Does urban greenness reduce loneliness and social isolation among Canadians? A cross-sectional study of middle-aged and older adults of the Canadian Longitudinal Study on Aging (CLSA).

OBJECTIVES: Urban greenness has been shown to confer many health benefits including reduced risks of chronic disease, depression, anxiety, and, in a limited number of studies, loneliness. In this first Canadian study on this topic, we investigated associations between residential surrounding greenness and loneliness and social isolation among older adults. METHODS: This cross-sectional analysis of the Canadian Longitudinal Study on Aging included 26,811 urban participants between 45 and 86 years of age. The Normalized Difference Vegetation Index (NDVI), a measure of greenness, was assigned to participants' residential addresses using a buffer distance of 500 m. We evaluated associations between the NDVI and (i) self-reported loneliness using the Center for Epidemiological Studies Depression Scale, (ii) whether participants reported "feeling lonely living in the local area", and (iii) social isolation. Logistic regression models were used to characterize associations between greenness and loneliness/social isolation while adjusting for individual socio-economic and health behaviours. RESULTS: Overall, 10.8% of participants perceived being lonely, while 6.5% reported "feeling lonely in their local area". Furthermore, 16.2% of participants were characterized as being socially isolated. In adjusted models, we observed no statistically significant difference (odds ratio (OR) = 0.99; 95% confidence interval (CI) 0.93-1.04) in self-reported loneliness in relation to an interquartile range (IQR) increase of NDVI (0.06). However, for the same change in greenness, there was a 15% (OR = 0.85; 95% CI 0.72-0.99) reduced risk for participants who strongly agreed with "feeling lonely living in the local area". For social isolation, for an IQR increase in the NDVI, we observed a 7% (OR = 0.93; 95% CI 0.88-0.97) reduction in prevalence. CONCLUSION: Our findings suggest that urban greenness plays a role in reducing loneliness and social isolation among Canadian urbanites.

RéSUMé: OBJECTIFS: Il est démontré que la verdure urbaine confère de nombreux avantages pour la santé; elle réduit notamment les risques de maladies chroniques, de dépression et d'anxiété et, selon un petit nombre d'études, le risque de solitude. Dans cette première étude canadienne sur le sujet, nous avons étudié les associations entre la verdure de l'environnement résidentiel et la solitude et l'isolement social chez les adultes d'âge mûr. MéTHODE: Cette analyse transversale de l'Étude longitudinale canadienne sur le vieillissement a inclus 26 811 participantes et participants urbains de 45 à 86 ans. L'indice de végétation par différence normalisée (IVDN), un indicateur de verdure, a été assigné à l'adresse domiciliaire dans une zone tampon de 500 m. Nous avons évalué les associations entre l'IVDN et i) la solitude autodéclarée selon l'échelle de dépression du Center for Epidemiological Studies, ii) le fait de déclarer « vivre de la solitude dans sa zone locale ¼ et iii) l'isolement social. Des modèles de régression logistique ont servi à caractériser les associations entre la verdure et la solitude/l'isolement social, et nous avons apporté des ajustements pour tenir compte du statut socioéconomique et des comportements de santé individuels. RéSULTATS: Globalement, 10,8 % des participantes et des participants se sentaient seuls, et 6,5 % disaient « vivre de la solitude dans leur zone locale ¼. De plus, 16,2 % des participantes et des participants ont été caractérisés comme étant socialement isolés. Dans nos modèles ajustés, nous n'avons observé aucun écart significatif (rapport de cotes (RC) = 0,99; IC de 95 % : 0,93­1,04) dans la solitude autodéclarée en lien avec une augmentation de l'écart interquartile (EI) de l'IVDN (0,06). Cependant, pour le même changement dans la verdure, la probabilité pour les participantes et les participants d'être tout à fait d'accord avec l'énoncé qu'ils « vivent de la solitude dans leur zone locale ¼ était réduite de 15 % (RC = 0,85, IC de 95 % : 0,72­0,99). Et pour chaque augmentation de l'EI de l'IVDN, nous avons observé une baisse de 7 % (RC = 0,93, IC de 95 % : 0,88­0,97) de la prévalence de l'isolement social. CONCLUSION: Nos constatations indiquent que la verdure urbaine joue un rôle dans la réduction de la solitude et de l'isolement social chez les citadins et citadines au Canada.

Neighborhood Fast-Food Environments and Hypertension in Canadian Adults.

INTRODUCTION: Hypertension is a leading cause of cardiovascular disease and premature death worldwide. Neighborhoods characterized by a high proportion of fast-food outlets may also contribute to hypertension in residents; however, limited research has explored these associations. This cross-sectional study assessed the associations between neighborhood fast-food environments, measured hypertension, and self-reported hypertension. METHODS: Data from 10,700 adults living in urban areas were obtained from six Canadian Health Measures Survey cycles (2007-2019). Each participant's blood pressure was measured at a mobile clinic six times. Measured hypertension was defined as having an average systolic blood pressure ≥140 or a diastolic blood pressure ≥90 mm Hg or being on blood pressure-lowering medication. Participants were also asked whether they had been diagnosed with high blood pressure or whether they take blood pressure-lowering medication (i.e., self-reported hypertension). The proportion of fast-food outlets relative to the sum of fast-food outlets and full-service restaurants in each participant's neighborhood was obtained from the Canadian Food Environment Dataset, and analyses were conducted in 2022. RESULTS: The mean proportion of fast-food outlets was 23.3% (SD=26.8%). A one SD increase in the proportion of fast-food outlets was associated with higher odds of measured hypertension in the full sample (OR=1.17, 95% CI=1.05, 1.31) and in sex-specific models (women: OR=1.14, 95% CI=1.01, 1.29; men: OR=1.21, 95% CI=1.03, 1.43). Associations between the proportion of fast-food outlets and self-reported hypertension were inconclusive. CONCLUSIONS: Findings suggest that reducing the proportion of fast-food restaurants in neighborhoods may be a factor that could help reduce hypertension rates.

Associations of free sugars from solid and liquid sources with cardiovascular disease: a retrospective cohort analysis.

BACKGROUND: The World Health Organization recommends a 10% total energy (TE%) limit for free sugars (i.e., added sugars and naturally occurring sugars in fruit juice, honey, and syrups) based on evidence linking higher intakes with overweight and dental caries. Evidence for cardiovascular disease (CVD) is limited. Impacts may differ by sex, age group, and solid vs. liquid sources; liquids may stimulate more adverse CVD profiles (due to their rapid absorption in the body along along with triggering less satiety). We examined associations of consuming total free sugars ≥ 10 TE% with CVD within four sex and age-defined groups. Given roughly equal free sugar intakes from solid and liquid sources, we also evaluated source-specific associations of free sugars ≥ 5 TE% thresholds. METHODS: In this retrospective cohort study, we estimated free sugars from 24-h dietary recall (Canadian Community Health Survey, 2004-2005) in relationship to nonfatal and fatal CVD (Discharge Abstract and Canadian Mortality Databases, 2004-2017; International Disease Classification-10 codes for ischemic heart disease and stroke) through multivariable Cox proportional hazards models adjusted for overweight/obesity, health behaviours, dietary factors, and food insecurity. We conducted analyses in separate models for men 55 to 75 years, women 55 to 75 years, men 35 to 55 years, and women 35 to 55 years. We dichotomized total free sugars at 10 TE% and source-specific free sugars at 5 TE%. RESULTS: Men 55 to 75 years of age had 34% higher CVD hazards with intakes of free sugars from solid sources ≥ 5 TE% vs. below (adjusted HR 1.34, 95% CI 1.05- 1.70). The other three age and sex-specific groups did not demonstrate conclusive associations with CVD. CONCLUSIONS: Our findings suggest that from a CVD prevention standpoint in men 55 to 75 years of age, there may be benefits from consuming less than 5 TE% as free sugars from solid sources.

Income inequality and population health: a political-economic research agenda.

There is more than 30 years of research on relationships between income inequality and population health. In this article, we propose a research agenda with five recommendations for future research to refine existing knowledge and examine new questions. First, we recommend that future research prioritise analyses with broader time horizons, exploring multiple temporal aspects of the relationship. Second, we recommend expanding research on the effect of public expenditures on the inequality-health relationship. Third, we introduce a new area of inquiry focused on interactions between social mobility, income inequality and population health. Fourth, we argue the need to examine new perspectives on 21st century capitalism, specifically the population health impacts of inequality in income from capital (especially housing), in contrast to inequality in income from labour. Finally, we propose that this research broaden beyond all-cause mortality, to cause-specific mortality, avoidable mortality and subcategories thereof. We believe that such a research agenda is important for policy to respond to the changes following the COVID-19 pandemic.

An international comparative study of active living environments and hospitalization for Wales and Canada.

Rationale: Previous studies indicate active living environments (ALEs) are associated with higher physical activity levels across different geographic contexts, and could lead to reductions in hospital burden. Both Wales UK and Canada have advanced data infrastructure that allows record linkage between survey data and administrative health information. Objective: To assess the relationship between ALEs and hospitalization in Wales and Canada. Methods: We performed a population-based comparison using individual-level survey data from the Welsh Health Survey (N = 9968) linked to the Patient Episode Database for Wales, and the Canadian Community Health Survey (N = 40,335) linked to the Discharge Abstract Database. Using equivalent protocols and open-source data for street networks, destinations, and residential density, we derived 5-class measures of the ALE for Wales and Canada (classed 1 through 5, considered least favourable to most favourable for active living, respectively). We evaluated relationships of ALEs to health, behaviours and hospitalization using multivariate regression (reference group was the lowest ALE class 1, considered least favourable for active living). Results: For Canada, those living in the highest ALE class 5 had lower odds of all-cause hospitalization (OR 0.66, 95% CI 0.54 to 0.81; as compared to the lowest ALE class 1). In contrast, those living in the highest ALE class 5 in Wales had higher odds of all-cause hospitalization (OR 1.37, 95% CI 1.04 to 1.80). The relationship between ALEs and cardiometabolic hospitalization was inconclusive for Canada (OR 0.75, 95% CI 0.50 to 1.12), but we observed higher odds of cardiometabolic hospitalization for respondents living in higher ALE classes for Wales (OR 1.46, 95% CI 1.10 to 1.78; comparing ALE class 4 to ALE class 1). Conclusion: Canadian respondents living in high ALE neighbourhoods that are understood to be favourable for active living had lower odds of all-cause hospitalization, whereas Welsh respondents living in high ALEs that were deemed favourable for active living exhibited higher odds of all-cause hospitalization. Environments which promote physical activity in one geographic context may not do so in another. There remains a need to identify relevant context-specific factors that encourage active living.

Does living near hospital obscure the association between active living environments and hospitalization?

Hospitals tend to be among the destinations that make densely populated, well-connected neighbourhoods more conducive to active living. In this study, we determined whether living near a hospital distorts the association between living in favourable ALEs and hospitalization for physical inactivity-related cardiometabolic diseases. We used a record linkage of 442,345 respondents of the Canadian Community Health Survey and their hospitalization records for cardiometabolic disease. We then assessed respondents' neighbourhoods using the Canadian Active Living Environments measure (Can-ALE), a measure based on ≥3-way intersection density, residential density, and points of interest. We then calculated the distance in kilometers between the centroids of respondents' assigned dissemination areas and the nearest user-contributed location for hospitals from OpenStreetMap. We monitored changes in estimates for the association between ALEs and odds of cardiometabolic disease hospitalization using a series of logistic regressions with indicator variables for distances to hospital of 500 meters to 10 kilometers. We found that living between 500 meters and six kilometers of a hospital and was associated with modestly higher odds of cardiometabolic hospitalization (OR 1.10, 95% CI 1.02 to 1.18 for 500 meters; OR 1.05, 95% CI 1.01 to 1.09 for six kilometers). Living in more favourable ALEs was associated with lower odds of hospitalization (OR 0.79, 95% CI 0.68 to 0.91; comparing the most favourable to least favourable ALEs). Effect estimates between more favourable ALEs and lower odds of hospitalization were marginally strengthened when living within 2-6 kilometers to a hospital was accounted for. This study demonstrates the importance of disentangling interrelated geographic factors and underlines the potential for built environments to elicit reductions in health care.

A Systematic Review and Narrative Synthesis of the Evolution of Adolescent and Young Adult Cannabis Consumption Before and After Legalization.

PURPOSE: To systematically review evidence assessing the evolution of cannabis consumption before and after the implementation of non-medical cannabis legislation. METHODS: MEDLINE, PubMED, PsycINFO, Scopus, and Web of Science were systematically searched for studies that examined change in cannabis consumption before and after nonmedical cannabis legislation. Data were tabulated by study design, levels of consumption, and individual subgroups. Data were analyzed using a narrative synthesis approach, considering study quality. RESULTS: 32 studies were included (11 higher quality and 21 lower quality). 40% of higher quality evidence supported an increase in postlegalization consumption (55% did not report a change and 5% reported a decrease). The increase was most evident for young adults (42% of higher quality evidence) and in the consumption in the past month (37% of higher quality evidence). There was limited supporting evidence for new users having grown in response to legalization. Based on subgroup analysis, the increase in postlegalization consumption was higher among women and those who engage in binge-drinking. CONCLUSIONS: Higher quality evidence suggests an increase in adolescent past-month consumption of cannabis following legalization in several geographical jurisdictions. Consumption evolution prelegalization and postlegalization differed by age group and for young women and for binge drinkers. Consumption evolution differences suggest a variety of strategies might be required in efforts to lower public health impacts of cannabis consumption following legalization.

A pan-Canadian dataset of neighbourhood retail food environment measures using Statistics Canada's Business Register.

BACKGROUND: The objective of this study was to create the Canadian Food Environment Dataset (Can-FED) and to demonstrate its validity. DATA AND METHODS: Food outlet data were extracted from Statistics Canada's Business Register (BR) in 2018. Retail food environment access measures (both absolute and relative measures) were calculated using network buffers around the centroid of 56,589 dissemination areas in Canada. A k-medians clustering approach was used to create categorical food environment variables that were easy to use and amenable to dissemination. Validity of the measures was assessed by comparing the food environment measures from Can-FED with measures created using Enhanced Points of Interest data by DMTI Spatial Inc. and data from a municipal health inspection list. Validity was also assessed by calculating the geographic variability in food environments across census metropolitan areas (CMAs) and assessing associations between CMA-level food environments and CMA-level health indicators. RESULTS: Two versions of Can-FED were created: a researcher file that must be accessed within a secure Statistics Canada environment and a general-use file available online. Agreement between Can-FED food environment measures and those derived from a proprietary dataset and a municipal health inspection list ranged from rs=0.28 for convenience store density and rs=0.53 for restaurant density. At the CMA level, there is wide geographic variation in the food environment with evidence of patterning by health indicators. INTERPRETATION: Can-FED is a valid and accessible dataset of pan-Canadian food environment measures that was created from the BR, a data source that has not been explored fully for health research.

Increased urban greenness associated with improved mental health among middle-aged and older adults of the Canadian Longitudinal Study on Aging (CLSA).

OBJECTIVES: Some studies suggest that residential surrounding greenness is associated with improved mental health. Few of these studies have focussed on middle-aged and older adults, explored the modifying effects of social determinants of health, or accounted for the extent to which individuals interact with their neighbourhood environments. METHODS: We analysed cross-sectional data collected from 26,811 urban participants of the Canadian Longitudinal Study of Aging who were between 45 and 86 years of age. Participants provided details on socioeconomic characteristics, health behaviours, and their frequency of neighbourhood interactions. The Normalized Difference Vegetation Index (NDVI), a measure of greenness, was assigned to participants' residential addresses at a buffer distance of 500 m. Four self-reported measures of mental health were considered: The Center for Epidemiologic Studies Depression Scale (CES-D-10; short scale), past diagnosis of clinical depression, perceptions of mental health, and the Satisfaction with Life Scale (SWLS). Regression models were used to describe associations between greenness and these outcomes, and spline models were fit to characterize the exposure-response function between greenness and CES-D-10 scores. Stratified analyses evaluated whether associations varied by sociodemographic status. RESULTS: In adjusted models, we observed a 5% (Odds Ratio (OR) = 0.95; 95% CI = 0.90, 0.99) reduced odds of depressive symptoms in relation to an interquartile range increase of NDVI (0.06) within a 500 m buffer of the participant's residence. Similarly, we found an inverse association with a self-reported clinical diagnosis of depression (OR = 0.97; 95% CI = 0.92-1.01). Increases in surrounding greenness were associated with improved perceptions of mental health, and the SWLS. Our spline analyses found that beneficial effects between greenness and the CES-D-10 were strongest among those of lower income. CONCLUSIONS: These findings suggest that residential greenness has mental health benefits, and that interventions to increase urban greenness can help reduce social inequalities in mental health.

Are school-based measures of walkability and greenness associated with modes of commuting to school? Findings from a student survey in Ontario, Canada.

OBJECTIVES: In Canada, students are increasingly reliant on motorized vehicles to commute to school, and few meet the recommended overall physical activity guidelines. Infrastructure and built environments around schools may promote active commuting to and from school, thereby increasing physical activity. To date, few Canadian studies have examined this research question. METHODS: This study is a cross-sectional analysis of 11,006 students, aged 11-20, who participated in the 2016/2017 Ontario Student Drug Use and Health Survey. The remote sensing-derived Normalized Difference Vegetation Index (NDVI), at a buffer of 500 m from the schools' locations, was used to characterize greenness, while the 2016 Canadian Active Living Environments (Can-ALE) measure was used for walkability. Students were asked about their mode of regular commuting to school, and to provide information on several socio-demographic variables. Multivariable logistic regression models were used to quantify associations between active commuting and greenness and the Can-ALE. The resulting odds ratios, and their 95% confidence intervals, were adjusted for a series of risk factors that were collected from the survey. RESULTS: Overall, 21% of students reported active commuting (biking or walking) to school, and this prevalence decreased with increasing age. Students whose schools had higher Can-ALE scores were more likely to be active commuters. Specifically, the adjusted odds ratio (OR) of being an active commuter for schools in the highest quartile of the Can-ALE was 2.11 (95% CI = 1.64, 2.72) when compared with those in the lowest. For children, aged 11-14 years, who attended schools in high dwelling density areas, a higher odds of active commuting was observed among those in the upper quartile of greenness relative to the lowest (OR = 1.41; 95% CI = 0.92, 2.15). In contrast, for lower dwelling density areas, greenness was inversely associated with active commuting across all ages. CONCLUSION: Our findings suggest that students attending schools with higher Can-ALE scores are more likely to actively commute to school, and that positive impacts of greenness on active commuting are evident only in younger children in more densely populated areas. Future studies should collect more detailed data on residential measures of the built environment, safety, distance between home and school, and mixed modes of commuting behaviours.

RéSUMé: OBJECTIFS: Au Canada, les élèves comptent de plus en plus sur les véhicules à moteur pour faire le trajet entre la maison et l'école, et ils sont peu nombreux à avoir des niveaux d'activité physique globaux conformes aux recommandations des lignes directrices. Les infrastructures et les milieux bâtis autour des écoles pourraient promouvoir les déplacements actifs entre la maison et l'école, faisant ainsi augmenter l'activité physique. Jusqu'à maintenant toutefois, très peu d'études canadiennes ont examiné cette question de recherche. MéTHODE: La présente étude est une analyse transversale de 11 006 élèves de 11 à 20 ans ayant participé au Sondage sur la consommation de drogues et la santé des élèves de l'Ontario en 2016-2017. L'indice de végétation par différence normalisée (IVDN) dérivé par télédétection, utilisé dans un rayon de 500 m des établissements scolaires, a servi à caractériser la verdure, et l'indice d'accessibilité à la vie active dans les milieux de vie au Canada (AVA-Can) a servi à caractériser la marchabilité. Les élèves ont répondu à une question sur leur mode de transport habituel pour se rendre à l'école et donné des informations sur plusieurs variables sociodémographiques. Des modèles de régression logistique multivariée ont servi à chiffrer les associations entre les déplacements actifs, la verdure et l'AVA-Can. Les rapports de cotes ainsi obtenus, et leurs intervalles de confiance de 95 %, ont été ajustés en fonction d'une série de facteurs de risque retracés dans l'enquête. RéSULTATS: Dans l'ensemble, 21 % des élèves ont dit utiliser un mode de déplacement actif (vélo ou marche) pour se rendre à l'école, et cette prévalence était inversement liée à l'âge. Les élèves dont les écoles avaient un indice Can-ALE élevé étaient plus susceptibles d'employer un mode de transport actif. Spécifiquement, le rapport de cotes (RC) ajusté pour le fait de se rendre à l'école par un mode de transport actif dans le quartile supérieur de l'indice Can-ALE était de 2,11 (IC de 95 % = 1,64, 2,72) comparativement au quartile inférieur. Pour les enfants (11 à 14 ans) fréquentant des écoles dans des zones à forte densité d'habitation, des probabilités plus élevées de déplacements actifs ont été observées chez ceux du quartile de verdure supérieur que chez ceux du quartile inférieur (RC = 1,41; IC de 95 % = 0,92, 2,15). Par contre, dans les zones à faible densité d'habitation, la verdure étaient inversement associée aux déplacements actifs, à tout âge. CONCLUSION: Nos constatations indiquent que les élèves fréquentant des écoles dont l'indice Can-ALE est élevé sont plus susceptibles d'utiliser un mode de déplacement actif pour se rendre à l'école, et que l'effet positif de la verdure n'est manifeste que chez les jeunes enfants, dans les zones urbaines densément peuplées. Les études futures devraient obtenir des données plus détaillées sur les indicateurs résidentiels du milieu bâti, la sécurité, la distance entre la maison et l'école et les modes de déplacement mixtes.

Moving to policy-amenable options for built environment research: The role of micro-scale neighborhood environment in promoting walking.

BACKGROUND: Altering micro-scale features of neighborhoods (e.g., the presence and condition of benches, sidewalks, trees, crossing signals, walking paths) could be a relatively cost-effective method of creating environments that are conducive to physical activity. The Virtual Systematic Tool for Evaluating Pedestrian Streetscapes (Virtual-STEPS) was created to virtually audit the microscale environment of cities using Google Street View (GSV). The objective of this study was to evaluate the collective influence of items from the Virtual-STEPS tool on walking outcomes (utilitarian walking and walking for leisure), while accounting for self-selection of walkers into walking-friendly neighborhoods. METHODS: Adults (N = 1403) were recruited from Montreal and Toronto from neighborhoods stratified by their level of macro-scale walking-friendliness and walking rates. The micro-scale environment of 5% of street segments from the selected neighborhoods was audited using the Virtual-STEPS tool and a micro-scale environment score was assigned. The scores were then linked to each respondent from the survey. A multilevel logistic regression analysis was used to model the relationship between the micro-scale environment score and odds of both utilitarian walking (i.e., walking for purpose such as to go shopping or go to work or school) and walking for leisure for at least 150 min per week, while accounting for environmental and demographic covariates as well as self-selection. RESULTS: Micro-scale neighborhood features were associated with elevated odds of walking for leisure (OR: 1.14, CI: 1.04-1.25). The association between micro-scale neighborhood features and walking for utilitarian purposes was, however, inconclusive (OR: 1.01, CI: 0.90-1.13). On the other hand, macro-scale walk-friendliness was associated with elevated odds of walking for utilitarian purposes (OR: 2.01, CI:1.42-2.84) and the association between macro-scale features and leisure walking was inconclusive (OR: 1.02, CI: 0.78-1.34). CONCLUSIONS: Our results imply that micro-scale features of neighborhoods collectively promote leisure walking but not necessarily utilitarian walking, even after accounting for self-selection. In contrast, macro-scale features may collectively promote utilitarian walking, but not leisure walking. Micro scale features of neighborhoods fall within the budget of local jurisdictions and our results suggest that jurisdictions that improve micro-scale features may expect increased leisure walking in populations.

Healthy built environment: Spatial patterns and relationships of multiple exposures and deprivation in Toronto, Montreal and Vancouver.

BACKGROUND: Various aspects of the urban environment and neighbourhood socio-economic status interact with each other to affect health. Few studies to date have quantitatively assessed intersections of multiple urban environmental factors and their distribution across levels of deprivation. OBJECTIVES: To explore the spatial patterns of urban environmental exposures within three large Canadian cities, assess how exposures are distributed across socio-economic deprivation gradients, and identify clusters of favourable or unfavourable environmental characteristics. METHODS: We indexed nationally standardized estimates of active living friendliness (i.e. "walkability"), NO2 air pollution, and greenness to 6-digit postal codes within the cities of Toronto, Montreal and Vancouver. We compared the distribution of within-city exposure tertiles across quintiles of material deprivation. Tertiles of each exposure were then overlaid with each other in order to identify potentially favorable (high walkability, low NO2, high greenness) and unfavorable (low walkability, high NO2, and low greenness) environments. RESULTS: In all three cities, high walkability was more common in least deprived areas and less prevalent in highly deprived areas. We also generally saw a greater prevalence of postal codes with high vegetation indices and low NO2 in areas with low deprivation, and a lower greenness prevalence and higher NO2 concentrations in highly deprived areas, suggesting environmental inequity is occurring. Our study showed that relatively few postal codes were simultaneously characterized by desirable or undesirable walkability, NO2and greenness tertiles. DISCUSSION: Spatial analyses of multiple standardized urban environmental factors such as the ones presented in this manuscript can help refine municipal investments and policy priorities. This study illustrates a methodology to prioritize areas for interventions that increase active living and exposure to urban vegetation, as well as lower air pollution. Our results also highlight the importance of considering the intersections between the built environment and socio-economic status in city planning and urban public health decision-making.

Active living environments, physical activity and premature cardiometabolic mortality in Canada: a nationwide cohort study.

OBJECTIVE: To evaluate sex-specific and age-specific associations of active living environments (ALEs) with premature cardiometabolic mortality. DESIGN: Population-based retrospective cohort study. SETTING: Residential neighbourhoods (1000-metre circular buffers from the centroids of dissemination areas) across Canada for which the Canadian ALE Measure was derived, based on intersection density, points of interest and dwelling density. PARTICIPANTS: 249 420 survey respondents from an individual-level record linkage between the Canadian Community Health Survey (2000-2010) and the Canadian Mortality Database until 2011, comprised of older women (65-85 years), older men (65-81 years), middle-aged women (45-64 years) and middle-aged men (45-64 years). PRIMARY OUTCOME MEASURES: Premature cardiometabolic mortality and average daily energy expenditure attributable to walking. Multivariable proportional hazards regression models were adjusted for age, educational attainment, dissemination area-level median income, smoking status, obesity, the presence of chronic conditions, season of survey response and survey cycle. RESULTS: Survey respondents contributed a total of 1 451 913 person-years. Greater walking was observed in more favourable ALEs. Walking was associated with lower cardiometabolic death in all groups except for middle-aged men. Favourable ALEs conferred a 22% reduction in death from cardiometabolic causes (HR 0.78, 95% CI 0.63 to 0.97) for older women. CONCLUSIONS: On average, people walk more in favourable ALEs, regardless of sex and age. With the exception of middle-aged men, walking is associated with lower premature cardiometabolic death. Older women living in neighbourhoods that favour active living live longer.

Neighbourhood retail food outlet access, diet and body mass index in Canada: a systematic review. / Accès aux points de vente d'aliments au détail de proximité, alimentation et indice de masse corporelle au Canada : revue systématique.

INTRODUCTION: There is growing interest in the role of food environments in suboptimal diet and overweight and obesity. This review assesses the evidence for the link between the retail food environment, diet quality and body mass index (BMI) in the Canadian population. METHODS: We conducted a systematic keyword search in two bibliometric databases. We tabulated proportions of conclusive associations for each outcome and exposure of interest. Absolute and relative measures of exposure to the food environment were compared and theoretical framing of the associations noted. We assessed two key methodological issues identified a priori-measurement of BMI, and validation of the underlying retail food environment data. RESULTS: Seventeen studies were included in the review. There was little evidence of a food environment-diet quality relationship and modest evidence of a food environment-BMI relationship. Relative measures of the food environment were more often associated with an outcome in the expected direction than absolute measures, but many results were inconclusive. Most studies adopted ecological theoretical frameworks but methodologies were similar regardless of stated theoretical approaches. Self-reported BMI was common and there was no "gold standard" database of food outlets nor a consensus on best ways to validate the data. CONCLUSION: There was limited evidence of a relationship between the food environment and diet quality, but stronger evidence of a relationship between the food environment and BMI for Canadians. Studies with broad geographic scope that adopt innovative methods to measure diet and health outcomes and use relative measures of the food environment derived in geographic information systems are warranted. Consensus on a gold standard food environment database and approaches to its validation would also advance the field.

The association between walkable neighbourhoods and physical activity across the lifespan.

BACKGROUND: Walkability is positively associated with physical activity in adults. Walkability is more consistently associated with walking for transportation than recreational walking. The purpose of this study is to examine how the association between walkable neighbourhoods and physical activity varies by age and type of physical activity using a new Canadian walkability database. DATA AND METHODS: The 2016 Canadian Active Living Environments (Can-ALE) database was attached to two cross-sectional health surveys: the Canadian Health Measures Survey (CHMS; 2009 to 2015) and the Canadian Community Health Survey (CCHS; 2015 to 2016). Physical activity was measured in the CHMS using the Actical accelerometer (n = 10,987; ages 3 to 79). Unorganized physical activity outside of school among children aged 3 to 11 was reported by parents in the CHMS (n = 4,030), and physical activity data by type (recreational, transportation-based, school-based, and household and occupational) was self-reported by respondents in the CCHS (n = 105,876; ages 12 and older). RESULTS: Walkability was positively associated with accelerometer-measured moderate-to-vigorous physical activity in youth (p < 0.05), younger adults (p < 0.0001) and older adults (p < 0.05), while walkability was negatively associated with light physical activity in youth (ages 12 to 17) and older adults (ages 60 to 79) (p < 0.05). Walkability was positively associated with self-reported transportation-based physical activity in youth (p < 0.001) and adults of all ages (p < 0.0001). Walkability was negatively associated with parent-reported unorganized physical activity of children aged 5 to 11, and children living in the most walkable neighbourhoods accumulated 10 minutes of physical activity less-on average-than those living in the least walkable neighbourhoods. DISCUSSION: The results of this study are consistent with previous studies indicating that walkability is more strongly associated with physical activity in adults than in children and that walkability is associated with transportation-based physical activity. Walkability is one of many built environment factors that may influence physical activity. More research is needed to identify and understand the built environment factors associated with physical activity in children and with recreational or leisure-time physical activity.

An examination of the associations between walkable neighbourhoods and obesity and self-rated health in Canadians.

BACKGROUND: Two-thirds of Canadian adults and one-third of Canadian children and youth are overweight or obese. There is increased interest in identifying features of the built environment-such as walkability-that facilitate lifestyle habits associated with reduced obesity and improved health. The purpose of this study is to examine how the associations between walkability and both obesity and self-rated health vary by age in Canadians using a new walkability dataset. DATA AND METHODS: The 2016 Canadian Active Living Environments (Can-ALE) database was attached to Canadian Health Measures Survey (CHMS; 2009 to 2015) data. Moderate-to-vigorous physical activity (MVPA), light physical activity (LPA) and step counts were measured in the CHMS using the Actical accelerometer (n = 10,852; ages 3 to 79). Body mass index (BMI) and waist circumference were measured in a mobile clinic. Self-rated general and mental health were assessed using a questionnaire. RESULTS: The percentage of adults aged 40 to 59 classified as overweight or obese was 28 percentage points lower in the most walkable Can-ALE category than in the least walkable category (49.1% vs. 77.5%, p < 0.0125). There was a significant downward linear trend in measured BMI and waist circumference across Can-ALE categories (from least to most walkable) for adults aged 18 to 59, but not for children and youth or older adults aged 60 to 79. MVPA was a significant mediating factor in the association between the Can-ALE index and BMI in adults aged 40 to 79 (and in the waist circumference of respondents aged 40 to 59). Young adults (aged 18 to 39) were more likely than older adults (aged 60 to 79) to report very good or excellent general health as walkability increased. DISCUSSION: Using a new and freely-available Canadian walkability index, this study observed a positive association between walkability and both measured obesity and self-rated general health in adults. Walkability is one of many built environment characteristics that should be considered when trying to understand the relative contribution of the built environment to a person's weight and overall health.

Assessing the micro-scale environment using Google Street View: the Virtual Systematic Tool for Evaluating Pedestrian Streetscapes (Virtual-STEPS).

BACKGROUND: Altering micro-scale features of neighborhood walkability (e.g., benches, sidewalks, and cues of social disorganization or crime) could be a relatively cost-effective method of creating environments that are conducive to active living. Traditionally, measuring the micro-scale environment has required researchers to perform observational audits. Technological advances have led to the development of virtual audits as alternatives to observational field audits with the enviable properties of cost-efficiency from elimination of travel time and increased safety for auditors. This study examined the reliability of the Virtual Systematic Tool for Evaluating Pedestrian Streetscapes (Virtual-STEPS), a Google Street View-based auditing tool specifically designed to remotely assess micro-scale characteristics of the built environment. METHODS: We created Virtual-STEPS, a tool with 40 items categorized into 6 domains (pedestrian infrastructure, traffic calming and streets, building characteristics, bicycling infrastructure, transit, and aesthetics). Items were selected based on their past abilities to predict active living and on their feasibility for a virtual auditing tool. Two raters performed virtual and field audits of street segments in Montreal neighborhoods stratified by the Walkscore that was used to determine the 'walking-friendliness' of a neighborhood. The reliability between virtual and field audits (n = 40), as well as inter-rater reliability (n = 60) were assessed using percent agreement, Cohen's Kappa statistic, and the Intra-class Correlation Coefficient. RESULTS: Virtual audits and field audits (excluding travel time) took similar amounts of time to perform (9.8 versus 8.2 min). Percentage agreement between virtual and field audits, and for inter-rater agreement was 80% or more for the majority of items included in the Virtual-STEPS tool. There was high reliability between virtual and field audits with Kappa and ICC statistics indicating that 20 out of 40 (50.0%) items had almost perfect agreement and 13 (32.5%) items had substantial agreement. Inter-rater reliability was also high with 17 items (42.5%) with almost perfect agreement and 11 (27.5%) items with substantial agreement. CONCLUSIONS: Virtual-STEPS is a reliable tool. Tools that measure the micro-scale environment are important because changing this environment could be a relatively cost-effective method of creating environments that are conducive to active living.

The planning and reporting of mixed methods studies on the built environment and health.

Researchers examining the influence of the built environment on health are increasingly using mixed methods approaches. The use of more than one type of methodology to address a single research question is compelling in this field because researchers investigating the impact of the built environment on health have been faced with proposing solutions to a complex societal problem involving interacting systems and social uncertainties. Mixed methods studies can help researchers to gain a better understanding of the relationships that exist between humans and their environment by drawing on qualitative and quantitative methods. Mixed methods studies could also be instrumental for providing effective policy solutions. This is because they allow researchers to identify built environment determinants of health in a population of interest and to understand the social and cultural factors that might influence the uptake of an intervention by this population. The objective of this paper is to assist those conducting research on the built environment and health who may have little background in mixed methods. We provide an overview of mixed methods research designs and provide concrete techniques for the integration of diverse methods. We also discuss the recommendations for mixed methods research in the field of built environment - health research, drawing on specific examples from published studies. Reporting a research design and an integration strategy in mixed methods studies could help to strengthen our ability to gain new insights into the multidimensional nature of the relationship between the built environment and health.

A pan-Canadian measure of active living environments using open data.

BACKGROUND: Neighbourhood environments that support active living, such as walking or cycling for transportation, may decrease the burden of chronic conditions related to sedentary behaviour. Many measures exist to summarize features of communities that support active living, but few are pan-Canadian and none use open data sources that can be widely shared. This study reports the development and validation of a novel set of indicators of active living environments using open data that can be linked to national health surveys and can be used by local, regional or national governments for public health surveillance. DATA AND METHODS: A Geographic Information System (GIS) was used to calculate a variety of measures of the connectivity, density and proximity to destinations for 56,589 dissemination areas (DAs) across Canada (2016 data). Pearson correlation coefficients were calculated to assess the association between each measure and the rates of walking to work and taking active transportation to work (a combination of walking, cycling and using public transportation) from census data. The active living environment measures selected for the final database were used to classify the DAs by the favourability of their active living environment into groups by k-medians clustering. RESULTS: All measures were correlated with walking-to-work and active-transportation-to-work rates at the DA level, whether they were derived using proprietary or open data sources. Coverage of open data was consistent across Canadian regions. Three measures were selected for the Canadian Active Living Environments (Can-ALE) dataset based on the correlation analysis, but also on the principles of suitability for a variety of community sizes and openly available data: (1) three-way intersection density of roads and footpaths derived from OpenStreetMap (OSM), (2) weighted dwelling density derived from Statistics Canada dwelling counts and (3) points of interest derived from OSM. A measure of access to public transportation was added for the subset of DAs in larger urban areas and was strongly related to active-transportation-to-work rates. Active-transportation-to-work rates were graded, in steps, by the five Can-ALE groups derived from the cluster analysis, although walking-to-work rates exceeded the national average only in the most favourable active living environments. DISCUSSION: Open data may be used to derive measures that characterize the active living environments of Canadian communities.