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.