Where the heart is: The impact of the neighbourhood built environment on cardiovascular health

While lifestyle behaviours such as diet and physical activity influence cardiovascular disease (CVD) risk, these are shaped by the built environment, the human-made or modified spaces where we spend most of our lives. This PhD thesis investigates how the neighbourhood built environment features affect cardiometabolic health, CVD outcomes, and mortality in adults.

Chapter 2 presents an umbrella review of 51 systematic reviews, identifying strong evidence that air pollution, residential noise, and high ambient temperatures increase CVD risk, while greenspace exposure may offer protection. Evidence for other built environment factors remains limited.

Chapter 3 focuses on food environments. A systematic review found that higher fast-food outlet density is often linked to increased CVD prevalence, incidence, and mortality, though findings vary. A longitudinal study of 4.2 million adults showed that unhealthy food environments are associated with higher mortality from obesity-related diseases, particularly cardiometabolic conditions.

In Chapter 4, a national study of 3 million Dutch adults revealed that compared to persistently high walkable neighbourhoods, both persistently low and increasing neighbourhood walkability over time were associated with a higher incidence of CVD.

Chapter 5 focused on whether obesogenic neighbourhood environments, which includes various aspects from the food and physical activity environment, affect clinical CVD risk factors and long-term CVD incidence. We used a previously developed Obesogenic Built-environmental CharacterisTics (OBCT) index, to quantify the obesogenicity of neighbourhoods. Cross-sectional and longitudinal analyses showed that more obesogenic neighbourhoods were associated with higher BMI, obesity, hypertension, and waist circumference. These association with waist-circumference was moderated by sociodemographic and psychological factors and partially mediated by diet and physical acitivity. In a cohort of 4.4 million adults, more obesogenic environments were linked to increased 14-year CVD risk.

This thesis highlights the impact of the built environment on cardiovascular health. Findings support the need for high-resolution environmental exposure data and large-scale population studies to inform urban planning and public health policies aimed at creating healthier neighbourhoods and reducing CVD risk.