Local-Area Walkability and Socioeconomic Disparities of Cardiovascular Disease Mortality in Japan

Changes in neighbourhood walkability and incident CVD: A population-based cohort study of three million adults covering 24 years

BACKGROUND

To investigate the relationship between changes in residential neighbourhood walkability and cardiovascular disease (CVD) incidence in adults.

METHODS

Using data from Statistics Netherlands we included all Dutch residents aged 40 or older at baseline (2009), without a history of CVD, and who did not move house after baseline (n = 3,019,069). A nationwide, objectively measured walkability index was calculated for Euclidean buffers of 500m around residential addresses for the years 1996, 2000, 2003, 2006 and 2008. To identify changes in neighbourhood walkability, latent class trajectory modelling was applied. Incident CVD between 2009 and 2019 was assessed using the Dutch Hospital Discharge Register and the National Cause of Death Register. Cox proportional hazards modelling was used to analyse associations between walkability trajectories and subsequent CVD incidence, adjusted for individual- and area-level sociodemographic characteristics.

FINDINGS

We observed a stable but relatively low walkability trajectory (Stable low, 91.1 %), a stable but relatively higher walkability trajectory (Stable high, 0.6 %), a relatively higher initial neighbourhood walkability which decreased over time (Decreasing, 1.7 %), and relatively lower neighbourhood walkability which increased over time (Increasing, 6.5 %). Compared to stable high walkability, individuals exposed to stable low, and increasing walkability, had a 5.1 % (HR: 1.051; CI: 1.011 to 1.093) and 4.9 % (HR: 1.049; CI: 1.008 to 1.092) higher risk of any CVD. Similar associations were observed for coronary heart disease and stroke, though not statistically significant. No significant associations were found for heart failure, and CVD mortality.

CONCLUSION

Adults exposed to low walkability over time had a higher risk of CVD compared to those in stable high walkability neighborhoods. Additionally, an increasing walkability trend was associated with higher CVD risk, likely due to the overall lower cumulative walkability during the exposure period. These findings highlight the importance of longitudinal research in this field, and of long-term urban planning for cardiovascular health.

The application of neighborhood area deprivation index to improve health equity across the spectrum of heart failure: a review

Neighborhood environments play a key role in the development of individual risk factors for heart failure (HF) and impact health outcomes across the spectrum of HF. The area deprivation index (ADI) is an important composite measure of neighborhood depravity that has been associated with poor cardiovascular outcomes. The objective of our review is to discuss how neighborhood deprivation, with an emphasis on ADI, influences the spectrum of HF among patients and to propose solutions for ADI applications to improve the implementation of equitable care across the HF spectrum. MEDLINE/Pubmed was systematically searched to identify observational studies published between 2016 and 2024, examining the impact of ADI on HF risk, management, and outcomes. The search involved crossing two sets of terms included in article titles and abstracts: (1) social deprivation, area deprivation index, and neighborhood deprivation; (2) cardiovascular disease risk, heart failure, heart failure medications, and heart failure outcomes. Additional references were identified through searching relevant author reference lists and review articles. Key findings suggest that (1) the prevalence of HF risk is increased in individuals residing in neighborhoods with higher ADI; (2) HF patients living in more deprived neighborhoods have increased odds of being hospitalized for HF; (3) after HF admission, the relationship between ADI and risk for readmissions varies by race; and (4) there is an excess 30-day mortality of HF associated with race and neighborhood deprivation. The ADI is an important value to consider in patients with HF, given its association with clinical outcomes. Therefore, we suggest practical ways to incorporate ADI into the management of patients with HF to improve equitable outcomes.

Built Environment and Cardiovascular Diseases - Insights from a Global Review

PURPOSE OF REVIEW

This narrative review aims to synthesize global literature on the relationship between cardiovascular diseases (CVD) and components of built environment (green spaces, walkability, food environment, accessibility and availability of recreational and healthcare facilities, and effects of air and noise pollution).

RECENT FINDINGS

Increased green space and neighborhood walkability are associated with lower CVD mortality and morbidity; however, benefits have shown differential effects by socioeconomic status (SES). Air pollution is a leading environmental risk factor contributing to CVDs, and it disproportionately impacts low SES populations and women. Findings on relationships between food environment and CVDs are inconsistent and limited. This global review reports on the multifactorial and complex relationship between built environment and higher CVD risk and poor CVD outcomes. Future research can address an unmet need to understand this relationship with further depth and breadth, and to investigate resulting health disparities.

Exploring the relationship between neighborhood walkability and mental health: A study of urban areas in Texas

Background

While importance of walkable neighborhoods for health is increasingly recognized, the relationship between walkability and mental health remains, especially in urban settings, unclear. This study investigated the link between walkability and mental health in urban Texas. We hypothesized that higher neighborhood walkability would correlate with lower mental health encounters.

Methods

A cross-sectional study using Texas adult outpatient encounters from 2014 to 2019 supplemented by ZIP Code-level US-census socioeconomics data. Neighborhood walkability was assessed using the 2019-WalkScore (0-100) and was categorized into four groups: from completely car-dependent to very walkable/walker's paradise. Outpatient mental health encounters included depression, bipolar disorder, anxiety, and stress disorders. Generalized linear models were used to assess the association between walkability and mental health, while adjusting for demographics and socioeconomics.

Results

We included 55 million encounters from 751 Texas ZIP Codes (median WalkScore 28, 73 % < 65 years, 64 % women, 15 % Blacks, 16 % Hispanics, 15 % live in poverty, and 17 % without health insurance). Anxiety/stress disorders contributed to 68 % of the mental health encounters. The rate of mental health encounters was at least 3 times higher (5543 vs 1827 encounters per 100,000 population) (RR 3.03, 95%CI 1.53-6.03) in urban areas with the highest WalkScores, compared to lowest walkability neighborhoods. A similar pattern was found among depression (RR 4.8, 95%CI 2.45-9.46) and bipolar (RR 10.8, 95%CI 4.17-28.07) encounters. After adjusting for demographic and socioeconomic factors, the positive association remained significant for both depression (aRR 1.94, 95%CI 1.19-3.17) and bipolar (aRR 2.76, 95%CI 1.65-4.65) encounters, but not for total mental health encounters (aRR 1.22, 95%CI 0.76-1.96, P = 0.416).

Conclusion

The study findings challenge our initial hypothesis, revealing a positive association between neighborhood walkability and various mental health encounters, emphasizing the complex intersection between urban environment and mental health. This suggests that walkability does not solely determine mental health outcomes. A deeper understanding of how demographics, socioeconomic factors, and neighborhood characteristics interact is essential to inform policies that create more equitable mentally-healthy cities.

Interaction between walkability and fine particulate matter on ischemic heart disease: A prospective cohort study in China

BACKGROUND

Previous studies have suggested that neighborhoods characterized by higher walkability are related to a reduced risk of ischemic heart disease (IHD), whereas exposure to PM2.5 is positively associated with risk of IHD. Nevertheless, their joint impact on IHD warrants further investigation.

METHODS

This prospective cohort study was performed in Yinzhou, Ningbo, China, comprising 47,516 participants. Individual-level walkability and PM2.5 were evaluated using a commercial walkability database and a land use regression (LUR) model, respectively. Hazard ratios (HRs) and 95 % confidence intervals (95 % CIs) were calculated using two Cox proportional hazards models: one based on two-year average PM2.5 levels prior to baseline, and the other incorporating time-varying PM2.5 assessed on a monthly scale. Dose-response relationships were explored using restricted cubic spline (RCS) functions. Interactions on both additive and multiplicative scales were assessed via relative excess risk due to interaction (RERI) and likelihood-ratio tests. Joint effects were explored and visualized using a 3D wireframe plot.

RESULTS

Over a median follow-up of 5.14 years, 1735 incident cases of IHD were identified. Adjusted HRs (95 % CIs) were 1.56 (1.34-1.81) per 10 μg/m3 increase in PM2.5 and 0.96 (0.94-0.98) per 10-unit increase in walkability, with both exposures exhibiting non-linear dose-response relationships. Walkability and PM2.5 were positively correlated (rs = 0.12, P < 0.001), and a multiplicative interaction was detected (Pinteraction = 0.019).

CONCLUSION

Walkability was inversely associated with risk of IHD, whereas exposure to PM2.5 was positively associated with IHD. Notably, the pernicious effects of PM2.5 could be attenuated in areas with higher levels of walkability. Our findings underscore the significance of walkable urban design, air quality improvement, as preventive strategies for IHD.

Association of socioeconomic status and life's essential 8 with cardiovascular diseases and all-cause mortality in north China: Kailuan study

BACKGROUND

We aimed to explore the association of socioeconomic status (SES) and life's essential 8 (LE8) with cardiovascular disease (CVD) and all-cause mortality in north China.

METHODS

A total of 91,365 adults from the Kailuan study were included in this study. Comprehensive individual SES, mainly including monthly household income, education, Occupation position, and community environment, was confirmed by latent class analysis. Furthermore, the mediation and combination effects of SES and LE8 on CVD and all-cause mortality were further assessed. The Cox regression model was conducted to estimate HRs and 95% CI.

RESULTS

During about 13 years of follow-up, 7,646 cardiovascular events and 11,749 deaths were recorded. Relative to the high SES, there were decreased risks of CVD [HR (95% CI): 1.57(1.43-1.72)] and high all-cause death [HR (95% CI): 1.43(1.31-1.53)] in the low SES. The associations between SES and CVD [Mediation % (95% CI): 22.3 (16.4-30.4)] and mortality [Mediation % (95% CI): 10.1 (7.1-14.0)] were partially mediated by LE8 when comparing medium SES to high SES. Meanwhile, relative to high LE8, the elevated risk of death [HR (95% CI): 1.72(1.56-1.89)], and incident CVD [HR (95% CI): 3.34(2.91-3.83)] were detected in low LE8. Compared to participants who had the high SES and LE8, participants who had both the low SES and LE8 further increased the risk of CVD [HR (95% CI): 7.76(5.21-11.55)] and all-cause mortality [HR (95% CI): 2.80(2.19-3.58)].

CONCLUSION

Low SES was related to a higher risk of CVD and mortality in low- and middle-income countries, which was partially mediated by LE8.

Investigating the role of the built environment, socio-economic status, and lifestyle factors in the prevalence of chronic diseases in Mashhad: PLS-SEM model

Background

Chronic diseases remain a significant contributor to both mortality and disability in our modern world. Physical inactivity and an unhealthy diet are recognized as significant behavioral risk factors for chronic diseases, which can be influenced by the built environment and socio-economic status (SES). This study aims to investigate the relationship between the built environment, SES, and lifestyle factors with chronic diseases.

Methods

The current study was conducted in Mashhad's Persian cohort, which included employees from Mashhad University of Medical Sciences (MUMS). In the study, 5,357 participants from the cohort were included. To assess the state of the built environment in Mashhad, a Geographic Information System (GIS) map was created for the city and participants in the Persian Mashhad study. Food intake and physical exercise were used to assess lifestyle. A food frequency questionnaire (FFQ) was used to assess food intake. To assess food intake, the diet quality index was computed. To assess the link between variables, the structural model was created in accordance with the study's objectives, and partial least square structural equation modeling (PLS-SEM) was utilized.

Results

The chronic diseases were positively associated with male sex (p < 0.001), married (p < 0.001), and higher age (p < 0.001). The chronic diseases were negatively associated with larger family size (p < 0.05), higher SES (p < 0.001), and higher diet quality index (DQI) (p < 0.001). No significant relationship was found between chronic disease and physical activity.

Conclusion

Food intake and socioeconomic status have a direct impact on the prevalence of chronic diseases. It seems that in order to reduce the prevalence of chronic diseases, increasing economic access, reducing the class gap and increasing literacy and awareness should be emphasized, and in the next step, emphasis should be placed on the built environment.

Associations of perceived built environment characteristics using NEWS questionnaires with all-cause mortality and major cardiovascular diseases: The prospective urban rural epidemiology (PURE)-China study

BACKGROUND

Despite increased literature focusing on the role of the built environment (BE) in health, few cohort studies have quantitatively analyzed neighborhood walkability environment in relation to the risk of death and cardiovascular disease (CVD). This longitudinal study aimed at evaluating the association between perceived BE attributeswith mortality and major CVD based on the Prospective Urban Rural Epidemiology study in China (PURE-China).

METHODS

The PURE-China study recruited 47,931 participants aged 35-70 years from 12 provinces of China between 2005 and 2009. The perceived BE information, including land use, street, aesthetics, and safety, was collected using the neighborhood environment walkability scale (NEWS) questionnaire, with higher scores indicating a more favorable rating. Two primary outcomes are all-cause mortality and major CVD event. The Cox frailty model with random intercepts was used to assess the association between the perceived total BE/subscales score and outcomes.

RESULTS

Of 32,163 participants included in this study, 19,253 (59.9 %) were women, and the mean (SD) age was 51.0 (9.5) years. After a median follow-up period of 11.7 years (IQR 9.4 - 12.2), we observed that one standard deviation higher of combined BE scores was related to a lower risk of all-cause mortality (HR = 0.85; 95 %CI, 0.80-0.90), and major CVD events (HR = 0.95; 95 %CI, 0.90-0.99). The subscales of perceived BE were related to a lower risk, although a few were not significant. Land use mix-diversity and safety from crime were the two most significant subscales. Stronger risks were observed among urban and female participants.

CONCLUSION

Favorable perceived BE characteristics were linked with a lower risk of all-cause mortality and major CVD events in Chinese population, especially in urban areas and females. Our findings can be used by policymakers to take action to mitigate the adverse effect of poor community conditions on health, such as improving local amenities and transport connectivity, providing building paths for walking, running and cycling.

Neighborhood Walkability and Cardiovascular Risk in the United States

Neighborhood walkability may be associated with increased physical activity and thus may confer protection against cardiovascular disease and associated risk factors. We sought to characterize the association between neighborhood-level cardiovascular diseases and risk factors with neighborhood walkability across US census tracts.We linked the Centers for Disease Control and Prevention (CDC) PLACES dataset which provided census-tract level prevalence of coronary artery disease (CAD) and cardiovascular risk factors (hypertension, high cholesterol, obesity, and diabetes), with census tract population-weighted national walkability index (NWI) from the US Environmental Protection Agency (EPA). We calculated the mean prevalence of each cardiovascular health indicator per quartile of the walkability score. We also fit a multivariable linear regression model to estimate the association between walkability index and the prevalence of CAD adjusting for age, sex, race, and the CDC'S social vulnerability index, an integrated metric of socioeconomic position. We additionally performed mediation analyses to understand the mediating effects of CAD risk factors on the relationship between NWI and CAD prevalence. A total of 70,123 census tracts were analyzed nationwide. Across walkability quartiles Q1 (least walkable) through Q4 (most walkable), we found statistically significant decrease in the prevalence of CAD (7.0% to 5.4%), and risk factors including hypertension (35.5% to 29.7%), high cholesterol (34.5% to 29.2%), obesity (35.0% to 30.2%), and diabetes (11.6% to 10.6%). After multivariable adjustment, continuous walkability index was negatively and significantly associated with the prevalence of CAD (β = -0.09, P<0.0001). The relationship between NWI and CAD is partially mediated by the risk factors. High cholesterol accounted for 45%, high blood pressure 41% and diabetes 10% of the total effect of walkability on CAD. While direct relationship between walkability and CAD accounted for 9% of the total effect. This nationwide analysis demonstrates that neighborhood walkability is associated with a lower prevalence of cardiovascular risk factors and CAD. The association between NWI and CAD seems to be partly mediated by prevalence of traditional risk factors.

Favorable Neighborhood Walkability is Associated With Lower Burden of Cardiovascular Risk Factors Among Patients Within an Integrated Health System: The Houston Methodist Learning Health System Outpatient Registry

This is the first study to investigate the relationship between neighborhood walkability and cardiovascular (CV) risk factors in the United States using a large population-based database. Cross-sectional study using data from 1.1 million patients over the age of 18 in the Houston Methodist Learning Health System Outpatient Registry (2016-2022). Using the 2019 WalkScore, patients were assigned to one of the 4 neighborhood walkability categories. The burden of CV risk factors (hypertension, diabetes, obesity, dyslipidemia, and smoking) was defined as poor, average, or optimal (>3, 1-2, 0 risk factors, respectively). We included 887,654 patients, of which 86% resided in the two least walkable neighborhoods. The prevalence of CV risk factors was significantly lower among participants in the most walkable neighborhoods irrespective of ASCVD status. After adjusting for age, sex, race/ethnicity, and socioeconomic factors, we found that adults living in the most walkable neighborhoods were more likely to have optimal CV risk profile than those in the least walkable ones (RRR 2.77, 95% CI 2.64-2.91). We observed an inverse association between neighborhood walkability and the burden of CV risk factors. These findings support multilevel health system stakeholder engagements and investments in walkable neighborhoods as a viable tool for mitigating the growing burden of modifiable CV risk factors.

Impact of land use and food environment on risk of type 2 diabetes: A national study of veterans, 2008-2018

BACKGROUND

Large-scale longitudinal studies evaluating influences of the built environment on risk for type 2 diabetes (T2D) are scarce, and findings have been inconsistent.

OBJECTIVE

To evaluate whether land use environment (LUE), a proxy of neighborhood walkability, is associated with T2D risk across different US community types, and to assess whether the association is modified by food environment.

METHODS

The Veteran's Administration Diabetes Risk (VADR) study is a retrospective cohort of diabetes-free US veteran patients enrolled in VA primary care facilities nationwide from January 1, 2008, to December 31, 2016, and followed longitudinally through December 31, 2018. A total of 4,096,629 patients had baseline addresses available in electronic health records that were geocoded and assigned a census tract-level LUE score. LUE scores were divided into quartiles, where a higher score indicated higher neighborhood walkability levels. New diagnoses for T2D were identified using a published computable phenotype. Adjusted time-to-event analyses using piecewise exponential models were fit within four strata of community types (higher-density urban, lower-density urban, suburban/small town, and rural). We also evaluated effect modification by tract-level food environment measures within each stratum.

RESULTS

In adjusted analyses, higher LUE had a protective effect on T2D risk in rural and suburban/small town communities (linear quartile trend test p-value <0.001). However, in lower density urban communities, higher LUE increased T2D risk (linear quartile trend test p-value <0.001) and no association was found in higher density urban communities (linear quartile trend test p-value = 0.317). Particularly strong protective effects were observed for veterans living in suburban/small towns with more supermarkets and more walkable spaces (p-interaction = 0.001).

CONCLUSION

Among veterans, LUE may influence T2D risk, particularly in rural and suburban communities. Food environment may modify the association between LUE and T2D.

The association between the socioeconomic deprivation level and ischemic heart disease mortality in Japan: an analysis using municipality-specific data

OBJECTIVES

Geographical variation in the standardized mortality ratio (SMR) for ischemic heart disease (IHD) among municipalities has not been assessed in Japan. Additionally, associations between area-level socioeconomic deprivation indices and IHD mortality have not been identified in Japan. The present study investigated this association.

METHODS

Information on IHD mortality was extracted from Vital Statistics data from 2018 to 2020 for each municipality in Japan. The socioeconomic deprivation level was derived from multiple socioeconomic characteristics. We classified municipalities into quintiles based on the deprivation level and investigated the association between the deprivation level and the SMR of IHD. Additionally, a Bayesian spatial regression model was used to investigate this association, adjusting for other municipal characteristics.

RESULTS

Geographical variation in the SMR of IHD was revealed, and municipalities with high SMRs were spatially clustered. There was a weak negative correlation between the socioeconomic deprivation level and the SMRs (correlation coefficient, -0.057 for men and -0.091 for women). In contrast, the regression analysis showed a statistically significant positive association between deprived areas and the IHD mortality rate, and the relative risks for the most deprived municipalities compared with the least deprived municipalities were 1.184 (95% credible interval [CrI], 1.110 to 1.277) and 1.138 (95% CrI, 1.048 to 1.249) for men and women, respectively.

CONCLUSIONS

A weak negative correlation between the socioeconomic deprivation level and the SMR was observed in the descriptive analysis, while the regression analysis showed that living in deprived areas was statistically positively associated with the IHD mortality rate.

Neighbourhood walkability and mortality: Findings from a 15-year follow-up of a nationally representative cohort of Canadian adults in urban areas

BACKGROUND

Using a nationally representative cohort of Canadian adults, we assessed associations between neighbourhood walkability and cause-specific mortality and investigated whether they differed by socioeconomic status.

METHODS

The study population was drawn from the 2001 Canadian Census Health and Environment Cohort, which contains individual-level data from a random sample of 20% of Canadian households mandated to complete the long-form census. We included those aged ≥ 25 years at baseline who lived in urban and suburban areas. The national death registry was used to ascertain annual vital status. Linkages to annual income tax data provided place of residence. The Canadian Active Living Environments, a national index that summarizes walkability across Canadian neighbourhoods, was assigned to individuals' residential history. The Cox proportional hazards model was used to assess associations between walkability and cause-specific mortality.

RESULTS

A total of 1.8 million participants (52.5% female) accrued 27.3 million person-years and 265 710 deaths during the 15-year follow-up. The adjusted hazard ratio (HR) for living in a highly walkable neighbourhood relative to living in the least walkable neighbourhoods was associated with a 9% (HR: 0.91 [0.88, 0.95]) and 3% (HR: 0.97 [0.94, 0.99]) reduced risk of cardiovascular and all non-accidental mortality, respectively. The strongest benefits of walkability were found among individuals within the lowest education and household income categories, and who lived in the most deprived neighbourhoods. There were no significant associations (most [class 5] versus least [class 1] walkable HR: 0.84 [0.61-1.16]) seen for accidental traffic mortality.

CONCLUSIONS

Canadian adults who live in walkable neighbourhoods have lower rates of cardiovascular and non-accidental mortality, with the greatest benefits seen in those from the lowest socioeconomic groups.

Neighborhood Walkability and Mortality in a Prospective Cohort of Women

BACKGROUND

There is a paucity of prospective cohort studies evaluating neighborhood walkability in relation to the risk of death.

METHODS

We geocoded baseline residential addresses of 13,832 women in the New York University Women's Health Study (NYUWHS) and estimated the Built Environment and Health Neighborhood Walkability Index (BEH-NWI) for each participant circa 1990. The participants were recruited from 1985 to 1991 in New York City and followed for an average of 27 years. We conducted survival analyses using Cox proportional hazards models to assess the association between neighborhood walkability and risk of death from any cause, obesity-related diseases, cardiometabolic diseases, and obesity-related cancers.

RESULTS

Residing in a neighborhood with a higher neighborhood walkability score was associated with a lower mortality rate. Comparing women in the top versus the lowest walkability tertile, the hazards ratios (and 95% CIs) were 0.96 (0.93, 0.99) for all-cause, 0.91 (0.86, 0.97) for obesity-related disease, and 0.72 (0.62, 0.85) for obesity-related cancer mortality, respectively, adjusting for potential confounders at both the individual and neighborhood level. We found no association between neighborhood walkability and risk of death from cardiometabolic diseases. Results were similar in analyses censoring participants who moved during follow-up, using multiple imputation for missing covariates, and using propensity scores matching women with high and low neighborhood walkability on potential confounders. Exploratory analyses indicate that outdoor walking and average BMI mediated the association between neighborhood walkability and mortality.

CONCLUSION

Our findings are consistent with a protective role of neighborhood walkability in obesity-related mortality in women, particularly obesity-related cancer mortality.

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.

Local-Area Walkability and Socioeconomic Disparities of Cardiovascular Disease Mortality in Japan

Background

There are spatial disparities in cardiovascular disease (CVD) mortality related to area‐level socioeconomic status (SES) disadvantage, but little is known about the spatial distribution of CVD mortality according to built environment factors. We examined joint associations of neighborhood walkability attributes and SES with CVD mortality rates through linkage of Japanese national data sets.

Methods and Results

National data were used from the 1824 municipalities (of the 1880 potentially eligible municipalities) across Japan. The outcome was mortality from CVD for a 5‐year period (2008–2012) for each municipality. A national index of neighborhood deprivation was used as an indicator of municipality‐level SES. A national walkability index (based on population density, road density, and access to commercial areas) was calculated. Compared with higher SES municipalities, relative rates for CVD mortality were significantly higher in medium SES municipalities (relative rate, 1.05; 95% CI, 1.02–1.07) and in lower SES municipalities (relative rate, 1.09; 95% CI, 1.07–1.12). There were walkability‐related gradients in CVD mortality within the high and medium SES areas, in which lower walkability was associated with higher rates of mortality; however, walkability‐related CVD mortality gradients were not apparent in lower SES municipalities.

Conclusions

CVD mortality rates varied not only by area‐level SES but also by walkability. Those living in areas of lower walkability were at higher risk of CVD mortality, even if the areas have a higher SES. Our findings provide a novel element of the evidence base needed to inform better allocation of services and resources for CVD prevention.