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Luque-García L, Muxika-Legorburu J, Mendia-Berasategui O, Lertxundi A, García-Baquero G, Ibarluzea J. Green and blue space exposure and non-communicable disease related hospitalizations: A systematic review. Environ Res 2024; 245:118059. [PMID: 38157973 DOI: 10.1016/j.envres.2023.118059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/05/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
The global increase in non-communicable diseases (NCDs) presents a critical public health concern. Emerging evidence suggests that exposure to natural environments may reduce the risk of developing NCDs through multiple pathways. The present systematic review aims to synthesize and evaluate the observational evidence regarding associations between exposure to green and blue spaces and hospital admissions related to NCDs. A comprehensive literature search strategy was conducted in Embase (Ovid), PubMed, and Web of Science. The risk of bias and quality of the evidence were assessed using The Navigation Guide methodology, an approach specifically designed for environmental health research. Of 3060 search results, 17 articles were included. Notably, the majority of the studies (n = 14; 82.4%) were published from 2020 onwards. Most studies were conducted in the United States (n = 6; 35.3%) and China (n = 4; 23.5%). Exposure to green spaces was assessed through all studies, while only three included blue spaces. In terms of study design, cohort design was employed in nearly half of the studies (n = 8; 47.1%), followed by case-crossover design (n = 3, 17.6%). Over 75% of the included studies (n = 13) had a high or probably high rating in the risk of bias assessment. The studies encompassed diverse NCD outcome domains; cardiovascular diseases (CVDs) (n = 10), respiratory diseases (RSDs) (n = 2), heat-related diseases (n = 1), metabolic diseases (n = 2), cancer (n = 1), neurodegenerative diseases (NDDs) (n = 2), and mental health disorders (n = 2). The present review suggests that a clear link between blue space exposure and NCD hospital admissions is not evident. However, exposure to green spaces appears to predominantly have a protective effect, although the direction of the association varies across different outcome domains. The heterogeneity among the outcome domains together with the limited number of studies, emphasizes the need for more robust evidence.
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Affiliation(s)
- L Luque-García
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of the Basque Country (UPV/EHU), Leioa, 48940, Spain; Biogipuzkoa Health Research Institute, Group of Environmental Epidemiology and Child Development, Paseo Doctor Begiristain S/n, 20014, Donostia- San Sebastián, Spain; Osakidetza Basque Health Service, Goierri Alto-Urola Integrated Health Organisation, Zumarraga Hospital, Zumarraga, 20700, Spain.
| | - J Muxika-Legorburu
- Osakidetza Basque Health Service, Goierri Alto-Urola Integrated Health Organisation, Zumarraga Hospital, Zumarraga, 20700, Spain
| | - O Mendia-Berasategui
- Osakidetza Basque Health Service, Goierri Alto-Urola Integrated Health Organisation, Zumarraga Hospital, Zumarraga, 20700, Spain
| | - A Lertxundi
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of the Basque Country (UPV/EHU), Leioa, 48940, Spain; Biogipuzkoa Health Research Institute, Group of Environmental Epidemiology and Child Development, Paseo Doctor Begiristain S/n, 20014, Donostia- San Sebastián, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), 28029, Madrid, Spain
| | - G García-Baquero
- Biogipuzkoa Health Research Institute, Group of Environmental Epidemiology and Child Development, Paseo Doctor Begiristain S/n, 20014, Donostia- San Sebastián, Spain; Faculty of Biology, University of Salamanca, Avda Licenciado Méndez Nieto S/n, 37007, Salamanca, Spain
| | - J Ibarluzea
- Biogipuzkoa Health Research Institute, Group of Environmental Epidemiology and Child Development, Paseo Doctor Begiristain S/n, 20014, Donostia- San Sebastián, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), 28029, Madrid, Spain; Ministry of Health of the Basque Government, Sub-Directorate for Public Health and Addictions of Gipuzkoa, 20013, San Sebastián, Spain; Faculty of Psychology of the University of the Basque Country, 20018, San Sebastian, Spain
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Patwary MM, Bardhan M, Browning MHEM, Astell-Burt T, van den Bosch M, Dong J, Dzhambov AM, Dadvand P, Fasolino T, Markevych I, McAnirlin O, Nieuwenhuijsen MJ, White MP, Van Den Eeden SK. The economics of nature's healing touch: A systematic review and conceptual framework of green space, pharmaceutical prescriptions, and healthcare expenditure associations. Sci Total Environ 2024; 914:169635. [PMID: 38159779 DOI: 10.1016/j.scitotenv.2023.169635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
Green spaces play a crucial role in promoting sustainable and healthy lives. Recent evidence shows that green space also may reduce the need for healthcare, prescription medications, and associated costs. This systematic review provides the first comprehensive assessment of the available literature examining green space exposure and its associations with healthcare prescriptions and expenditures. We applied Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search MEDLINE, Scopus, and Web of Science for observational studies published in English through May 6, 2023. A quality assessment of the included studies was conducted using the Office of Health Assessment and Translation (OHAT) tool, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment was used to evaluate the overall quality of evidence. Our search retrieved 26 studies that met the inclusion criteria and were included in our review. Among these, 20 studies (77 % of the total) showed beneficial associations of green space exposure with healthcare prescriptions or expenditures. However, most studies had risks of bias, and the overall strength of evidence for both outcomes was limited. Based on our findings and related bodies of literature, we present a conceptual framework to explain the possible associations and complex mechanisms underlying green space and healthcare outcomes. The framework differs from existing green space and health models by including upstream factors related to healthcare access (i.e., rurality and socioeconomic status), which may flip the direction of associations. Additional research with lower risks of bias is necessary to validate this framework and better understand the potential for green space to reduce healthcare prescriptions and expenditures.
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Affiliation(s)
- Muhammad Mainuddin Patwary
- Environment and Sustainability Research Initiative, Khulna, Bangladesh; Environmental Science Discipline, Life Science School, Khulna University, Khulna, Bangladesh.
| | - Mondira Bardhan
- Environment and Sustainability Research Initiative, Khulna, Bangladesh; Department of Park, Recreation and Tourism Management, Clemson University, Clemson, SC, USA
| | - Matthew H E M Browning
- Department of Park, Recreation and Tourism Management, Clemson University, Clemson, SC, USA.
| | - Thomas Astell-Burt
- School of Architecture, Design, and Planning, University of Sydney, Australia
| | - Matilda van den Bosch
- ISGlobal, Barcelona, Spain; European Forest Institute, Biocities Facility, Rome, Italy; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Jiaying Dong
- Department of Park, Recreation and Tourism Management, Clemson University, Clemson, SC, USA; School of Architecture, Clemson University, Clemson, SC, USA
| | - Angel M Dzhambov
- Research Group "Health and Quality of Life in a Green and Sustainable Environment", Strategic Research and Innovation Program for the Development of MU - Plovdiv, Medical University of Plovdiv, Plovdiv, Bulgaria; Environmental Health Division, Research Institute at Medical University of Plovdiv, Medical University of Plovdiv, Plovdiv, Bulgaria; Department of Hygiene, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria; Institute of Highway Engineering and Transport Planning, Graz University of Technology, Graz, Austria
| | - Payam Dadvand
- ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | - Iana Markevych
- Research Group "Health and Quality of Life in a Green and Sustainable Environment", Strategic Research and Innovation Program for the Development of MU - Plovdiv, Medical University of Plovdiv, Plovdiv, Bulgaria; Environmental Health Division, Research Institute at Medical University of Plovdiv, Medical University of Plovdiv, Plovdiv, Bulgaria; Institute of Psychology, Jagiellonian University, Krakow, Poland
| | - Olivia McAnirlin
- Department of Park, Recreation and Tourism Management, Clemson University, Clemson, SC, USA
| | - Mark J Nieuwenhuijsen
- ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Mathew P White
- Cognitive Science Hub, University of Vienna, Vienna, Austria
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Scheer C, Plans-Beriso E, Pastor-Barriuso R, Ortolá R, Sotos-Prieto M, Cabañas-Sánchez V, Gullón P, Ojeda Sánchez C, Ramis R, Fernández-Navarro P, Rodríguez-Artalejo F, García-Esquinas E. Exposure to green spaces, cardiovascular risk biomarkers and incident cardiovascular disease in older adults: The Seniors-Enrica II cohort. Environ Int 2024; 185:108570. [PMID: 38484611 DOI: 10.1016/j.envint.2024.108570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/07/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION The impact of residential green spaces on cardiovascular health in older adults remains uncertain. METHODS Cohort study involving 2114 adults aged ≥ 65 years without cardiovascular disease (CVD), residing in five dense municipalities (Prince et al., 2015) of the Madrid region and with detailed characterization of their socioeconomic background, health behaviors, CVD biological risk factors, and mental, physical, and cognitive health. Greenness exposure was measured using the Normalized Difference Vegetation Index (NDVI) at varying distances from participants' homes. Traffic exposure, neighborhood environment, neighborhood walkability, and socioeconomic deprivation at the census level were also assessed. Serum N-terminal pro-B-type natriuretic peptide (NT-ProBNP), high-sensitivity troponin T (hs-TnT), interleukin 6 (IL-6), and Growth Differentiation Factor 15 (GDF-15) were measured at baseline, and incident CVD events identified through electronic medical records (International Classification of Primary Care-2 codes K74, K75, K77, K90, and K92). RESULTS After adjusting for sex, age, educational attainment, financial hardship and socioeconomic deprivation at the census level, an interquartile range (IQR) increase in NDVI at 250, 500, 750, and 1000 m around participants' homes was associated with mean differences in ProBNP of -5.56 % (95 %CI: -9.77; -1.35), -5.05 % (-9.58; -0.53), -4.24 % (-8.19, -0.19), and -4.16 % (-7.59; -0.74), respectively; and mean differences in hs-TnT among diabetic participants of -8.03 % (95 %CI: -13.30; -2.77), -9.52 % (-16.08; -2.96), -8.05 % (-13.94, -2.16) and -5.56 % (-10.75; -0.54), respectively. Of similar magnitude, although only statistically significant at 250 and 500 m, were the observed lower IL-6 levels with increasing greenness. GDF-15 levels were independent of NDVI. In prospective analyses (median follow-up 6.29 years), an IQR increase in residential greenness at 500, 750, and 1000 m was associated with a lower risk of incident CVD. The variables that contributed most to the apparent beneficial effects of greenness on CVD were lower exposure to traffic, improved cardiovascular risk factors, and enhanced physical performance. Additionally, neighborhood walkability and increased physical activity were notable contributors among individuals with diabetes. CONCLUSION Increased exposure to residential green space was associated with a moderate reduction in CVD risk in older adults residing in densely populated areas.
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Affiliation(s)
- Cara Scheer
- Fulda University of Applied Sciences. Fulda, Germany
| | - Elena Plans-Beriso
- Public Health and Epidemiology Research Group, School of Medicine, Universidad de Alcala, 28871 Madrid, Spain; Department of Chronic Diseases, National Center of Epidemiology, Carlos III Health Institute, Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Roberto Pastor-Barriuso
- Department of Chronic Diseases, National Center of Epidemiology, Carlos III Health Institute, Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Rosario Ortolá
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid. Madrid, Spain/ CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Mercedes Sotos-Prieto
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid. Madrid, Spain/ CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA; IMDEA Food Institute. CEI UAM+CSIC, Madrid, Spain
| | - Verónica Cabañas-Sánchez
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid. Madrid, Spain/ CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Pedro Gullón
- Department of Surgery, Social and Medical Sciences. School of Medicine and Health Sciences, Universidad de Alcala. Alcala de Henares, Madrid, Spain; Centre for Urban Research, RMIT University, Melbourne, Australia
| | | | - Rebeca Ramis
- Department of Chronic Diseases, National Center of Epidemiology, Carlos III Health Institute, Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Pablo Fernández-Navarro
- Department of Chronic Diseases, National Center of Epidemiology, Carlos III Health Institute, Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Fernando Rodríguez-Artalejo
- Department of Chronic Diseases, National Center of Epidemiology, Carlos III Health Institute, Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain; IMDEA Food Institute. CEI UAM+CSIC, Madrid, Spain
| | - Esther García-Esquinas
- Department of Chronic Diseases, National Center of Epidemiology, Carlos III Health Institute, Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.
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Egorov AI, Griffin SM, Styles JN, Kobylanski J, Klein J, Wickersham L, Ritter R, Sams E, Hudgens EE, Wade TJ. Time outdoors and residential greenness are associated with reduced systemic inflammation and allostatic load. Environ Pollut 2024; 344:123408. [PMID: 38278402 DOI: 10.1016/j.envpol.2024.123408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 01/09/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024]
Abstract
Contacts with nature are linked with reduced morbidity and mortality. Hypothesized pathways include relaxation, physical activity, and improved immune function. This cross-sectional study of 320 adults in central North Carolina assessed health benefits of residential greenness using allostatic load (AL) and systemic inflammation (INFL) indices, composite biomarker-based measures of physiological dysregulation and inflammation, respectively. Distance-to-residence weighted tree cover and vegetated land cover measures were estimated within 500 m of each residence; 37 biomarkers of immune, neuroendocrine, cardiovascular, and metabolic functions were dichotomized at distribution or health-based cut-offs. AL was calculated as a sum of potentially unhealthy values of all biomarkers; INFL was based on a subset of 18 immune biomarkers. Regression analysis used generalized additive models for Poisson-distributed outcome. An interquartile range (IQR) increase in tree cover was associated with 0.89 (95 % Confidence Limits 0.82; 0.97) and 0.90 (0.79; 1.03)-fold change in AL and INFL, respectively. Greater daily outdoor time was associated with reduced AL and INFL, while leisure screen time, problems with sleeping, and common chronic infections were linked with increased AL and INFL. Among 138 individuals spending more than 1 h outdoors daily, an IQR increase in tree cover was associated with 0.76 (0.67; 0.86) and 0.81 (0.65; 1.02)-fold changes in AL and INFL, respectively. Among individuals with residential tree cover above the 50th percentile, spending more than 3 h outdoors daily was associated with 0.54 (0.37; 0.78) and 0.28 (0.15; 0.54)-fold changes in AL and INFL, respectively, compared to spending less than 30 min outdoors; there were no significant effects in the low tree cover stratum. Consistent but weaker effects were observed for vegetated land cover. Interaction effects of tree and vegetative cover and time spent outdoors on AL and INFL were statistically significant. This biomarker-based approach can help to assess public health benefits of green spaces.
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Affiliation(s)
- Andrey I Egorov
- Office of Research and Development, United States Environmental Protection Agency, Research Triangle Park, NC, USA.
| | - Shannon M Griffin
- Office of Research and Development, United States Environmental Protection Agency, Cincinnati, OH, USA
| | - Jennifer N Styles
- Office of Research and Development, United States Environmental Protection Agency, Research Triangle Park, NC, USA; Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jason Kobylanski
- ORAU Student Services Contractor, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Jo Klein
- ORAU Student Services Contractor, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Lindsay Wickersham
- ORAU Student Services Contractor, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Rebecca Ritter
- ORAU Student Services Contractor, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Elizabeth Sams
- Office of Research and Development, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Edward E Hudgens
- Office of Research and Development, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Timothy J Wade
- Office of Research and Development, United States Environmental Protection Agency, Research Triangle Park, NC, USA
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Fiffer MR, Li H, Iyer HS, Nethery RC, Sun Q, James P, Yanosky JD, Kaufman JD, Hart JE, Laden F. Associations between air pollution, residential greenness, and glycated hemoglobin (HbA1c) in three prospective cohorts of U.S. adults. Environ Res 2023; 239:117371. [PMID: 37839528 PMCID: PMC10873087 DOI: 10.1016/j.envres.2023.117371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND While studies suggest impacts of individual environmental exposures on type 2 diabetes (T2D) risk, mechanisms remain poorly characterized. Glycated hemoglobin (HbA1c) is a biomarker of glycemia and diagnostic criterion for prediabetes and T2D. We explored associations between multiple environmental exposures and HbA1c in non-diabetic adults. METHODS HbA1c was assessed once in 12,315 women and men in three U.S.-based prospective cohorts: the Nurses' Health Study (NHS), Nurses' Health Study II (NHSII), and Health Professionals Follow-up Study (HPFS). Residential greenness within 270 m and 1,230 m (normalized difference vegetation index, NDVI) was obtained from Landsat. Fine particulate matter (PM2.5) and nitrogen dioxide (NO2) were estimated from nationwide spatiotemporal models. Three-month and one-year averages prior to blood draw were assigned to participants' addresses. We assessed associations between single exposure, multi-exposure, and component scores from Principal Components Analysis (PCA) and HbA1c. Fully-adjusted models built on basic models of age and year at blood draw, BMI, alcohol use, and neighborhood socioeconomic status (nSES) to include diet quality, race, family history, smoking status, postmenopausal hormone use, population density, and season. We assessed interactions between environmental exposures, and effect modification by population density, nSES, and sex. RESULTS Based on HbA1c, 19% of participants had prediabetes. In single exposure fully-adjusted models, an IQR (0.14) higher 1-year 1,230 m NDVI was associated with a 0.27% (95% CI: 0.05%, 0.49%) lower HbA1c. In basic component score models, a SD increase in Component 1 (high loadings for 1-year NDVI) was associated with a 0.19% (95% CI: 0.04%, 0.34%) lower HbA1c. CI's crossed the null in multi-exposure and fully-adjusted component score models. There was little evidence of associations between air pollution and HbA1c, and no evidence of effect modification. CONCLUSIONS Among non-diabetic adults, environmental exposures were not consistently associated with HbA1c. More work is needed to elucidate biological pathways between the environment and prediabetes.
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Affiliation(s)
- Melissa R Fiffer
- Harvard T.H. Chan School of Public Health, Department of Environmental Health, Boston, MA, USA; University of Illinois Chicago, Children's Environmental Health Initiative, Chicago, IL, USA.
| | - Huichu Li
- Harvard T.H. Chan School of Public Health, Department of Environmental Health, Boston, MA, USA
| | - Hari S Iyer
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA; Dana-Farber Cancer Institute, Division of Population Sciences, Boston, MA, USA; Rutgers Cancer Institute of New Jersey, Section of Cancer Epidemiology and Health Outcomes, New Brunswick, NJ, USA
| | - Rachel C Nethery
- Harvard T.H. Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Qi Sun
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Department of Nutrition, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter James
- Harvard T.H. Chan School of Public Health, Department of Environmental Health, Boston, MA, USA; Harvard Medical School and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Boston, MA, USA
| | - Jeff D Yanosky
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, USA
| | - Joel D Kaufman
- Department of Epidemiology, University of Washington, Seattle, USA; Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, USA
| | - Jaime E Hart
- Harvard T.H. Chan School of Public Health, Department of Environmental Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Francine Laden
- Harvard T.H. Chan School of Public Health, Department of Environmental Health, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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