Mechanisms underlying the associations between different types of nature exposure and sleep duration: An 18-country analysis.

Whilst green space has been linked to healthier sleep outcomes, the roles of specific types of nature exposure, potential underlying mechanisms, and between-country variations in nature-sleep associations have received little attention. Drawing on cross-sectional survey data from an 18-country sample of adults (N = 16,077) the current study examined: 1) the relative associations between six different types of nature exposure (streetscape greenery, blue view from home, green space within 1 km, coast within 1 km, green space visits, blue space visits) and insufficient sleep (<6 h vs. 7-10 h per day); 2) whether these relationships were mediated by better mental wellbeing and/or physical activity; and 3) the consistency of these pathways among the different countries. After controlling for covariates, neighbourhood nature measures (green space, coast within 1 km) were not significantly associated with insufficient sleep; but nature visible from home (streetscape greenery, blue views) and recreational visits to green and blue spaces were each associated with less insufficient sleep. Significant nature-sleep associations were mediated, to varying degrees, by better mental wellbeing, but not self-reported physical activity. Country-level heterogeneity in the strength of nature-sleep associations was observed. Increasing nature visible from the home may represent a promising strategy for promoting healthier sleep duration at the population level, whilst nature-based interventions encouraging individuals to spend time in local green/blue spaces may be an appropriate target to assist individuals affected by insufficient sleep.

Evaluating the effectiveness of implementing a more severe law on prevention of road traffic injury mortality in mainland China: an interrupted time series study based on national mortality surveillance.

BACKGROUND: In China, road traffic injury (RTI) is the seventh-leading cause of death More than 1.5 million adults in China live with permanent disabilities due to road traffic accidents. In 2011, the Chinese government implemented a more severe law that increased the penalty points and fines for persons charged with drink-driving as a criminal offence. OBJECTIVES: This study evaluated the short-term and long-term effects of the drink-driving law. It also aimed to establish whether punishments of increased severity resulted in greater reductions in RTI mortality. METHODS: RTI mortality data was obtained from the Disease Surveillance Points System. A two-level interrupted time series model was used to analyse daily and monthly road traffic mortality rates, accounting for the varying trends among counties. RESULTS: The overall RTI mortality rate showed a decreasing trend from 2007 to 2015 in mainland China, especially after 2011, and similarly decreasing trends were noted among males and females and in urban and rural areas. After the Criminal Law and Road Traffic Law amendment was implemented in 2011, charging drink-driving as a criminal offence, the immediate daily RTI mortality rate reduced by 1.57% (RR=0.9843, 95% CI: 0.9444 to 1.0259), while the slope change significantly decreased by 0.04% (RR=0.9996, 95% CI: 0.9994 to 0.9997) compared with the period before the Law was revised. Stratified analysis showed that the effect size of the law was higher for males in urban and high socioeconomic circumstances (SEC) than females in rural and low and moderate SEC. Meanwhile, the increase in penalty points for dangerous driving behaviours showed no significant effects. CONCLUSION: Evidence was found that charging criminal responsibility for drink-driving is associated with reducing RTI deaths in China.

What types of green space disrupt a lonelygenic environment? A cohort study.

INTRODUCTION: Associations between green space type and social loneliness (a scarcity of people one feels they can depend on) were investigated in city-living participants in the Sax Institute's 45 and Up Study. METHODS: Availability of green space, tree canopy and open grass were measured as a percentage of land-use within 1.6 km road-network distance buffers using high-resolution data. Multilevel logistic regressions adjusted for confounding tested associations between each green space indicator with the odds of social loneliness at baseline (prevalence) and follow-up (incidence), adjusted for demographic and socioeconomic confounders. RESULTS: The prevalence of social loneliness at baseline was 5.3% (n = 5627 /105,498). Incidence of social loneliness at follow-up was 3.4% (n = 1772/51,365). Adjusted regressions indicated reduced odds of prevalent (OR = 0.95, 95%CI = 0.92-0.98) and incident social loneliness with 10% more green space (OR = 0.92, 95%CI = 0.90- 0.96). Similar associations were found with a 10% increase in tree canopy for both prevalent (OR = 0.92, 95%CI = 0.88-0.95) and incident social loneliness (OR = 0.92, 95%CI = 0.88-0.97). Two-way interaction terms indicated effect modification by sex but not couple status. Among women, a 10% increase in total green space was associated with lower odds of prevalent (OR = 0.95, 0.91-0.95) and incident (OR = 0.89, 0.85-0.95) social loneliness. A 10% increase in tree canopy among women was associated with lower odds of prevalent (OR = 0.89, 085-0.92) and incident (OR = 0.85, 0.80-0.92) social loneliness. Meanwhile, a 10% increase in open grass among women was associated with higher odds of prevalent (OR = 1.08, 1.01-1.15) and incident (OR = 1.19, 1.03-1.35) social loneliness. Associations for men were statistically significant for a 10% increase in total green space (OR = 0.96, 0.92-0.99) and tree canopy (OR = 0.93, 0.90-0.97) for prevalent social loneliness only. CONCLUSION: Urban greening and tree canopy restoration may reduce risks of social loneliness, perhaps especially in women.

Diabetes during the COVID-19 pandemic: are people getting access to the right level of care?

INTRODUCTION: Avoidance of health services, in particular hospital and community services, is problematic for people with diabetes. Evidence has demonstrated that such missed attendances are associated with worse health, faster declines in functioning, and higher rates of mortality long-term. This paper investigated the impact of the pandemic on healthcare access across community and hospital care, including Virtual Care (VC) using several large datasets of General Practice (GP) and hospital services in western Sydney. METHODS: A retrospective cohort study using a time-series database of 173,805 HbA1c tests done at Blacktown and Mt Druitt hospitals and 1.8 million recorded consultations at GP clinics in the region was undertaken. RESULTS: The average rate of diabetes in Emergency Department fell from 17.8% pre-pandemic to 11% after January 2020 (p < 0.001). This rate varied substantially over time, and correlated well with large outbreaks of COVID-19 in the state. Conversely, attendances of people with diabetes to GP clinics, especially using VC services, increased substantially over the pandemic period. DISCUSSION/CONCLUSION: During the pandemic there was a substantial avoidance of hospital care by patients with diabetes. However, this may have been replaced by VC offered in the community for those with less severe diseases.

Development of a composite healthy ageing score: evidence from middle-to-older aged Australians.

We developed and validated a composite healthy ageing score (HAS) to address the absence of a definitive composite score comprising multiple health domains that measure healthy ageing in epidemiology. The HAS is developed from 13 health domains reported to influence healthy ageing. Data to measure these domains was extracted from the 45 and Up Study baseline. We applied best practices for scale validation and development. Physical functioning, cognitive function, mental health, sleep, quality of life, balance, social connections and overall health were retained. Functional capacity and resilience were uncovered as underlying latent structures. The HAS ranges from 0 to 16 with higher scores indicating a better health profile. This research contributes a comprehensive measuring tool, HAS, It enables examination and comparison of individual or collective health profiles and the investigation of the factors that influence their chances of living healthy for longer.

The proportion of the population living longer is increasing, but longevity does not necessarily imply ageing well. Advancements in medicine have made it possible for people to live longer even while managing multiple ailments. The determinants of how well one age result from a complex interaction of various factors. This paper examined thirteen factors that can influence healthy ageing to construct a healthy ageing score comprising the crucial health domains relevant to ageing well. We found that 8 of the 13 health domains, namely: physical functioning, cognitive function, balance and falls, overall health, mental health, quality of life, sleep and social connections were crucial to ageing well. Individuals were scored a 2, a 1 or 0 based on whether they met recommended levels for each domain item and aggregated as the healthy ageing score. The score ranges from 0 to 16, with higher scores indicating a healthier ageing profile.

Nurses and nature; Does green space make a difference?

How we engage in and with nature is of growing interest in relation to our health and well-being. For nurses with stressful workloads that are contributing to fatigue, psychological burden, insomnia, and decreased coping strategies, interactions with nature or green space are essential as it has been demonstrated to facilitate better environments and outcomes for nurses. Evidence of the impact of nature is limited. However, the value of interactions with nature has been prioritised by the World Health Organization and so healthcare organizations should be considering overt and practical ways to ensure nurses, and other healthcare providers, are exposed to nature to contribute towards healthier environments.

Leafier Communities, Healthier Hearts: An Australian Cohort Study of 104,725 Adults Tracking Cardiovascular Events and Mortality Across 10 Years of Linked Health Data.

OBJECTIVE: Green space reduces cardiovascular disease (CVD) risk, but few studies examine what types of green space matter, which is an important consideration as cities densify and apartments become more common. METHOD: Participants were 86,727 in houses and 17,998 in apartments from the 45 and Up Study (Sax Institute) baseline survey with 10 years of linked hospitalisation and death data used to define: (i) all-cause; and (ii) CVD-mortality; (iii) fatal and non-fatal CVD events; and (iv) acute myocardial infarction (AMI). Associations with total green space, tree canopy cover and open grass within 1.6 km buffers were assessed using survival analysis adjusted for potential confounders. RESULTS: Mean percentage green space indicators were all higher among participants in houses than in apartments. Among residents of houses, a 10% increase in total green space was associated with reduced risk of CVD mortality (HR 0.97, 95%CI 0.95-1.00). A 10% increase in tree canopy cover was associated with reduced risks of all-cause mortality (HR 0.97, 95%CI 0.95-0.99), CVD mortality (HR 0.96, 95%CI 0.93-0.98), and fatal or non-fatal AMI (HR 0.93, 95%CI 0.89-0.96). In contrast, a 10% increase in open grass was associated with an increased risk of fatal or non-fatal AMI (HR 1.15, 95%CI 1.09-1.20) in residents of houses. Among residents of apartments, a 10% increase in total green space was associated with increased risk of all-cause mortality (HR 1.04, 95%CI 1.00-1.08) and CVD mortality (HR 1.03, 95%CI 1.00-1.08). CONCLUSIONS: Urban reforestation may be a population-level intervention to protect cardiovascular health, especially for people living in houses. The intersection of urban greening and cardiovascular health among residents of apartments warrants further investigation.

Need and Interest in Nature Prescriptions to Protect Cardiovascular and Mental Health: A Nationally-Representative Study With Insights for Future Randomised Trials.

OBJECTIVE: "Nature prescriptions" are increasingly being adopted by health sectors as an adjunct to standard care to attend to health and social needs. We investigated levels of need and interest in nature prescriptions in adults with cardiovascular diseases, psychological distress and concomitants (e.g. physical inactivity, sedentary behaviour, obesity, loneliness, burn-out). METHODS: A nationally-representative survey of 3,319 adults across all states and territories of Australia was completed in February 2021 (response 84.0%). Participants were classified across 15 target groups using validated health indicators and surveyed on (1) time and frequency of visits to green and blue spaces (nature spaces), (2) interest in a nature prescription, and (3) potential confounders (e.g. age, income). Analyses were done using weighted logistic regressions. RESULTS: The sample was 50.5% female, 52.0% were aged ≥45 years, 15.2% were living alone and 19.3% were born overseas in non-English-speaking countries. Two-thirds of the sample spent 2 hours or more a week in nature, but these levels were generally lower in target groups (e.g. 57.7% in adults with type 2 diabetes). Most participants (81.9%) were interested in a nature prescription, even among those spending fewer than 2 hours a week in nature (76.4%). For example, 2 hours a week or more in nature was lowest among sedentary adults (36.9%) yet interest in nature prescriptions in this group was still high (74.0%). Lower levels of nature contact in target groups was not explained by differences in access to or preference for local nature spaces. CONCLUSIONS: High levels of interest in nature prescriptions amid low levels of nature contact in many target health groups provides impetus for developing randomised trials of interventions that enable people to spend more time in nature. These findings can inform intervention co-design processes with a wide range of community stakeholders, end-users in target health groups, and the health professionals who support them.

Association between built environments and weight status: evidence from longitudinal data of 9589 Australian children.

BACKGROUND: No studies appear to examine potential associations between changes in built environments across childhood and the developmental trajectories of child weight status. OBJECTIVE: Examine the developmental trajectories of child weight status with respect to changes in childhood exposure to the built environments. METHODS: This study used data of 9589 children with biennial follow-up (2004-2016), retrieved from the Longitudinal Study of Australian Children. Changes in objectively-measured child weight status (i.e., body mass index-BMI, waist circumference) were investigated in relation to changes in seven built environments (i.e., neighbourhood safety; green space quality; footpaths and street conditions; public transport; shopping facilities; basic services; and local traffic) subjectively reported by caregivers. Group-based discrete trajectory mixture models were used to classify children according to their developmental trajectories of built environments and weight status. Multilevel multinomial logistic regression was employed to examine associations between built environments and child weight status adjusted for confounding. RESULTS: Two, four, and six trajectory groups were developed for built environment variables. Three groups namely "moderate", "high", and "extreme increase" were generated for each BMI and waist circumference. Findings from multilevel analyses indicated that growing up in neighbourhoods that are considered highly safe, with better quality of green space nearby, and in areas with low local traffic over time are protective against unhealthy weight increase in childhood. Meanwhile, living with better access to shopping facilities and basic services was associated with an unhealthy increase in BMI and/or waist circumference. No clear associations appeared between the quality of footpath and street conditions, access to public transport, and child weight status. CONCLUSIONS: Built environments might act either as a risk or protective factor of an unhealthy increase in child weight status. Enabling health-promoting neighbourhoods (i.e., highly safe, quality green space nearby, low local traffic) is important to support a healthy weight trajectory across childhood.

Caregiver perceptions of neighbourhood green space quality, heavy traffic conditions, and asthma symptoms: Group-based trajectory modelling and multilevel longitudinal analysis of 9,589 Australian children.

BACKGROUND: This study assessed the associations between changes in exposure to green space quality, heavy traffic conditions, and asthma symptoms among children. METHODS: 10-year cohort data of 9589 children, retrieved from the Longitudinal Study of Australian Children, were analysed. Caregiver-reported neighbourhood green space quality, heavy traffic conditions, and asthma symptoms were measured biennially. Group-based trajectory mixture models were used to develop trajectory groups, denoting different patterns of, or changes in, exposure to green space quality, heavy traffic conditions, and asthma symptoms across childhood. Multilevel multinomial logistic regression was used to identify factors associated with trajectory group membership and examine the confounders-adjusted associations between trajectory groups of green space quality, heavy traffic conditions, and asthma symptoms. RESULTS: Four trajectory groups for each green space quality and heavy traffic conditions, and five trajectory groups for asthma symptoms were developed. Children in less disadvantaged areas were more likely to be in trajectory groups with exposure to quality green space, but less likely to be exposed to heavy neighbourhood traffic. Living in more remote areas was associated with the decreased likelihood to be in groups with exposure to both quality green space and heavy traffic conditions over time. Accumulation of exposure to quality green space across childhood was not found to be protective against asthma symptoms. However, children whose caregiver perceptions of heavy traffic conditions trended from low to moderate levels; or were consistently in high levels across childhood had a higher likelihood to be in trajectory groups with a higher risk of asthma symptoms. CONCLUSION: Exposure to quality green space was not associated with the reduced risk of asthma symptoms. The accumulation of exposure to heavy traffic conditions increased the likelihood of asthma symptoms among children. Reducing the presence of heavy traffic in neighbourhoods might reduce the risk of childhood asthma.

Green space quality and adolescent mental health: do personality traits matter?

INTRODUCTION: Adolescents, especially females, tend to experience poorer mental health if they are higher in introversion and neuroticism. As a result, they also may have more to gain from having quality green space (e.g. parks) nearby to enable restoration, but this remains tested. METHOD: Cross-sectional data on 2946 adolescents aged 16-17y were extracted from the Longitudinal Study of Australian Children. Multilevel linear regressions assessed association between parent/caregiver green space quality perception with self-reported Strengths and Difficulties Questionnaire Total Difficulties Scores (TDS) and internalising (e.g. anxiety) and externalising (e.g. fidgetiness) subscales. Models were weighted for representativeness, accounted for spatial clustering within postcodes, and adjusted for geographic stratum and socioeconomic confounders. This was followed by adjustment for introversion and neuroticism, and then three-way interaction terms between each trait, green space quality and sex to assess for potential effect modification. RESULTS: Quality green spaces was associated with higher TDS (ß = 1.506; SE = 0.371), internalising (ß = 0.982; SE = 0.220) and externalising (ß = 0.518; SE = 0.234) scores (i.e. poorer mental health). Introversion was associated with higher TDS (ß = 1.416; SE = 0.089), higher internalising (ß = 1.233; SE = 0.050) and higher externalising scores (ß = 0.181; SE = 0.056). Similar associations were observed for neuroticism and TDS (ß = 2.283; SE = 0.084), internalising (ß = 1.627; SE = 0.046) and externalising scores (ß = 0.656; SE = 0.056). Mean levels of introversion were similar for girls and boys (1.73 vs 1.76, p = 0.6573), but mean levels of neuroticism were notably higher in girls than boys (2.42 and 1.67, p < 0.0001). Likelihood ratio tests indicated three-way interactions improved models analysing the internalising subscale outcome only. Green space quality made no difference to associations between introversion or neuroticism and internalising scores in males. Quality green space was associated with 3.2 and 2.1 reductions in mean internalising scores among females with the highest levels of introversion or neuroticism, respectively. CONCLUSIONS: Individual differences in psychological traits may predispose some adolescents, and females especially, to restoration from green space.

Weekly green space visit duration is positively associated with favorable health outcomes in people with hypertension: Evidence from Shenzhen, China.

BACKGROUND: Studies from high income 'western' countries indicate that green space visit duration is associated with better health. However, scant comparable research has been done in developing countries with rapid urbanization and on the potential health impacts of specific green infrastructure. OBJECTIVE: Associations between green space visit duration, green infrastructure and various health outcomes were assessed in hypertensive patients. METHODS: A stratified multi-stage cluster random sampling method was applied to select 1116 patients with hypertension aged 35 years or older in Shenzhen, China. Face-to-face survey, physical examination and laboratory biochemical tests were applied to obtain information. Binary logistic regressions with restricted cubic splines were used to explore the degree of linearity in associations between green space visit duration and the following health outcomes: central obesity; diabetes; blood pressure; dyslipidemia; poor physical health; poor mental health. Models were adjusted for age, sex, education, marital status, occupation, and socioeconomic status. Further analysis was made for presence of the following health promoting green infrastructure: health knowledge promotion areas; walking trails; fitness areas; group exercise venues. RESULTS: Each additional 30 min green space visitation was linearly associated with lower odds of self-reported poor mental health [OR (95%CI): 0.937 (0.891-0.985)], self-reported poor physical health [OR (95%CI): 0.918 (0.872-0.966)], and central obesity [OR (95%CI): 0.951 (0.907-0.997)]. Odds of poor mental health [OR (95%CI): 0.886 (0.788-0.997)], poor physical health [OR (95%CI): 0.882 (0.782-0.996)] and central obesity [OR (95%CI): 0.855 (0.765-0.955)] were founded to decrease with a greater number of health promoting green infrastructure. CONCLUSION: More time spent in green space and with more types of green infrastructure were favourably associated with central obesity, and physical and mental health in people with hypertension.

The nexus between urban green space, housing type, and mental health.

INTRODUCTION: Momentum for urban densification is increasing opportunities for apartment-living, but can result in reduced green space availability that negatively influences mental health. However, in contexts where apartment-living is atypical and commonly viewed as secondary to house-ownership, it may be a stressful antecedent condition (or marker of selective processes aligned with psychological distress) wherein occupants could benefit disproportionately from green space. METHOD: Data were extracted from the Sax Institute's 45 and Up Study baseline (2006-2009, n = 267,153). The focus was on subsets of 13,196 people living in apartments and 66,453 people living in households within the cities of Sydney, Newcastle and Wollongong. Multilevel models adjusted for confounders tested associations between psychological distress (Kessler 10 scale) with percentage total green space, tree canopy and open grass within 1.6 km road network buffers. RESULTS: Psychological distress was higher in occupants of apartments (11.3%) compared with houses (7.9%). More green space was associated with less psychological distress for house-dwellers (OR = 0.94, 95% CI = 0.91-0.98), but there was no association for apartment-dwellers. More tree canopy was associated with lower psychological distress for house-dwellers (OR = 0.88, 95% CI = 0.85-0.92) and apartment-dwellers (OR = 0.87, 95% CI = 0.79-0.96). Open grass was associated with more psychological distress among house-dwellers (OR = 1.06, 95% CI = 1.00-1.13) and also for apartment-dwellers (OR = 1.20, 95% CI = 1.07-1.35). CONCLUSIONS: Overall, investments in tree canopy may benefit the mental health of house and apartment residents relatively equally. Urban tree canopy in densely populated areas where apartments are common needs to be protected. Further work is needed to understand factors constraining the prevention potential of open grass, to unlock its benefits for mental health.

Is prosocial behaviour a missing link between green space quality and child health-related outcomes?

BACKGROUND: This study aimed to investigate prosocial behaviour-those behaviours that benefit others or enhance relationships with others-as a mediator of the associations between green space quality and child health-related outcomes (physical activity, mental health, and health-related quality of life (HRQOL)). METHODS: This study involved data from 4983 children with 10-year follow-up (2004-2014) retrieved from the Longitudinal Study of Australian Children. Green space quality (the exposure), prosocial behaviour (the candidate mediator), and child health-related outcomes were assessed biennially based on caregiver reports. Causal mediation analysis was used, with four mediation models developed for each outcome. RESULTS: Mediation by prosocial behaviour appeared in the late childhood mediation model with higher mediation proportions reported compared to models of earlier and middle childhood. Prosocial behaviour had moderate mediation consistency for the association between green space quality and physical activity enjoyment, but no mediation was evident for other physical activity variables. Prosocial behaviour had low mediation consistency for child mental health (internalising and externalising subscales). Similarly, low mediation consistency of prosocial behaviour was also evident for all HRQOL variables, such as physical, emotional, social, school functioning, psychosocial health, and total quality of life (QOL). CONCLUSION: Prosocial behaviour partially mediated the association between green space quality and child health-related outcomes (physical activity enjoyment, mental health, and HRQOL). Improving the quality of neighbourhood green space that supports the development of prosocial behaviour may result in better child health-related outcomes. Other physical activity variables might not specifically relate to social interactions, and therefore, no mediation by prosocial behaviour was apparent.

Mental health clinicians' perceptions of nature-based interventions within community mental health services: evidence from Australia.

BACKGROUND: Mental health conditions are one of the largest burdens of disease in Australia and globally. There is a need to seek innovative and alternative interventions that can prevent and alleviate mental health symptoms. Nature-based interventions (NBIs), namely programs and activities where individuals engage with natural environments with the aim of improving their health and wellbeing (e.g., nature walking groups), may be such an alternative. This study aimed to explore the perceptions of mental health clinicians on the potential benefits of, and barriers to, implementing NBIs within a community mental health setting. METHODS: This study used a qualitative, exploratory research design. Fifteen mental health clinicians were recruited from the Illawarra Shoalhaven Local Health District, Australia, and interviewed (September-October 2021) about their perceptions of NBIs within mental health settings. The semi-structured interviews were analysed using an inductive thematic approach and managed with NVivo. RESULTS: Mental health clinicians viewed spending time in nature as relaxing, refreshing, and therapeutic. Many described it as part of their lifestyle and encouraged consumers to engage in nature-based activities on their own time. If NBIs were to be introduced as part of mental health services, clinicians expressed willingness to promote them to their consumers. Clinicians listed many potential benefits of NBIs for mental health consumers including improved mood, calmness and relaxation, a sense of empowerment, and social connections. Despite these benefits, clinicians were concerned about a variety of barriers to NBIs including consumers' mental health symptoms such as anxiety or lack of motivation, scepticism, and geographic accessibility, as well as organisational barriers such as policies around safety risk. CONCLUSION: Responding to the individual and organisational factors that could hinder the implementation of NBIs while building on the existing evidence of the positive impact of nature on health and wellbeing and, as demonstrated in this study, mental health clinicians' interest and supportiveness of NBIs, mental health services should consider the implementation of NBIs as part of routine practice.

Behavioural change, weight loss and risk of dementia: A longitudinal study.

Recent meta-analysis reported higher dementia risks associated with lower body mass index (BMI) and decreasing BMI. We examined to what extent these associations were attenuated by changes in behaviours and local environment. Multilevel discrete time-to-event models examined associations between baseline and change in BMI with dementia detected through prescription medications (source: Department of Human Services), hospitalisations and death certificates among 144,456 participants in the Sax Institute's 45 and Up Study. Models were adjusted for socioeconomic factors and measures of change in adherence to published guidelines for moderate to vigorous physical activity, sleep duration, alcohol, and fruit and vegetable consumption, as well as incidence of cardiometabolic diseases, and indicators of area-level disadvantage and rurality. Data was analysed in 2020. Higher dementia risks (albeit with imprecision) were found among participants who were underweight (Incidence Hazard Ratio (IHR) 1.30, 95%CI=0.86-1.86) and lower risks among those who were overweight (IHR=0.78, 95%CI=0.70-0.86) or obese (IHR=0.72, 95%CI=0.62-0.83) compared with 'normal' BMI. A ≥0.8 kg/m2 reduction in BMI associated with IHR=1.81 (95%CI=1.64-2.01) higher dementia risk relative to those with stable BMI. Higher dementia risk with decreasing BMI was fairly consistent relative to baseline BMI category. Adherence to physical activity and sleep duration guidelines were associated with reduced dementia risk, but neither these, nor adjustment for other behaviours and local factors, explained the BMI-dementia association. In conclusion, we replicated the BMI-dementia findings from a recent meta-analysis and provide further support to preventive strategies focussed on increasing physical activity and improving sleep duration. Other potential environmental risk factors outside of socioeconomic and urban/rural circumstances warrant investigation.

Association between green space quality and prosocial behaviour: A 10-year multilevel longitudinal analysis of Australian children.

BACKGROUND: Current evidence from studies on green space and child prosocial behaviour suggests a paucity of studies investigating the plausible role of green space quality in shaping the development of prosocial behaviour. This study aimed to examine longitudinal association between green space quality and prosocial behaviour among children. METHODS: We analysed 10-year longitudinal data (2004-2014) from the Longitudinal Study of Australian Children (LSAC), a nationally representative cohort study. Prosocial behaviour that covers positive behaviours (e.g. sharing, helping) was measured using a prosocial scale from Goodman's Strengths and Difficulties Questionnaire (SDQ). Parents' perceptions on the availability of "good" parks, playgrounds, and play space in the neighbourhood assessed green space quality. Multilevel linear regression models were used to examine potential changes in prosocial behaviour across childhood in relation to green space quality. A two-way interaction term between green space and age was fitted to assess potential differences in the effect of green space quality by age. Sensitivity analyses by child's sex and history of residential movement were also performed. RESULTS: From the analysis of 24,418 observations nested in 4969 children, prosocial behaviour was relatively high (mean = 8.13 out of 10; SD = 1.79) and about balanced proportions between girls (48.74%) and boys (51.26%) were included. Prosocial behaviour was higher among children whose parents agreed (ß = 0.10; 95%CI = 0.04, 0.16) and strongly agreed (ß = 0.20; 95%CI = 0.13, 0.27) to having quality green space in their neighbourhood. The benefit of exposure to favourable green space on prosocial behaviour was similar among both children who changed and did not change neighbourhood, but reported higher among boys than girls. Younger compared with older children or adolescents tended to benefit more by the presence of quality green space. CONCLUSION: Green space quality was positively associated with child prosocial behaviour. Boys and younger children tended to benefit more from quality green space. Future research might seek to identify preferred characteristics of quality green spaces, and to understand how these preferences vary by gender and age, to best support the development of prosocial behaviour across childhood and adolescence.

Dietary patterns and their associations with overweight/obesity among preschool children in Dongcheng District of Beijing: a cross-sectional study.

BACKGROUND: Few studies investigated the associations between dietary patterns and overweight/obesity among Chinese preschool children. Thus, the study aims to explore dietary patterns and their associations with overweight/obesity among preschool children in the Dongcheng District of Beijing. METHODS: With a stratified proportionate cluster sampling, the study included 3373 pairs of preschool children and their guardians. Children's weight and height were measured by school nurses, and their food and beverage consumption frequencies were reported by guardians via a food frequency questionnaire. Children's age, gender, physical activity time, and sedentary time, as well as their parents' highest level of educational attainment, occupation, weight, and height were also collected. Dietary patterns were identified through exploratory factor analysis. Among these identified dietary patterns, the one with the largest factor score was defined as the predominant dietary pattern for each child. The associations between predominant dietary patterns and overweight/obesity were tested by two-level random-intercept logistic models with cluster-robust standard errors. RESULTS: Four dietary patterns, i.e., a "Sugar-sweetened beverage (SSB) and snack" pattern, a "Chinese traditional" pattern, a "Health conscious" pattern, and a "Snack" pattern, were identified. Among the children, 21.02% (95% CI: 19.68 to 22.43%) were predominated by the "SSB and snack" pattern, 27.78% (95% CI: 26.29 to 29.32%) by the "Chinese traditional" pattern, 24.90% (95% CI: 23.47 to 26.39%) by the "Health conscious" pattern, and 26.30% (95% CI: 24.84 to 27.81%) by the "Snack" pattern. After controlling for potential confounders, the "SSB and snack" pattern characterized by fresh fruit/vegetable juice, flavored milk drinks, carbonated drinks, flavored fruit/vegetable drinks, tea drinks, plant-protein drinks, puffed foods, fried foods, and Western fast foods was associated with a higher risk of overweight/obesity (OR: 1.61, 95% CI:1.09 to 2.38), compared with the "Chinese traditional" pattern. CONCLUSIONS: The preference for dietary patterns with high energy density but low nutritional value was prevalent among preschool children in the Dongcheng District of Beijing. Comprehensive measures to simultaneously reduce consumption of SSBs and unhealthy snacks among preschool children should be taken urgently to address the childhood obesity problem in China, particularly in metropolises.

Augmenting cancer registry data with health survey data with no cases in common: the relationship between pre-diagnosis health behaviour and post-diagnosis survival in oesophageal cancer.

BACKGROUND: For epidemiological research, cancer registry datasets often need to be augmented with additional data. Data linkage is not feasible when there are no cases in common between data sets. We present a novel approach to augmenting cancer registry data by imputing pre-diagnosis health behaviour and estimating its relationship with post-diagnosis survival time. METHODS: Six measures of pre-diagnosis health behaviours (focussing on tobacco smoking, 'at risk' alcohol consumption, overweight and exercise) were imputed for 28,000 cancer registry data records of US oesophageal cancers using cold deck imputation from an unrelated health behaviour dataset. Each data point was imputed twice. This calibration allowed us to estimate the misclassification rate. We applied statistical correction for the misclassification to estimate the relative risk of dying within 1 year of diagnosis for each of the imputed behaviour variables. Subgroup analyses were conducted for adenocarcinoma and squamous cell carcinoma separately. RESULTS: Simulated survival data confirmed that accurate estimates of true relative risks could be retrieved for health behaviours with greater than 5% prevalence, although confidence intervals were wide. Applied to real datasets, the estimated relative risks were largely consistent with current knowledge. For example, tobacco smoking status 5 years prior to diagnosis was associated with an increased age-adjusted risk of all cause death within 1 year of diagnosis for oesophageal squamous cell carcinoma (RR = 1.99 95% CI 1.24,3.12) but not oesophageal adenocarcinoma RR = 1.61, 95% CI 0.79,2.57). CONCLUSIONS: We have demonstrated a novel imputation-based algorithm for augmenting cancer registry data for epidemiological research which can be used when there are no cases in common between data sets. The algorithm allows investigation of research questions which could not be addressed through direct data linkage.

Using estimated probability of pre-diagnosis behavior as a predictor of cancer survival time: an example in esophageal cancer.

BACKGROUND: Information on the associations between pre-diagnosis health behavior and post-diagnosis survival time in esophageal cancer could assist in planning health services but can be difficult to obtain using established study designs. We postulated that, with a large data set, using estimated probability for a behavior as a predictor of survival times could provide useful insight as to the impact of actual behavior. METHODS: Data from a national health survey and logistic regression were used to calculate the probability of selected health behaviors from participant's demographic characteristics for each esophageal cancer case within a large cancer registry data base. The associations between survival time and the probability of the health behaviors were investigated using Cox regression. RESULTS: Observed associations include: a 0.1 increase in the probability of smoking 1 year prior to diagnosis was detrimental to survival (Hazard Ratio (HR) 1.21, 95% CI 1.19,1.23); a 0.1 increase in the probability of hazardous alcohol consumption 10 years prior to diagnosis was associated with decreased survival in squamous cell cancer (HR 1.29, 95% CI 1.07, 1.56) but not adenocarcinoma (HR 1.08, 95% CI 0.94,1.25); a 0.1 increase in the probability of physical activity outside the workplace is protective (HR 0.83, 95% CI 0.81,0.84). CONCLUSIONS: We conclude that probability for health behavior estimated from demographic characteristics can provide an initial assessment of the association between pre-diagnosis health behavior and post-diagnosis health outcomes, allowing some sharing of information across otherwise unrelated data collections.