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Associations of Urban Built Environment with Cardiovascular Risks and Mortality: a Systematic Review

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Abstract

With rapid urbanization, built environment has emerged as a set of modifiable factors of cardiovascular disease (CVD) risks. We conducted a systematic review to synthesize evidence on the associations of attributes of urban built environment (e.g. residential density, land use mix, greenness and walkability) with cardiovascular risk factors (e.g. hypertension and arterial stiffness) and major CVD events including mortality. A total of 63 studies, including 31 of cross-sectional design and 32 of longitudinal design conducted across 21 geographical locations and published between 2012 and 2023 were extracted for review. Overall, we report moderately consistent evidence of protective associations of greenness with cardiovascular risks and major CVD events (cross-sectional studies: 12 of 15 on hypertension/blood pressure (BP) and 2 of 3 on arterial stiffness; and longitudinal studies: 6 of 8 on hypertension/BP, 7 of 8 on CVD mortality, 3 of 3 on ischemic heart disease mortality and 5 of 8 studies on stroke hospitalization or mortality reporting significant inverse associations). Consistently, walkability was associated with lower risks of hypertension, arterial stiffness and major CVD events (cross-sectional studies: 11 of 12 on hypertension/BP and 1 of 1 on arterial stiffness; and longitudinal studies: 3 of 6 on hypertension/BP and 1 of 2 studies on CVD events being protective). Sixty-seven percent of the studies were rated as “probably high” risk of confounding bias because of inability to adjust for underlying comorbidities/family history of diseases in their statistical models. Forty-six percent and 14% of the studies were rated as “probably high” risk of bias for exposure and outcome measurements, respectively. Future studies with robust design will further help elucidate the linkages between urban built environment and cardiovascular health, thereby informing planning policies for creating healthy cities.

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Acknowledgments

C.S. acknowledges support from Hong Kong Research Grant Commission and General Research Fund (GRF grant 17613220) and the US National Academy of Medicine — The University of Hong Kong Fellowship in Global Health Leadership.

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Authors and Affiliations

  1. Healthy High Density Cities Lab, HKUrbanLab, The University of Hong Kong, Knowles Building, Pokfulam Road, Hong Kong Special Administrative Region, China

    Ka Yan Lai, Chris Webster & Chinmoy Sarkar

  2. Department of Urban Planning and Design, Faculty of Architecture, The University of Hong Kong, Knowles Building, Pokfulam Road, Hong Kong Special Administrative Region, China

    Ka Yan Lai, Chris Webster & Chinmoy Sarkar

  3. Urban Systems Institute, The University of Hong Kong, Hong Kong Special Administrative Region, China

    Chris Webster

  4. Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK

    John EJ Gallacher & Chinmoy Sarkar

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Lai, K.Y., Webster, C., Gallacher, J.E. et al. Associations of Urban Built Environment with Cardiovascular Risks and Mortality: a Systematic Review. J Urban Health 100, 745–787 (2023). https://doi.org/10.1007/s11524-023-00764-5

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