Residential neighbourhood greenspace is associated with reduced risk of cardiovascular disease: A prospective cohort study

Autoři: Alice M. Dalton aff001;  Andrew P. Jones aff001
Působiště autorů: Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom aff001;  Centre for Diet & Activity Research (CEDAR), MRC Epidemiology Unit, University of Cambridge, Cambridge , United Kingdom aff002
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
prolekare.web.journal.doi_sk: 10.1371/journal.pone.0226524



Living in a greener neighbourhood may reduce the risk of developing incident cardiovascular disease, but evidence is limited by reliance on cross-sectional comparisons. We use data from a longitudinal study with a time-independent measure of risk to explore the association between exposure to greenspace and cardiovascular disease.


Data was from the European Prospective Investigation of Cancer Norfolk UK cohort, baseline 1993–1997 (n = 24,420). Neighbourhoods were defined as 800m radius zones around participants’ home, according to their home postcode (zip code) in the year 2000. Greenspace exposure was identified using classified satellite imagery. Adjusted Cox proportional hazards regression examined associations between greenspace and incident cardiovascular disease. Mediation analysis assessed if physical activity mediated associations, whilst modification by rurality, socio-economic status and age was explored.


The mean age of participants was 59.2 years at baseline, 54.7% were female, and mean follow-up time was 14.5 years. Individuals living in the greenest neighbourhood quartile had a 7% lower relative hazard of developing cardiovascular disease than other neighbourhoods (HR 0.93; 95% CI 0.88, 0.97; p = 0.003) after adjusting for age, sex, BMI, prevalent diabetes and socio-economic status (SES). Physical activity did not mediate the relationship (greenest compared to the least green quartile HR 0.99; 95% CI 0.97, 1.01; p = 0.416). Models predicted incidence of cardiovascular disease in the least green neighbourhoods (19.4% greenspace on average) would fall by 4.8% (95% CI 1.6%, 8.2% p = 0.003) if they were as green as the average neighbourhood (59.0% greenspace). Occupation moderated the relationship, whereby exposure to greenspace was not associated with incident CVD for participants engaged in manual occupations.


Greener home neighbourhoods may protect against risk of cardiovascular disease even after accounting for SES, whilst the mechanism does not appear to be strongly associated with physical activity. Putative causal mechanisms require investigation.

Klíčová slova:

Cardiovascular diseases – Cohort studies – Elderly – Hospitals – Physical activity – Questionnaires – Surveys – Diabetes mellitus


1. World Health Organization. Cardiovascular diseases (CVDs). Copenhagen: WHO;2017. Accessed 11 May 2018.

2. Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, et al. European Cardiovascular Disease Statistics 2017. Brussels: European Heart Network;2017. Accessed 11 May 2018.

3. British Heart Foundation. CVD Statistics—BHF UK Factsheet. London: BHF;2017. 12 July 2017. Accessed 11 May 2018.

4. Murray CJL, Richards MA, Newton J.N, Fenton KA, Anderson HR. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet (London, England). 2013;381(9871):997–1020. doi: 10.1016/S0140-6736(13)60355-4

5. Lee ACK, Maheswaran R. The health benefits of urban green spaces: a review of the evidence. J Public Health. 2010;33(2):212–22. doi: 10.1093/pubmed/fdq068 20833671

6. Van Cauwenberg J, De Bourdeaudhuij I, De Meester F, Van Dyck D, Salmon J, Clarys P, et al. Relationship between the physical environment and physical activity in older adults: A systematic review. Health Place. 2011;17(2):458–69. doi: 10.1016/j.healthplace.2010.11.010 21257333

7. van den Berg M, Wendel-Vos W, van Poppel M, Kemper H, van Mechelen W, Maas J. Health benefits of green spaces in the living environment: A systematic review of epidemiological studies. Urban For Urban Green. 2015;14(4):806–16. doi: 10.1016/j.ufug.2015.07.008

8. Gascon M, Triguero-Mas M, Martínez D, Dadvand P, Rojas-Rueda D, Plasència A, et al. Residential green spaces and mortality: A systematic review. Environ Int. 2016;86:60–7. doi: 10.1016/j.envint.2015.10.013 26540085

9. Dadvand P, Bartoll X, Basagaña X, Dalmau-Bueno A, Martinez D, Ambros A, et al. Green spaces and General Health: Roles of mental health status, social support, and physical activity. Environment International. 2016;91:161–7. doi: 10.1016/j.envint.2016.02.029 26949869

10. Taylor L, Hochuli DF. Defining greenspace: Multiple uses across multiple disciplines. Landscape Urban Plan. 2017;158:25–38. doi: 10.1016/j.landurbplan.2016.09.024

11. Bixby H, Hodgson S, Fortunato L, Hansell A, Fecht D. Associations between Green Space and Health in English Cities: An Ecological, Cross-Sectional Study. PLoS ONE. 2015;10(3):e0119495. doi: 10.1371/journal.pone.0119495 25775020

12. Chum A, O’Campo P. Cross-sectional associations between residential environmental exposures and cardiovascular diseases. BMC Public Health. 2015;15(1):438. doi: 10.1186/s12889-015-1788-0 25924669

13. Coutts C, Horner M, Chapin T. Using geographical information system to model the effects of green space accessibility on mortality in Florida. Geocarto International. 2010;25(6):471–84. doi: 10.1080/10106049.2010.505302

14. Maas J, Verheij RA, de Vries S, Spreeuwenberg P, Schellevis FG, Groenewegen PP. Morbidity is related to a green living environment. J Epidemiol Community Health. 2009;63(12):967–73. doi: 10.1136/jech.2008.079038 19833605

15. Ngom R, Gosselin P, Blais C, Rochette L. Type and Proximity of Green Spaces Are Important for Preventing Cardiovascular Morbidity and Diabetes—A Cross-Sectional Study for Quebec, Canada. Int J Environ Res Public Health. 2016;13(4):423. doi: 10.3390/ijerph13040423 27089356

16. Richardson E, Pearce J, Mitchell R, Day P, Kingham S. The association between green space and cause-specific mortality in urban New Zealand: an ecological analysis of green space utility. BMC Public Health. 2010;10(1):240.

17. Richardson EA, Mitchell R. Gender differences in relationships between urban green space and health in the United Kingdom. Soc Sci Med. 2010;71(3):568–75. doi: 10.1016/j.socscimed.2010.04.015 20621750

18. Richardson EA, Pearce J, Mitchell R, Kingham S. Role of physical activity in the relationship between urban green space and health. Public Health. 2013;127(4):318–24. doi: 10.1016/j.puhe.2013.01.004 23587672

19. Richardson EA, Mitchell R, Hartig T, de Vries S, Astell-Burt T, Frumkin H. Green cities and health: a question of scale? J Epidemiol Community Health. 2011;66(2):160. doi: 10.1136/jech.2011.137240 22003083

20. Wilker EH, Wu CD, McNeely E, Mostofsky E, Spengler J, Wellenius GA, et al. Green space and mortality following ischemic stroke. Environ Res. 2014;133:42–8. doi: 10.1016/j.envres.2014.05.005 24906067

21. Seo S, Choi S, Kim K, Kim SM, Park SM. Association between urban green space and the risk of cardiovascular disease: A longitudinal study in seven Korean metropolitan areas. Environment International. 2019;125:51–7. doi: 10.1016/j.envint.2019.01.038 30703611

22. Villeneuve PJ, Jerrett M, G. Su J, Burnett RT, Chen H, Wheeler AJ, et al. A cohort study relating urban green space with mortality in Ontario, Canada. Environ Res. 2012;115:51–8. doi: 10.1016/j.envres.2012.03.003 22483437

23. Tamosiunas A, Grazuleviciene R, Luksiene D, Dedele A, Reklaitiene R, Baceviciene M, et al. Accessibility and use of urban green spaces, and cardiovascular health: findings from a Kaunas cohort study. Environmental Health. 2014;13(1):20. doi: 10.1186/1476-069X-13-20 24645935

24. Okura Y, Urban LH, Mahoney DW, Jacobsen SJ, Rodeheffer RJ. Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure. J Clin Epidemiol. 2004;57(10):1096–103. doi: 10.1016/j.jclinepi.2004.04.005 15528061

25. Woodfield R, Sudlow C, Al-Shahi Salman R, Beral V, Chen Y, Chen Z, et al. Accuracy of patient self-report of stroke: A systematic review from the UK biobank stroke outcomes group. PLoS ONE. 2015;10(9). doi: 10.1371/journal.pone.0137538 26355837

26. James P, Banay RF, Hart JE, Laden F. A Review of the Health Benefits of Greenness. Current Epidemiology Reports. 2015;2(2):131–42. doi: 10.1007/s40471-015-0043-7 26185745

27. Stare J, Maucort-Boulch D. Odds Ratio, Hazard Ratio and Relative Risk. Advances in Methodology & Statistics. 2016;13(1):59–67.

28. British Heart Foundation. BHF CVD Statistics Compendium 2017. London: BHF;2017. Accessed 11 May 2018.

29. Lachowycz K, Jones AP. Towards a better understanding of the relationship between greenspace and health: Development of a theoretical framework. Landscape Urban Plan. 2013;118(0):62–9. doi: 10.1016/j.landurbplan.2012.10.012

30. Markevych I, Schoierer J, Hartig T, Chudnovsky A, Hystad P, Dzhambov AM, et al. Exploring pathways linking greenspace to health: Theoretical and methodological guidance. Environmental research. 2017;158:301–17. doi: 10.1016/j.envres.2017.06.028 28672128

31. Paquet C, Orschulok TP, Coffee NT, Howard NJ, Hugo G, Taylor AW, et al. Are accessibility and characteristics of public open spaces associated with a better cardiometabolic health? Landscape Urban Plan. 2013;118(0):70–8. doi: 10.1016/j.landurbplan.2012.11.011

32. McCormack G, Shiell A. In search of causality: a systematic review of the relationship between the built environment and physical activity among adults. Int J Behav Nutr Phys Act. 2011;8(1):125.

33. Nocon M, Hiemann T, Muller-Riemenschneider F, Thalau F, Roll S, Willich SN. Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil. 2008;15(3):239–46. doi: 10.1097/HJR.0b013e3282f55e09 18525377

34. Leung FP, Yung LM, Laher I, Yao X, Chen ZY, Huang Y. Exercise, Vascular Wall and Cardiovascular Diseases. Sports Medicine. 2008;38(12):1009–24. doi: 10.2165/00007256-200838120-00005 19026018

35. Bassuk SS, Manson JE. Physical activity and cardiovascular disease prevention in women: A review of the epidemiologic evidence. Nutrition, Metabolism and Cardiovascular Diseases. 2010;20(6):467–73. doi: 10.1016/j.numecd.2009.12.015 20399084

36. Dalton A, Jones A, Sharp S, Cooper A, Griffin S, Wareham N. Residential neighbourhood greenspace is associated with reduced risk of incident diabetes in older people: a prospective cohort study. BMC Public Health. 2016;16(1171). doi: 10.1186/s12889-016-3833-z 27863516

37. Day N, Oakes S, Luben R, Khaw KT, Bingham S, Welch A, et al. EPIC-Norfolk: study design and characteristics of the cohort. European Prospective Investigation of Cancer. Br J Cancer. 1999;80(Suppl 1):95–103.

38. Consortium InterAct. Design and cohort description of the InterAct Project: an examination of the interaction of genetic and lifestyle factors on the incidence of type 2 diabetes in the EPIC Study. Diabetologia. 2011;54(9):2272–82. doi: 10.1007/s00125-011-2182-9 21717116

39. World Health Orgainisation. International statistical classification of diseases and related health problems, 10th revision (ICD-10) Geneva, Switzerland: World Health Organization 2016. 12 May 2016. Accessed 11 May 2018.

40. Ordnance Survey. Code-Point Southampton: Ordnance Survey; 2014 [ Accessed 10 September

41. ESRI. ArcGIS 10.4.1. California: ESRI; 2015.

42. Nomis. Postcode Headcounts and Household Estimates—2011 Census Fareham, England: ONS; 2011 [ Accessed 11 October

43. Centre for Ecology and Hydrology (CEH). Land Cover Map 2007 (LCM2007). In: Centre for Ecology and Hydrology (CEH), editor. Wallingford, UK: CEH; 2013.

44. Agardh E, Allebeck P, Hallqvist J, Moradi T, Sidorchuk A. Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. Int J Epidemiol. 2011;40:804–18. doi: 10.1093/ije/dyr029 21335614

45. Boruff B, Nathan A, Nijenstein S. Using GPS technology to (re)-examine operational definitions of 'neighbourhood' in place-based health research. Int J Health Geog [Internet]. 2012 12 December 2014; 11(22):[1–14 pp.]. Available from:

46. Hurvitz PM, Moudon AV. Home versus nonhome neighborhood: quantifying differences in exposure to the built environment. Am J Prev Med. 2012;42(4):411–7. doi: 10.1016/j.amepre.2011.11.015 22424255

47. Besson H, Ekelund U, Brage S, Luben R, Bingham S, Khaw KT, et al. Relationship between subdomains of total physical activity and mortality. Med Sci Sports Exerc. 2008;40(11):1909–15. doi: 10.1249/MSS.0b013e318180bcad 18845964

48. Khaw KT, Jakes R, Bingham S, Welch A, Luben R, Day N, et al. Work and leisure time physical activity assessed using a simple, pragmatic, validated questionnaire and incident cardiovascular disease and all-cause mortality in men and women: The European Prospective Investigation into Cancer in Norfolk prospective population study. Int J Epidemiol. 2006;35(4):1034–43. doi: 10.1093/ije/dyl079 16709620

49. Lachman S, Peters RJG, Lentjes MAH, Mulligan AA, Luben RN, Wareham NJ, et al. Ideal cardiovascular health and risk of cardiovascular events in the EPIC-Norfolk prospective population study. Eur J Prev Cardiol. 2015;23(9):986–94. doi: 10.1177/2047487315602015 26336197

50. Wareham NJ, Jakes RW, Rennie KL, Schuit J, Mitchell J, Hennings S, et al. Validity and repeatability of a simple index derived from the short physical activity questionnaire used in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Public Health Nutrition. 2003;6(4):407–13. doi: 10.1079/PHN2002439 12795830

51. Collins GS, Altman DG. An independent and external validation of QRISK2 cardiovascular disease risk score: a prospective open cohort study. BMJ. 2010;340. doi: 10.1136/bmj.c2442 20466793

52. Townsend P, Phillimore P, Beattie A. Health and Deprivation: Inequality and the North. London: Routledge; 1988.

53. Bhopal R, Hayes L, White M, Unwin N, Harland J, Ayis S, et al. Ethnic and socio-economic inequalities in coronary heart disease, diabetes and risk factors in Europeans and South Asians. J Public Health Med. 2002;24(2):95–105. doi: 10.1093/pubmed/24.2.95 12141592

54. Collett D. Modelling Survival Data in Medical Research. Second ed. London: Chapman & Hall/CRC; 2003.

55. Kaplan EL, Meier P. Nonparametric Estimation from Incomplete Observations. Journal of the American Statistical Association. 1958;53(282):457–81. doi: 10.2307/2281868

56. Ekelund U, Ward HA, Norat T, Luan Ja, May AM, Weiderpass E, et al. Physical activity and all-cause mortality across levels of overall and abdominal adiposity in European men and women: the European Prospective Investigation into Cancer and Nutrition Study (EPIC). Am J Clinic Nutr. 2015;101(3):613–21. doi: 10.3945/ajcn.114.100065 25733647

57. Newson RB. Attributable and unattributable risks and fractions and other scenario comparisons. Stata Journal. 2013;13(4):672–98.

58. Bellera CA, MacGrogan G, Debled M, de Lara CT, Brouste V, Mathoulin-Pélissier S. Variables with time-varying effects and the Cox model: Some statistical concepts illustrated with a prognostic factor study in breast cancer. BMC Medical Research Methodology. 2010;10(1):20. doi: 10.1186/1471-2288-10-20 20233435

59. Jones A, Hillsdon M, Coombes E. Greenspace access, use, and physical activity: Understanding the effects of area deprivation. Prev Med. 2009;49(6):500–5. doi: 10.1016/j.ypmed.2009.10.012 19857513

60. Wheeler BW, Lovell R, Higgins SL, White MP, Alcock I, Osborne NJ, et al. Beyond greenspace: an ecological study of population general health and indicators of natural environment type and quality. Int J Health Geogr. 2015;14(1):17. doi: 10.1186/s12942-015-0009-5 25924685

61. Schipperijn J, Ekholm O, Stigsdotter UK, Toftager M, Bentsen P, Kamper-Jørgensen F, et al. Factors influencing the use of green space: Results from a Danish national representative survey. Landsc Urban Plan. 2010;95(3):130–7. doi: 10.1016/j.landurbplan.2009.12.010

62. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51(6):1173–82. doi: 10.1037//0022-3514.51.6.1173 3806354

63. Preacher K, Hayes A. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers. 2004;36(4):717–31. doi: 10.3758/BF03206553 15641418

64. Preacher K, Hayes A. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods. 2008;40(3):879–91. doi: 10.3758/brm.40.3.879 18697684

65. Rochon J, du Bois A, Lange T. Mediation analysis of the relationship between institutional research activity and patient survival. BMC Medical Research Methodology [Internet]. 2014 12 December 2014; 14(1):[9 p.]. Available from:

66. Lange T, Hansen JV. Direct and indirect effects in a survival context. Epidemiology. 2011;22(4):575–81. doi: 10.1097/EDE.0b013e31821c680c 21552129

67. Lange T, Vansteelandt S, Bekaert M. A simple unified approach for estimating natural direct and indirect effects. Am J Epidemiol. 2012;176(3):190–5. doi: 10.1093/aje/kwr525 22781427

68. R Development Core Team. R: A language and environment for statistical computing. Vienna, Austria 2014. Accessed 1 December 2014.

69. Stata Corp. Stata/SE 13.0 for Unix. Stata Corp, editor. College Station, Texas: Stata Corp,; 2013.

70. de Vries S, van Dillen SME, Groenewegen PP, Spreeuwenberg P. Streetscape greenery and health: Stress, social cohesion and physical activity as mediators. Soc Sci Med. 2013;94:26–33. doi: 10.1016/j.socscimed.2013.06.030 23931942

71. Frumkin H, Bratman GN, Breslow SJ, Cochran B, Kahn PH Jr., Lawler JJ, et al. Nature Contact and Human Health: A Research Agenda. Environ Health Perspect. 2017;125(7):075001. doi: 10.1289/EHP1663 28796634

72. Ord K, Mitchell R, Pearce J. Is level of neighbourhood green space associated with physical activity in green space? Int J Behav Nutr Phys Act. 2013;10(1):127. doi: 10.1186/1479-5868-10-127 24219824

73. Nieuwenhuijsen MJ, Khreis H, Triguero-Mas M, Gascon M, Dadvand P. Fifty Shades of Green: Pathway to Healthy Urban Living. Epidemiology. 2017;28(1):63–71. doi: 10.1097/EDE.0000000000000549 27525811

74. Maas J, van Dillen SME, Verheij RA, Groenewegen PP. Social contacts as a possible mechanism behind the relation between green space and health. Health Place. 2009;15(2):586–95. doi: 10.1016/j.healthplace.2008.09.006 19022699

75. Ellaway A, Macintyre S, Bonnefoy X. Graffiti, greenery, and obesity in adults: secondary analysis of European cross sectional survey. BMJ. 2005;331(7517):611–2. doi: 10.1136/bmj.38575.664549.F7 16113034

76. Aerts R, Honnay O, Van Nieuwenhuyse A. Biodiversity and human health: mechanisms and evidence of the positive health effects of diversity in nature and green spaces. British Medical Bulletin. 2018;127(1):5–22. doi: 10.1093/bmb/ldy021 30007287

77. Lai H, Flies EJ, Weinstein P, Woodward A. The impact of green space and biodiversity on health. Frontiers in Ecology and the Environment. 2019;17(7):383–90. doi: 10.1002/fee.2077

78. Haahtela T. A biodiversity hypothesis. Allergy. 2019;74(8):1445–56. doi: 10.1111/all.13763 30835837

79. Tsao T-M, Tsai M-J, Hwang J-S, Cheng W-F, Wu C-F, Chou C-CK, et al. Health effects of a forest environment on natural killer cells in humans: an observational pilot study. Oncotarget. 2018;9(23):16501–11. doi: 10.18632/oncotarget.24741 29662662

80. Lange T, Vansteelandt S, Bekaert M. A Simple Unified Approach for Estimating Natural Direct and Indirect Effects. Am J Epidemiol. 2012;176(3):190–5. doi: 10.1093/aje/kwr525 22781427

81. The InterAct Consortium. Validity of a short questionnaire to assess physical activity in 10 European countries. European Journal of Epidemiology. 2012;27(1):15–25. doi: 10.1007/s10654-011-9625-y 22089423

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