Childhood sound disturbance and sleep problems in Alpine valleys with high levels of traffic exposures and greenspace.

Sound disturbance and sleep problems are regarded as the most common adverse effects of environmental noise but evidence of the role of air pollution and greenspace is scant. This is especially true for children who find themselves in a sensitive developmental period and experience their environment differently than adults. This study examined the joint effects of traffic exposures and residential greenspace on child sound disturbance and sleep problems via perceptions of neighborhood quality. We used cross-sectional data for 1251 schoolchildren (8-12 years) in the Tyrol region of Austria/Italy. Questionnaires provided information on sociodemographic and housing factors, perceived neighborhood quality, sound disturbance in different situations, and sleep problems. Modelled acoustic indicators included day-evening-night sound levels and the highest percentile level, and night-time sound level and a bespoke sleep disturbance index. Nitrogen dioxide served as a proxy for traffic-related air pollution. The normalized difference vegetation index was calculated as a measure of residential greenspace, and presence of a domestic garden was self-reported. Results showed that higher level of traffic-related exposures was positively associated with sound disturbance and sleep problems, while living in a greener area, especially in a house with a garden, was associated with lower sound disturbance and less sleep problems even in the presence of traffic. Traffic exposures contributed to more unfavorable, and greenspace to more positive perceptions in terms of traffic-related stressors, opportunities for outdoor recreation, and general satisfaction with the neighborhood. This indirect path seemed more important for greenspace than for traffic exposures. In conclusion, it seems advantageous to combine traffic-related mitigation with improving access to greenspace in interventions for supporting the acoustic comfort of children during day and nighttime. Even highly nature-dominated environments could still benefit from proximal green infrastructure, especially from domestic gardens.

Sociodemographic inequalities in residential nighttime light pollution in urban Bulgaria: An environmental justice analysis.

INTRODUCTION: Outdoor nighttime light (NTL) is a potential anthropogenic stressor in urban settings. While ecological studies have identified outdoor NTL exposure disparities, uncertainties remain about disparities in individual exposure levels, particularly in Europe. AIM: To assess whether some populations are disproportionately affected by outdoor NTL at their residences in urban Bulgaria. METHODS: We analyzed 2023 data from a representative cross-sectional survey of 4,270 adults from the five largest Bulgarian cities. Respondents' annual exposures to outdoor artificial nighttime luminance were measured using satellite imagery and assigned at their places of residence. We calculated the Gini coefficient as a descriptive NTL inequality measure. Associations between respondents' NTL exposure levels and sociodemographic characteristics were assessed by estimating quantile mixed regression models. Stratified regressions were fitted by gender and for each city. RESULTS: We found moderate distributive NTL inequalities, as indicated by a 0.214 Gini coefficient. Regression analyses found associations between greater NTL exposure and higher educational attainment. Respondents with incomes perceived as moderate experienced less NTL exposure at the 0.5 and 0.8 quantiles, while unemployed respondents experienced lower exposure at the 0.2 and 0.5 quantiles. We observed null associations for the elderly and non-Bulgarian ethnicities. Regardless of the quantile, greater population density was associated with higher NTL levels. Stratification by sex did not yield substantial differences in the associations. We observed notable city-specific heterogeneities in the associations, with differences in the magnitudes and directions of the associations and the NTL quantiles. CONCLUSIONS: NTL exposures appeared to embody an environmental injustice dimension in Bulgaria. Our findings suggest that some sociodemographic populations experience higher exposure levels to NTL; however, those are not necessarily the underprivileged or marginalized. Identifying populations with high exposure levels is critical to influencing lighting policies to ease related health implications.

The Superblock model: A review of an innovative urban model for sustainability, liveability, health and well-being.

INTRODUCTION: Current urban and transport planning practices have significant negative health, environmental, social and economic impacts in most cities. New urban development models and policies are needed to reduce these negative impacts. The Superblock model is one such innovative urban model that can significantly reduce these negative impacts through reshaping public spaces into more diverse uses such as increase in green space, infrastructure supporting social contacts and physical activity, and through prioritization of active mobility and public transport, thereby reducing air pollution, noise and urban heat island effects. This paper reviews key aspects of the Superblock model, its implementation and initial evaluations in Barcelona and the potential international uptake of the model in Europe and globally, focusing on environmental, climate, lifestyle, liveability and health aspects. METHODS: We used a narrative meta-review approach and PubMed and Google scholar databases were searched using specific terms. RESULTS: The implementation of the Super block model in Barcelona is slow, but with initial improvement in, for example, environmental, lifestyle, liveability and health indicators, although not so consistently. When applied on a large scale, the implementation of the Superblock model is not only likely to result in better environmental conditions, health and wellbeing, but can also contribute to the fight against the climate crisis. There is a need for further expansion of the program and further evaluation of its impacts and answers to related concerns, such as environmental equity and gentrification, traffic and related environmental exposure displacement. The implementation of the Superblock model gained a growing international reputation and variations of it are being planned or implemented in cities worldwide. Initial modelling exercises showed that it could be implemented in large parts of many cities. CONCLUSION: The Superblock model is an innovative urban model that addresses environmental, climate, liveability and health concerns in cities. Adapted versions of the Barcelona Superblock model are being implemented in cities around Europe and further implementation, monitoring and evaluation are encouraged. The Superblock model can be considered an important public health intervention that will reduce mortality and morbidity and generate cost savings for health and other sectors.

Joint associations and pathways from greenspace, traffic-related air pollution, and noise to poor self-rated general health: A population-based study in Sofia, Bulgaria.

BACKGROUND: Little is still known of how multiple urban exposures interact as health determinants. This study investigated various ways in which greenspace, traffic-related air pollution, and noise could operate together, influencing general health status. METHODS: In 2022, a cross-sectional population-based survey was conducted in Sofia, Bulgaria. Included were 917 long-term adult residents who completed questionnaires on poor self-rated health (PSRH), total time spent in physical activity (PA), home garden presence, time spent in urban greenspace and nature, and sociodemographics. Residential greenspace was operationalized using the normalized difference vegetation index (NDVI), tree cover density, number of trees, and access to local greenspace and parks. Nitrogen dioxide (NO2) was modeled for the study area. Road traffic, railway, and aircraft day-evening-night sound levels (Lden) were extracted from EU noise maps. Area-level income and urbanicity were considered. Analyses included multivariate ordinal regressions, interactions, and structural equation modeling (SEM). RESULTS: Associations with PSRH were per 0.10 NDVI 300 m: OR = 0.65 (0.42-1.01), home garden: OR = 0.72 (0.49-1.07), per 5 µg/m3 NO2: OR = 1.57 (1.00-2.48), per 5 dB(A) Lden road traffic: OR = 1.06 (0.91-1.23), railway: OR = 1.11 (1.03-1.20), and aircraft: OR = 1.22 (1.11-1.34). Spending >30 min/week in nature related to better health. In multi-exposure models, only associations with aircraft and railway Lden persisted. People with lower education and financial difficulties or living in poorer districts experienced some exposures stronger. In SEM, time spent in nature and PA mediated the effect of greenspace. CONCLUSIONS: Greenspace was associated with better general health, with time spent in nature and PA emerging as intermediate pathways. NO2, railway, and aircraft noise were associated with poorer general health. These results could inform decision-makers, urban planners, and civil society organizations facing urban development problems. Mitigation and abatement policies and measures should target socioeconomically disadvantaged citizens.

Perfluoroalkyl and polyfluoroalkyl substances and hypertensive disorders of pregnancy: A systematic review and meta-analysis.

Hypertensive disorders of pregnancy (HDP), including gestational hypertension (GH) and preeclampsia (PE), cause significant morbidity and mortality among pregnant women. Several environmental toxins, particularly those that affect the normal function of the placenta and the endothelium, are emerging as potential risk factors for HDP. Among them, per- and polyfluoroalkyl substances (PFAS), widely used in a variety of commercial products, have been related to a variety of adverse health effects including HDP. This study was conducted by searching three databases for observational studies reporting associations between PFAS and HDP, all of which were published before December 2022. We used random-effects meta-analysis to calculate pooled risk estimates, and assessing each combination of exposure and outcome for quality and level of evidence. In total, 15 studies were included in the systematic review and meta-analysis. The results from meta-analyses showed that risk of PE was increased with exposure to PFOA (perfluorooctanoic acid) (RR = 1.39, 95% CI = 1.05, 1.85; N = 6 studies; exposure = 1 ln-unit increment; low certainty), PFOS (perfluorooctane sulfonate) (RR = 1.51, 95% CI = 1.23, 1.86; N = 6 studies; exposure = 1 ln-unit increment; moderate certainty), and PFHxS (perfluorohexane sulfonate) (RR = 1.39, 95% CI = 1.10, 1.76; N = 6 studies; exposure = 1 ln-unit increment; low certainty). PFOS was also associated with an increased risk of HDP (RR = 1.39, 95% CI = 1.10, 1.76; exposure = 1 ln-unit increment; low certainty). Exposure to legacy PFAS (PFOA, PFOS, PFHxS) is associated with an increased risk of PE, and PFOS is further associated with HDP. In view of the limitations of meta-analysis and quality of evidence, these findings should be interpreted with caution. Further research is required that assesses exposure to multiple PFAS in diverse and well-powered cohorts.

Protective effect of restorative possibilities on cognitive function and mental health in children and adolescents: A scoping review including the role of physical activity.

Background The exposome approach can be a powerful tool for understanding the intertwining of social, physical, and internal influences that shape mental health and cognitive development throughout childhood. To distil conceptual models for subsequent analyses, the EU-funded project Early Environmental quality and Life-course mental health effects (Equal-Life) has conducted literature reviews on potential mediators linking the exposome to these outcomes. We report on a scoping review and a conceptual model of the role of restorative possibilities and physical activity. Methods Peer-reviewed studies published since the year 2000 in English, on the association between the exposome and mental health/cognition in children/adolescents, and quantitatively investigating restoration/restorative quality as a mediating variable were considered. Database searches were last updated in December 2022. We used an unstructured expert-driven approach to fill in gaps in the reviewed literature. Results Five records of three distinct studies were identified, indicating a scarcity of empirical evidence in this newly developing research area. Not only were these studies few in numbers, but also cross-sectional, lending only tentative support to the idea that perceived restorative quality of adolescent's living environment might mediate the association between greenspace and mental health. Physical activity emerged as a mediator leading to better psychological outcomes in restorative environments. We provide a critical discussion of potential caveats when investigating the restoration mechanism in children and propose a hierarchical model including restoration, physical activity, and relational dynamics between children and their environment, including social context, as well as restorative environments other than nature. Conclusions It is justified to further explore the role of restoration and physical activity as mediators in the association between early-life exposome and mental health/cognitive development. It is important to consider the child perspective and specific methodological caveats. Given the evolving conceptual definitions/operationalizations, Equal-Life will attempt to fill in a critical gap in the literature.

Adopting a child perspective for exposome research on mental health and cognitive development - Conceptualisation and opportunities.

Mental disorders among children and adolescents pose a significant global challenge. The exposome framework covering the totality of internal, social and physical exposures over a lifetime provides opportunities to better understand the causes of and processes related to mental health, and cognitive functioning. The paper presents a conceptual framework on exposome, mental health, and cognitive development in children and adolescents, with potential mediating pathways, providing a possibility for interventions along the life course. The paper underscores the significance of adopting a child perspective to the exposome, acknowledging children's specific vulnerability, including differential exposures, susceptibility of effects and capacity to respond; their susceptibility during development and growth, highlighting neurodevelopmental processes from conception to young adulthood that are highly sensitive to external exposures. Further, critical periods when exposures may have significant effects on a child's development and future health are addressed. The paper stresses that children's behaviour, physiology, activity pattern and place for activities make them differently vulnerable to environmental pollutants, and calls for child-specific assessment methods, currently lacking within today's health frameworks. The importance of understanding the interplay between structure and agency is emphasized, where agency is guided by social structures and practices and vice-versa. An intersectional approach that acknowledges the interplay of social and physical exposures as well as a global and rural perspective on exposome is further pointed out. To advance the exposome field, interdisciplinary efforts that involve multiple scientific disciplines are crucial. By adopting a child perspective and incorporating an exposome approach, we can gain a comprehensive understanding of how exposures impact children's mental health and cognitive development leading to better outcomes.

Natural and built environments and blood pressure of Alpine schoolchildren.

BACKGROUND: Early life environments may influence children's blood pressure (BP), but evidence on the combined effects of natural and built environment exposures is scarce. The present study investigates the associations of natural and built environment indicators, traffic noise, and air pollution with BP in children living in Alpine valleys. METHODS: In 2004/2005, 1251 school children (8-12 years old) were sampled for a cross-sectional survey in several Austrian and Italian mountain valleys. Children's mothers completed a questionnaire. The outcomes of interest were systolic and diastolic BP measured with a calibrated oscillometric device. Indicators of land cover assigned to the residential and school coordinates within 100 and 1000 m included normalized difference vegetation index (NDVI), tree canopy cover, and a broader naturalness indicator titled distance to nature (D2N). The presence of a home garden was also measured via self-report. Imperviousness density served as a proxy for the built environment. Residential air pollution (NO2) and noise (Lden) from traffic were calculated using bespoke modeling. NO2, Lden, physical activity, and body mass index (BMI) were treated as mediating pathways. RESULTS: Higher NDVI and tree cover levels in residential and school surroundings and home gardens were consistently associated with lower BP. The built environment was associated with higher BP. Counterintuitive inverse associations between NO2 and Lden and BP were also found. Structural equation modeling showed that higher levels of greenspace and presence of a home garden were weakly associated with more outdoor play spaces, and in turn with lower BMI, and ultimately with lower BP. CONCLUSIONS: Exposure to natural environments may help maintain normal BP in children, while built environment may increase children's BP. Outdoor play and less adiposity in greener areas may mediate some of these associations. Evidence on air pollution and noise remains controversial and difficult to explain.

Allergic symptoms in association with naturalness, greenness, and greyness: A cross-sectional study in schoolchildren in the Alps.

BACKGROUND: Greenness may protect from or contribute to allergy risk by influencing air pollution and human-microbe interactions. However, existing research on the issue is heterogeneous and produced conflicting results. Less in known about the effects of greyness. This study investigated the association between different characteristics of residential and school environment and allergic symptoms in schoolchildren. METHODS: The present cross-sectional survey was undertaken in 2004/2005 among 1251 schoolchildren (8-12 years old) in several alpine valleys in Austria and Italy. Children's mothers completed a questionnaire that asked about allergic symptoms (International Study of Asthma and Allergies in Childhood questionnaire), sociodemographic information, lifestyle, perinatal data, and housing conditions. We constructed four aggregate outcome variables: current asthma symptoms, ever asthma symptoms, ever allergic rhinitis (AR) symptoms, and ever eczema symptoms. We employed well-known greenness and greyness exposure indicators (Normalized Difference Vegetation Index, tree canopy cover, agricultural cover, imperviousness cover, and industrial cover), as well as an alternative naturalness index (Distance to Nature, D2N). Adjusted logistic regressions were used to explore associations between each exposure-outcome pair. Air pollution (NO2), traffic noise and time spent outdoors were tested as potential mediators in causal mediation analysis. RESULTS: Decrease in naturalness in a 500-m buffer around the home was associated with higher prevalence of AR symptoms. Associations with asthma symptoms were in the same direction but marginally significant. Residential NDVI and tree cover were marginally associated with lower prevalence of asthma and AR symptoms. Having a domestic garden was associated with lower prevalence of asthma symptoms. School greenness in a 100-m buffer was associated with lower prevalence of AR symptoms. Residential greyness was associated with higher prevalence of AR and asthma symptoms. We observed stronger associations for greenness and greyness in non-movers and in children without a family history of allergies. Mediation by NO2 and time spent outdoors was present in some of the exposure-outcome pairs. CONCLUSIONS: Schoolchildren residing in places with lower naturalness and higher greyness may be more likely to have allergic rhinitis and possibly asthma. Considering more comprehensive indicators than greenness and greyness and conducting research in children without a family history of allergic diseases may be key to better understanding who can profit from natural landscapes.

Does greenery experienced indoors and outdoors provide an escape and support mental health during the COVID-19 quarantine?

BACKGROUND: The COVID-19 pandemic has profoundly changed people's ability to recreate in public green spaces, which is likely to exacerbate the psychological impacts of the pandemic. In the current study, we seek to understand whether greenery can support mental health even with insufficient outdoor exposure in times of physical isolation from the outdoor environment. METHODS: Between 17 May and 10 June, 2020, we conducted an online survey among 323 students (21.99 ± 3.10 years; 31% male) in health-related programs from two universities in the city of Plovdiv, Bulgaria. Severities of depressive and anxiety symptoms over the past two weeks were measured with the Patient Health Questionnaire 9-item and the Generalized Anxiety Disorder 7-item scale. We employed two self-reported measures of greenery experienced indoors (number of houseplants in the home and proportion of exterior greenery visible from inside the home) and two measures of greenery experienced outdoors (presence/absence of a domestic garden and availability of neighborhood greenery). Restorative quality of the home (the "being away" dimension of the Perceived Restorativeness Scale; PRS) and the neighborhood (the "being away" and "fascination" dimensions of the PRS), engagement with outdoor greenery (frequency of different types of interaction) and perceived social support were treated as mediators. Associations between greenery and mental health were tested using generalized linear regression and logistic regression. Structural equation modelling (SEM) techniques were used to test the theoretically-indicated relations among the variables. RESULTS: Clinically-meaningful symptoms of moderate depression and anxiety were reported by approximately 33% and 20% of the students, respectively. The relative abundance of greenery visible from the home or in the neighborhood was associated with reduced depressive/anxiety symptoms and lower depression/anxiety rates. Having more houseplants or a garden was also associated with some of these markers of mental health. As hypothesized, the mental health-supportive effects of indoor greenery were largely explained by increased feelings of being away while at home. Neighborhood greenery contributed to neighborhood restorative quality, which in turn facilitated social support and more frequent engagement with greenery, and that led to better mental health. CONCLUSIONS: Students who spent most of their time at home during the COVID-19 epidemic experienced better mental health when exposed to more greenery. Our findings support the idea that exposure to greenery may be a valuable resource during social isolation in the home. However, causal interpretation of these associations is not straightforward.

Analytical approaches to testing pathways linking greenspace to health: A scoping review of the empirical literature.

BACKGROUND: Inadequate translation from theoretical to statistical models of the greenspace - health relationship may lead to incorrect conclusions about the importance of some pathways, which in turn may reduce the effectiveness of public health interventions involving urban greening. In this scoping review we aimed to: (1) summarize the general characteristics of approaches to intervening variable inference (mediation analysis) employed in epidemiological research in the field; (2) identify potential threats to the validity of findings; and (3) propose recommendations for planning, conducting, and reporting mediation analyses. METHODS: We conducted a scoping review, searching PubMed, Scopus, and Web of Science for peer-reviewed epidemiological studies published by December 31, 2019. The list of potential studies was continuously updated through other sources until March 2020. Narrative presentation of the results was coupled with descriptive summary of study characteristics. RESULTS: We found 106 studies, most of which were cross-sectional in design. Most studies only had a spatial measure of greenspace. Mental health/well-being was the most commonly studied outcome, and physical activity and air pollution were the most commonly tested intervening variables. Most studies only conducted single mediation analysis, even when multiple potentially intertwined mediators were measured. The analytical approaches used were causal steps, difference-of-coefficients, product-of-coefficients, counterfactual framework, and structural equation modelling (SEM). Bootstrapping was the most commonly used method to construct the 95% CI of the indirect effect. The product-of-coefficients method and SEM as used to investigate serial mediation components were more likely to yield findings of indirect effect. In some cases, the causal steps approach thwarted tests of indirect effect, even though both links in an indirect effect were supported. In most studies, sensitivity analyses and proper methodological discussion of the modelling approach were missing. CONCLUSIONS: We found a persistent pattern of suboptimal conduct and reporting of mediation analysis in epidemiological studies investigating pathways linking greenspace to health; however, recent years have seen improvements in these respects. Better planning, conduct, and reporting of mediation analyses are warranted.

Residential greenspace is associated with mental health via intertwined capacity-building and capacity-restoring pathways.

BACKGROUND: Experiences afforded by natural settings promote health by helping people to build new adaptive capacities and to restore existing capacities. The aim of this study was to examine relations among restorative experience, mindfulness, rumination and psychological resilience in pathways linking residential greenspace to anxiety and depression symptoms. METHODS: We sampled 529 university students residing in Plovdiv, Bulgaria. Residential greenspace was measured in terms of the Normalized Difference Vegetation Index (NDVI) and tree cover density for different buffer sizes. Symptoms of anxiety and depression were measured with the Generalized Anxiety Disorder scale (7-item) and Patient Health Questionnaire (9-item), respectively. The following mediators were assessed by self-report: perceived greenspace, restorative quality of the neighborhood, dispositional mindfulness, rumination, and psychological resilience. Structural equation modelling techniques were used to test the theoretically-indicated relations among the variables. RESULTS: Across different buffer sizes, higher greenspace was consistently associated with reduced scores on the anxiety and depression scales. This effect was partially mediated via several pathways. Specifically, higher NDVI 500-m was associated with higher perceived greenspace, and in turn, with higher restorative quality, and then with higher mindfulness, lower rumination, and greater resilience to stress, and consequently, with better mental health. CONCLUSIONS: Our findings affirm the potential of greenspace for building psychological resilience and promoting health by offsetting dysfunctional rumination and facilitating mindfulness as components of intertwined capacity-building and capacity-restoring pathways.

Pathways linking residential noise and air pollution to mental ill-health in young adults.

BACKGROUND: Recent years have seen growing, but still tentative, evidence of the potential associations of environmental noise and air pollution with mental disorders. In the present study, we aimed to examine the associations between residential noise and air pollution exposures and general mental health in young adults with a focus on underlying processes METHODS: We sampled 720 students (18-35 years) from one university in the city of Plovdiv, Bulgaria. Residential noise (LAeq; day equivalent noise level) and air pollution (NO2) were assessed at participant's residential address by land use regression models. General mental health was measured with a short form of the General Health Questionnaire (GHQ). The following putative mediators were considered: annoyance from environmental pollution, sleep disturbance, restorative quality of the neighborhood, neighborhood social cohesion, and commuting/leisure time physical activity. Structural equation modeling was used to analyze the theoretically-indicated interplay between exposures, mediators, and GHQ. RESULTS: We observed an association between higher LAeq and GHQ, in which environmental annoyance and neighborhood restorative quality emerged as key mediators. First, LAeq was associated with higher annoyance, and through it with lower restorative quality, and then in turn with lower physical activity, and thus with higher GHQ. Simultaneously, higher annoyance was associated with higher sleep disturbance, and thereby with higher GHQ. NO2 had no overall association with GHQ, but it was indirectly associated with it through higher annoyance, lower restorative quality, and lower physical activity working in serial. CONCLUSION: We found evidence that increased residential noise was related to mental ill-health through several indirect pathways. Air pollution was associated with mental health only indirectly.

Multiple pathways link urban green- and bluespace to mental health in young adults.

BACKGROUND: A growing body of scientific literature indicates that urban green- and bluespace support mental health; however, little research has attempted to address the complexities in likely interrelations among the pathways through which benefits plausibly are realized. OBJECTIVES: The present study examines how different plausible pathways between green/bluespace and mental health can work together. Both objective and perceived measures of green- and bluespace are used in these models. METHODS: We sampled 720 students from the city of Plovdiv, Bulgaria. Residential greenspace was measured in terms of the Normalized Difference Vegetation Index (NDVI), tree cover density, percentage of green areas, and Euclidean distance to the nearest green space. Bluespace was measured in terms of its presence in the neighborhood and the Euclidean distance to the nearest bluespace. Mental health was measured with the 12-item form of the General Health Questionnaire (GHQ-12). The following mediators were considered: perceived neighborhood green/bluespace, restorative quality of the neighborhood, social cohesion, physical activity, noise and air pollution, and environmental annoyance. Structural equation modelling techniques were used to analyze the data. RESULTS: Higher NDVI within a 300 m buffer around the residence was associated with better mental health through higher perceived greenspace; through higher perceived greenspace, leading to increased restorative quality, and subsequently to increased physical activity (i.e., serial mediation); through lower noise exposure, which in turn was associated with lower annoyance; and through higher perceived greenspace, which was associated with lower annoyance. Presence of bluespace within a 300 m buffer did not have a straightforward association with mental health owing to competitive indirect paths: one supporting mental health through higher perceived bluespace, restorative quality, and physical activity; and another engendering mental ill-health through higher noise exposure and annoyance. CONCLUSIONS: We found evidence that having more greenspace near the residence supported mental health through several indirect pathways with serial components. Conversely, bluespace was not clearly associated with mental health.

Children's blood pressure and its association with road traffic noise exposure - A systematic review with meta-analysis.

BACKGROUND: Primary and synthetic research on road traffic noise (RTN) and blood pressure (BP) is more common for adults than it is for children and adolescents. Given the conflicting evidence from primary studies, this study aimed to conduct an up-to-date systematic review with meta-analysis of the association between RTN and children's BP, by using advanced statistical techniques, to take into account the heterogeneity in primary studies. METHODS: MEDLINE (PubMed), EMBASE (ScienceDirect with filters), and the Internet (Google) were searched (last update: July 21, 2016) in English, Spanish, and Russian. Thirteen articles (total n=8 770) were included in the systematic review and 37 effect size estimates were pooled in different meta-analyses under the quality effects model. RESULTS: Results showed 0.48mmHg (95% CI: -0.87, 1.83) increase in systolic blood pressure (SBP) and 0.22mmHg (95% CI: -0.64, 1.07) in diastolic blood pressure (DBP) per 5dB increase in RTN at school/kindergarten; and 0.20mmHg (95% CI: -0.30, 0.71) increase in SBP and 0.03mmHg (95% CI: -0.18, 0.25) in DBP per 5dB increase in RTN at home. There was high heterogeneity in the first three models and evidence of publication bias in the first. The following categorical and linear factors were significant effect modifiers in different exposure - outcome scenarios: country where the study was conducted, the mode of noise assessment, the mode of BP measurement, the type of reported effect size estimate, the overall quality score of the estimate, the minimum number of BP readings, and children's mean age. CONCLUSIONS: All evidence considered, the observed association between RTN and BP is weak and further flattened by methodological issues of primary studies, but its long-term consequences should not be ignored.

Exploring pathways linking greenspace to health: Theoretical and methodological guidance.

BACKGROUND: In a rapidly urbanizing world, many people have little contact with natural environments, which may affect health and well-being. Existing reviews generally conclude that residential greenspace is beneficial to health. However, the processes generating these benefits and how they can be best promoted remain unclear. OBJECTIVES: During an Expert Workshop held in September 2016, the evidence linking greenspace and health was reviewed from a transdisciplinary standpoint, with a particular focus on potential underlying biopsychosocial pathways and how these can be explored and organized to support policy-relevant population health research. DISCUSSIONS: Potential pathways linking greenspace to health are here presented in three domains, which emphasize three general functions of greenspace: reducing harm (e.g. reducing exposure to air pollution, noise and heat), restoring capacities (e.g. attention restoration and physiological stress recovery) and building capacities (e.g. encouraging physical activity and facilitating social cohesion). Interrelations between among the three domains are also noted. Among several recommendations, future studies should: use greenspace and behavioural measures that are relevant to hypothesized pathways; include assessment of presence, access and use of greenspace; use longitudinal, interventional and (quasi)experimental study designs to assess causation; and include low and middle income countries given their absence in the existing literature. Cultural, climatic, geographic and other contextual factors also need further consideration. CONCLUSIONS: While the existing evidence affirms beneficial impacts of greenspace on health, much remains to be learned about the specific pathways and functional form of such relationships, and how these may vary by context, population groups and health outcomes. This Report provides guidance for further epidemiological research with the goal of creating new evidence upon which to develop policy recommendations.

Self-reported occupational noise may be associated with prevalent chronic obstructive pulmonary disease in the us general population.

INTRODUCTION: Occupational noise exposure and chronic obstructive pulmonary disease (COPD) are common in the United States, but so far their association has not been explored. Given the neuroimmunological effects of noise, such an association seems plausible. Thus, the present study aimed to explore the association of occupational noise exposure with prevalent COPD in the US general population. MATERIALS AND METHODS: We used data from the population-based National Health Interview Survey (NHIS) 2014. The cross-sectional association of self-reported duration of exposure to very loud noise during participants' occupational lifetime with self-reported COPD and emphysema was explored using weighted logistic regression. RESULTS AND DISCUSSION: The fully adjusted model yielded odds ratio (OR)≥15 years = 1.68 [95% confidence interval (CI): 1.28, 2.21] for COPD and OR≥15 years = 1.61 (95% CI: 1.13, 2.30) for emphysema. Race/ethnicity was a significant effect modifier. In sensitivity analysis with cumulative noise exposure based on a job exposure matrix, we found no effect. CONCLUSION: In conclusion, we found a relationship between self-reported occupational noise exposure and the risk of prevalent COPD in the US general population, but none with objective noise levels. Being the first study on the subject matter, and given the design limitations, these findings are tentative and should be treated with caution.

Association between community noise and adiposity in patients with cardiovascular disease.

INTRODUCTION: This study aimed to explore the effect of community noise on body mass index (BMI) and waist circumference (WC) in patients with cardiovascular disease (CVD). MATERIALS AND METHODS: A representative sample of 132 patients from three tertiary hospitals in the city of Plovdiv, Bulgaria was collected. Anthropometric measurements were linked to global noise annoyance (GNA) based on different residential noise annoyances, day-evening-night (Lden), and nighttime (Lnight) road traffic noise exposure. Noise map Lden and Lnight were determined at the living room and bedroom façades, respectively, and further corrected to indoor exposure based on the window-opening frequency and soundproofing insulation. RESULTS AND DISCUSSION: Results showed that BMI and WC increased (non-significantly) per 5 dB. The effect of indoor noise was stronger in comparison with that of outdoor noise. For indoor Lden, the effect was more pronounced in men, those with diabetes, family history of diabetes, high noise sensitivity, using solid fuel/gas for domestic heating/cooking, and living on the first floor. As regards indoor Lnight, its effect was more pronounced in those with low socioeconomic status, hearing loss, and using solid fuel/gas for domestic heating/cooking. GNA was associated with lower BMI and WC. CONCLUSION: Road traffic noise was associated with an increase in adiposity in some potentially vulnerable patients with CVD.

Community Noise Exposure and its Effect on Blood Pressure and Renal Function in Patients with Hypertension and Cardiovascular Disease.

BACKGROUND: Road traffic noise (RTN) is a risk factor for cardiovascular disease (CVD) and hypertension; however, few studies have looked into its association with blood pressure (BP) and renal function in patients with prior CVD. AIM: This study aimed to explore the effect of residential RTN exposure on BP and renal function in patients with CVD from Plovdiv Province. MATERIALS AND METHODS: We included 217 patients with ischemic heart disease and/or hypertension from three tertiary hospitals in the city of Plovdiv (March - May 2016). Patients' medical history, medical documentation, and medication regimen were reviewed, and blood pressure and anthropometric measurements were taken. Blood samples were analyzed for creatinine, total cholesterol, and blood glucose. Participants also filled a questionnaire. Glomerular filtration rate was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. All participants were asked about their annoyance by different noise sources at home, and those living in the city of Plovdiv (n = 132) were assigned noise map Lden and Lnight exposure. The effects of noise exposure on systolic blood pressure (SBP), diastolic blood pressure (DBP), and estimated glomerular filtration rate (eGFR) were explored using mixed linear models. RESULTS: Traffic noise annoyance was associated with higher SBP in the total sample. The other noise indicators were associated with non-significant elevation in SBP and reduction in eGFR. The effect of Lden was more pronounced in patients with prior ischemic heart disease/stroke, diabetes, obesity, not taking Ca-channel blockers, and using solid fuel/gas at home. Lnight had stronger effect among those not taking statins, sleeping in a bedroom with noisy façade, having a living room with quiet façade, and spending more time at home. The increase in Lden was associated with a significant decrease in eGFR among men, patients with ischemic heart disease/stroke, and those exposed to lower air pollution. Regarding Lnight, there was significant effect modification by gender, diabetes, obesity, and time spent at home. In some subgroups, the effect of RTN was statistically significant. CONCLUSIONS: Given that generic risk factors for poor progression of cardiovascular diseases cannot be controlled sufficiently at individual level, environmental interventions to reduce residential noise exposure might result in some improvement in the management of blood pressure and kidney function in patients with CVD.

Exposures to road traffic, noise, and air pollution as risk factors for type 2 diabetes: A feasibility study in Bulgaria.

Type 2 diabetes mellitus (T2DM) is a growing public health problem in Bulgaria. While individual and lifestyle determinants have been researched; till date there has been no study on environmental risks such as road traffic, noise, and air pollution. As a first step toward designing a large-scale population-based survey, we aimed at exploring the overall associations of prevalent T2DM with exposures to road traffic, noise, and air pollution. A total of 513 residents of Plovdiv city, Bulgaria were recruited. Individual data on self-reported doctor-diagnosed T2DM and confounding factors were linked to objective and self-rated exposure indicators. Logistic and log-link Poisson regressions were conducted. In the fully adjusted logistic models, T2DM was positively associated with exposures to L(den) 71-80 dB (odds ratio (OR) = 4.49, 95% confidence interval (CI): 1.38, 14.68), fine particulate matter (PM) 2.5 25.0-66.8 µg/m 3 (OR = 1.32, 95% CI: 0.28, 6.24), benzo alpha pyrene 6.0-14.02 ng/m 3 (OR = 1.76, 95% CI: 0.52, 5.98) and high road traffic (OR = 1.40, 95% CI: 0.48, 4.07). L(den) remained a significant risk factor in the: Poisson regression model. Other covariates with consistently high multivariate effects were age, gender, body mass index, family history of T2DM, subjective sleep disturbance, and especially bedroom location. We concluded that residential noise exposure might be associated with elevated risk of prevalent T2DM. The inferences made by this research and the lessons learned from its limitations could guide the designing of a longitudinal epidemiological survey in Bulgaria.