Exploring non-linear relationships between neighbourhood walkability and health: a cross-sectional study among US primary care patients with chronic conditions

Levi Nicolas Bonnell, Austin R Troy, Benjamin Littenberg, Levi Nicolas Bonnell, Austin R Troy, Benjamin Littenberg

Abstract

Background: A recent study of licensed drivers found a non-linear relationship between density of non-residential destinations (NRDs), a proxy for walkability and body mass index (BMI) across a wide range of development patterns. It is unclear if this relationship can be replicated in a population with multiple chronic conditions or translated to health outcomes other than BMI.

Methods: We obtained health data and home addresses for 2405 adults with multiple chronic conditions from 44 primary care clinics across 13 states using the Integrating Behavioral health and Primary Care Trial. In this cross-sectional study, the relationships between density of NRDs (from a commercial database) within 1 km of the home address and self-reported BMI, and mental and physical health indices were assessed using several non-linear methods, including restricted cubic splines, LOWESS smoothing curves, non-parametric regression with a spline basis and piecewise linear regression.

Results: All methods demonstrated similar non-linear relationships. Piecewise linear regression was selected for ease of interpretation. BMI had a positive marginal rate of change below the NRD density inflection point of 15 establishments/hectare (β=+0.09 kg/m2/non-residential buildings ha-1; 95% CI +0.01 to +0.14), and a negative marginal rate of change above the inflection point (β=-0.02; 95% CI -0.06 to 0.02). Mental health decreased with NRD density below the inflection point (β=-0.24; 95% CI -0.31 to -0.17) and increased above it (β=+0.03; 95% CI -0.00 to +0.07). Results were similar for physical health (β= -0.28; 95% CI -0.35 to -0.20) and (β=+0.06; 95% CI 0.01 to +0.10).

Conclusion: Health indicators were the lowest in middle density (typically suburban) areas and got progressively better moving in either direction from the peak. NRDs may affect health differently depending on home-address NRD density.

Trial registration number: NCT02868983.

Keywords: mental health; public health; statistics & research methods.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Consort diagram of participants.
Figure 2
Figure 2
Non-parametric regression with a spline basis, LOWESS smoothing curve, restricted cubic splines and piecewise linear regression used to visualise BMI as a function of NRDs. (B) Non-parametric regression with a spline basis, LOWESS (locally weighted scatterplot smoothing) curve, restricted cubic splines and piecewise linear regression used to visualise mental health summary score as a function of NRDs. (C) Non-parametric regression with a spline basis, LOWESS smoothing curve, restricted cubic splines and piecewise linear regression used to visualise physical health summary score as a function of NRDs. BMI, body mass index; NRDs, non-residential destinations.

References

    1. Druss B, Walker E. Mental disorders and medical comorbidity the synthesis project; 2011. [Accessed 8 Jun 2011].
    1. U.S. Department of Health and Human Services . Physical activity guidelines for Americans. 2nd ed. Washington, DC: U.S. Department of Health and Human Services, 2018.
    1. Wingood M, Bonnell L, LaCroix AZ, et al. . Community-Dwelling older adults and physical activity recommendations: patterns of aerobic, strengthening, and balance activities. J Aging Phys Act 2021:1–13. 10.1123/japa.2021-0194
    1. U.S. Department of Health and Human Services . Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities. Washington, DC: U.S. Dept of Health and Human Services, Office of the Surgeon General; 2015.
    1. Ewing R, Cervero R. Travel and the built environment: a synthesis. Transportation Research Record 1780;2001:87–114.
    1. Creatore MI, Glazier RH, Moineddin R, et al. . Association of neighborhood Walkability with change in overweight, obesity, and diabetes. JAMA 2016;315:2211–20. 10.1001/jama.2016.5898
    1. Glazier RH, Creatore MI, Weyman JT, et al. . Density, destinations or both? A comparison of measures of walkability in relation to transportation behaviors, obesity and diabetes in Toronto, Canada. PLoS One 2014;9:e85295. 10.1371/journal.pone.0085295
    1. Jia P, Pan X, Liu F, et al. . Land use mix in the neighbourhood and childhood obesity. Obes Rev 2021;22 Suppl 1:e13098. 10.1111/obr.13098
    1. King TL, Bentley RJ, Thornton LE, et al. . Using kernel density estimation to understand the influence of neighbourhood destinations on BMI. BMJ Open 2016;6:e008878. 10.1136/bmjopen-2015-008878
    1. Rundle AG, Heymsfield SB. Can Walkable urban design play a role in reducing the incidence of obesity-related conditions? JAMA 2016;315:2175–7. 10.1001/jama.2016.5635
    1. Feng J, Glass TA, Curriero FC, et al. . The built environment and obesity: a systematic review of the epidemiologic evidence. Health Place 2010;16:175–90. 10.1016/j.healthplace.2009.09.008
    1. Roe J, Mondschein A, Neale C, et al. . The urban built environment, walking and mental health outcomes among older adults: a pilot study. Front Public Health 2020;8:575946. 10.3389/fpubh.2020.575946
    1. Evans GW. The built environment and mental health. J Urban Health 2003;80:536–55. 10.1093/jurban/jtg063
    1. Berke EM, Gottlieb LM, Moudon AV, et al. . Protective association between neighborhood walkability and depression in older men. J Am Geriatr Soc 2007;55:526–33. 10.1111/j.1532-5415.2007.01108.x
    1. Rachele JN, Sugiyama T, Davies S, et al. . Neighbourhood built environment and physical function among mid-to-older aged adults: a systematic review. Health Place 2019;58:102137. 10.1016/j.healthplace.2019.05.015
    1. Barnett DW, Barnett A, Nathan A, et al. . Built environmental correlates of older adults' total physical activity and walking: a systematic review and meta-analysis. Int J Behav Nutr Phys Act 2017;14:103. 10.1186/s12966-017-0558-z
    1. Cerin E, Nathan A, van Cauwenberg J, et al. . The neighbourhood physical environment and active travel in older adults: a systematic review and meta-analysis. Int J Behav Nutr Phys Act 2017;14:15. 10.1186/s12966-017-0471-5
    1. Sugiyama T, Neuhaus M, Cole R, et al. . Destination and route attributes associated with adults' walking: a review. Med Sci Sports Exerc 2012;44:1275–86. 10.1249/MSS.0b013e318247d286
    1. Day K. Built environmental correlates of physical activity in China: a review. Prev Med Rep 2016;3:303–16. 10.1016/j.pmedr.2016.03.007
    1. Troped PJ, Starnes HA, Puett RC, et al. . Relationships between the built environment and walking and weight status among older women in three U.S. states. J Aging Phys Act 2014;22:114–25. 10.1123/japa.2012-0137
    1. Booth GL, Creatore MI, Luo J, et al. . Neighbourhood walkability and the incidence of diabetes: an inverse probability of treatment weighting analysis. J Epidemiol Community Health 2019;73:287–94. 10.1136/jech-2018-210510
    1. Howell NA, Tu JV, Moineddin R, et al. . Association between neighborhood Walkability and predicted 10-year cardiovascular disease risk: the CANHEART (cardiovascular health in ambulatory care research team) cohort. J Am Heart Assoc 2019;8:e013146. 10.1161/JAHA.119.013146
    1. Braver NR, Rutters F, Wagtendonk AJ, et al. . Neighborhood walkability, physical activity and changes in glycemic markers in people with type 2 diabetes: the Hoorn diabetes care system cohort. Health Place 2021;69:102560. 10.1016/j.healthplace.2021.102560
    1. Boehmer TK, Lovegreen SL, Haire-Joshu D, et al. . What constitutes an obesogenic environment in rural communities? Am J Health Promot 2006;20:411–21. 10.4278/0890-1171-20.6.411
    1. Zhang X, Zhang M, Zhao Z, et al. . Obesogenic environmental factors of adult obesity in China: a nationally representative cross-sectional study. Environmental Research Letters 2020;15:044009. 10.1088/1748-9326/ab6614
    1. Rutt CD, Coleman KJ. Examining the relationships among built environment, physical activity, and body mass index in El Paso, tx. Prev Med 2005;40:831–41. 10.1016/j.ypmed.2004.09.035
    1. Troy AR, Bonnell LN, Littenberg B. Relationship between the built environment and body mass index in a rural context: a cross-sectional study from Vermont. Cureus 2018;10:e3040. 10.7759/cureus.3040
    1. Bonnell LN, Troy AR, Littenberg B. Nonlinear relationship between nonresidential destinations and body mass index across a wide range of development. Prev Med 2021;153:106775. 10.1016/j.ypmed.2021.106775
    1. Crocker AM, Kessler R, van Eeghen C, et al. . Integrating behavioral health and primary care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial. Trials 2021;22:200. 10.1186/s13063-021-05133-8
    1. Buehler R, Pucher J, Merom D, et al. . Active travel in Germany and the U.S. contributions of daily walking and cycling to physical activity. Am J Prev Med 2011;41:241–50. 10.1016/j.amepre.2011.04.012
    1. Pucher J, Buehler R, Merom D, et al. . Walking and cycling in the United States, 2001-2009: evidence from the National household travel surveys. Am J Public Health 2011;101 Suppl 1:S310–7. 10.2105/AJPH.2010.300067
    1. Butler DC, Petterson S, Phillips RL, et al. . Measures of social deprivation that predict health care access and need within a rational area of primary care service delivery. Health Serv Res 2013;48:539–59. 10.1111/j.1475-6773.2012.01449.x
    1. Rural Health Research Center (RHRC) . Rural-Urban commuting area codes (RUCAs), 2008. Available:
    1. Khan S, Pinault L, Tjepkema M, et al. . Positional accuracy of geocoding from residential postal codes versus full street addresses. Health Rep 2018;29:3–9.
    1. Royston P. Lowess smoothing. Stata Tech Bull Reprints 1991;1:41–4.
    1. Moran PAP. Notes on continuous stochastic phenomena. Biometrika 1950;37:17–23.
    1. Anselin L, Syabri I, Kho Y. GeoDa: An Introduction to Spatial Data Analysis. In: Fischer MM, Getis A, eds. Handbook of applied spatial analysis: software tools, methods and applications. Berlin, Heidelberg: Springer Berlin Heidelberg, 2010: 73–89.
    1. Jia P, Yu C, Remais JV, et al. . Spatial lifecourse epidemiology reporting standards (ISLE-ReSt) statement. Health Place 2020;61:102243. 10.1016/j.healthplace.2019.102243
    1. Stierman BAJ, Carroll MD, Chen TC, Davy O, Fink S. National health and nutrition examination survey 2017–March 2020 prepandemic data files—Development of files and prevalence estimates for selected health outcomes National Health Statistics Reports; no 158. Hyattsville, MD: National Center for Health Statistics; 2021.
    1. Bassett DR, Tremblay MS, Esliger DW, et al. . Physical activity and body mass index of children in an old order Amish community. Med Sci Sports Exerc 2007;39:410–5. 10.1249/mss.0b013e31802d3aa7
    1. Bassett DR, Schneider PL, Huntington GE. Physical activity in an old order Amish community. Med Sci Sports Exerc 2004;36:79–85. 10.1249/01.MSS.0000106184.71258.32
    1. Roy B, Hajduk AM, Tsang S, et al. . The association of neighborhood walkability with health outcomes in older adults after acute myocardial infarction: the SILVER-AMI study. Prev Med Rep 2021;23:101391. 10.1016/j.pmedr.2021.101391
    1. Dark SJ, Bram D. The modifiable areal unit problem (MAUP) in physical geography. Progress in Physical Geography: Earth and Environment 2007;31:471–9.
    1. Le A, Judd SE, Allison DB, et al. . The geographic distribution of obesity in the US and the potential regional differences in misreporting of obesity. Obesity 2014;22:300–6. 10.1002/oby.20451
    1. Williamson EJ, Walker AJ, Bhaskaran K, et al. . Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020;584:430–6. 10.1038/s41586-020-2521-4

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