian population. Can-EQI scores ranged from 21.1 to 88.9 out of 100, and in Canada's largest cities were 10.2 (95% CI: -10.7, -9.7) points lower than the smallest cities. Mapping the Can-EQI revealed high geographic variability within and between cities.

DISCUSSION

Our work demonstrates a valuable methodology for exploring variations in environmental conditions in Canada's largest urban areas and provides a means for exploring the role of environmental factors in explaining urban health inequalities and disparities. Additionally, the Can-EQI may be of value to municipal planners and decision makers considering the allocation of investments to improve urban conditions.

Cross-sectional associations between neighbourhood walkability and objective physical activity levels in identical twins

OBJECTIVES

Physical activity is a cornerstone of chronic disease prevention and treatment, yet most US adults do not perform levels recommended for health. The neighborhood-built environment (BE) may support or hinder physical activity levels. This study investigated whether identical twins who reside in more walkable BEs have greater activity levels than twins who reside in less walkable BEs (between-twin analysis), and whether associations remain significant when controlling for genetic and shared environmental factors (within-twin analysis).

DESIGN

A cross-sectional study.

SETTING

The Puget Sound region around Seattle, Washington, USA.

PARTICIPANTS

The sample consisted of 112 identical twin pairs who completed an in-person assessment and 2-week at-home measurement protocol using a global positioning system (GPS)monitor and accelerometer.

EXPOSURE

The walkability of each participants' place of residence was calculated using three BE dimensions (intersection density, population density and destination accessibility). For each variable, z scores were calculated and summed to produce the final walkability score.

OUTCOMES

Objectively measured bouts of walking and moderate-to-vigorous physical activity (MVPA), expressed as minutes per week.

RESULTS

Walkability was associated with walking bouts (but not MVPA) within the neighbourhood, both between (b=0.58, SE=0.13, p<0.001) and within pairs (b=0.61, SE=0.18, p=0.001). For a pair with a 2-unit difference in walkability, the twin in a more walkable neighbourhood is likely to walk approximately 16 min per week more than the co-twin who lives in a less walkable neighbourhood.

CONCLUSIONS

This study provides robust evidence of an association between walkability and objective walking bouts. Improvements to the neighbourhood BE could potentially lead to increased activity levels in communities throughout the USA.

How Do Different Urban Footpath Environments Affect the Jogging Preferences of Residents of Different Genders? Empirical Research Based on Trajectory Data

In recent years, the impact of the urban environment on residents' physical activity (PA) has received extensive attention, but whether this impact has differences in the jogging preferences of residents in different footpath environments and different genders requires further research. Therefore, based on jogging trajectory data, this paper uses the grouping multiple linear regression model to study the different influencing factors of different footpath environments on the jogging of residents of different genders. The results show that (1) jogging activities (JA) were mainly concentrated in the community footpath environment, and its peak was reached at night; (2) the rise and fall of elements in built environments, social environments, and natural environments significantly affected the relative jogging distance of residents; (3) Residential land density (RLD) has a positive impact on the JA of community and green land footpaths and has a negative impact on the JA of urban footpaths. However, arterial road density (ARD) and bus distance density (BDD) have opposite significant effects on the JA of communities and green land footpaths; (4) ARD has the significant opposite effect on the JA for residents of different genders on urban footpaths and community footpaths. Facilities diversity (FD), population density (PD), and bus stop density (BSD) also had significant opposite effects on the JA of residents of different genders on green land footpaths. In general, we put forward a method theory to identify the footpath environment and provide references for improving the layout and construction of different gender residents for different footpath environment elements.

The TROLLEY Study: assessing travel, health, and equity impacts of a new light rail transit investment during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic disrupted life in extraordinary ways impacting health and daily mobility. Public transit provides a strategy to improve individual and population health through increased active travel and reduced vehicle dependency, while ensuring equitable access to jobs, healthcare, education, and mitigating climate change. However, health safety concerns during the COVID-19 pandemic eroded ridership, which could have longstanding negative consequences. Research is needed to understand how mobility and health change as the pandemic recedes and how transit investments impact health and equity outcomes.

METHODS

The TROLLEY (TRansit Opportunities for HeaLth, Livability, Exercise and EquitY) study will prospectively investigate a diverse cohort of university employees after the opening of a new light rail transit (LRT) line and the easing of campus COVID-19 restrictions. Participants are current staff who live either < 1 mile, 1-2 miles, or  > 2 miles from LRT, with equal distribution across economic and racial/ethnic strata. The primary aim is to assess change in physical activity, travel mode, and vehicle miles travelled using accelerometer and GPS devices. Equity outcomes include household transportation and health-related expenditures. Change in health outcomes, including depressive symptoms, stress, quality of life, body mass index and behavior change constructs related to transit use will be assessed via self-report. Pre-pandemic variables will be retrospectively collected. Participants will be measured at 3 times over 2 years of follow up. Longitudinal changes in outcomes will be assessed using multilevel mixed effects models. Analyses will evaluate whether proximity to LRT, sociodemographic, and environmental factors modify change in outcomes over time.

DISCUSSION

The TROLLEY study will utilize rigorous methods to advance our understanding of health, well-being, and equity-oriented outcomes of new LRT infrastructure through the COVID-19 recovery period, in a sample of demographically diverse adult workers whose employment location is accessed by new transit. Results will inform land use, transportation and health investments, and workplace interventions. Findings have the potential to elevate LRT as a public health priority and provide insight on how to ensure public transit meets the needs of vulnerable users and is more resilient in the face of future health pandemics.

TRIAL REGISTRATION

The TROLLEY study was registered at ClinicalTrials.gov ( NCT04940481 ) June 17, 2021, and OSF Registries ( https://doi.org/10.17605/OSF.IO/PGEHU ) June 24, 2021, prior to participant enrollment.

Renal Health Benefits of Rural City Planning in Japan

Progression of chronic kidney disease (CKD) is a substantial threat because it is associated with reduced healthy life expectancy and quality of life, and increase in economic burden. Research indicates people with nondialysis CKD often have lower physical functioning and that improvement of physical activity may contribute to maintaining renal health. Another issue with the current treatment of CKD is that the synergistic effects of rural depopulation due to aging and uncontrolled rural city sprawling will increase the number of under-served healthcare areas. To ensure the quality of renal health care, hospital integration is desirable, under the condition of reconstruction of the public transport system for physically and socially vulnerable people. Recently, medical and non-medical scientists advocate the challenge of city planning for population health. The links between city design and health such as cardiovascular disease, obesity, type 2 diabetes and mental disorders, have been widely studied, except for renal health. Based on our experience in a Kidney and Lifestyle-related Disease Center, we propose the idea that city planning be prioritized to improve renal health through two main streams: 1) Improve physical status by use of public and active transportation including daily walking and cycling; and 2) Equal accessibility to renal health services. Many countries, including Japan, have enacted plans and public policy initiatives that encourage increased levels of physical activity. We should focus on the impact of such movement on renal as well as general health.