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Built Environment and Burden of Cardiovascular Diseases: a new, old threat.

Comment by Demosthenes Panagiotakos, former Population Science and Public Health Section member

Preventive Cardiology
Risk Factors and Prevention

In a recent paper published in the European Journal of Preventive Cardiology (EJPC) by Liu et al., authors provided a systematic overview of the current evidence on neighbourhood-built environment exposures (i.e. outdoor air pollution, food environment, physical activity environment, urbanisation, light pollution, residential noise, and ambient temperature) in relation to cardiovascular disease (CVD) incidence. Based on an extensive literature search, the authors concluded that there was strong evidence of the associations between increased air pollutants, residential noise, as well as ambient temperature, with greater risk of CVD. The study confirmed previous knowledge on certain environmental characteristics, e.g., outdoor air pollution, affecting CVD incidence, especially in urban populations, and highlighted the lack of evidence from low-to-middle-income countries, as well as on the potential interplays of built-and-food environment on CVD risk. 

Built and food environment have been suggested as motors in shaping human’s health, by influencing, among others, behaviours such as nutrition habits and physical activity. Although there is a considerable amount of evidence suggesting that built environment also influences food environment, however, at what extent they may interact increasing the risk for CVDs is not well understood and appreciated. The last years there is growing interest regarding the effect of residential areas’ characteristics on people’s dietary habits, and consequently, health status. The frequency of supermarkets and street markets per neighbourhood, as well as the land coverage by green urban areas, the greenspaces, and the public sports facilities, are some of the determinants of food and built environment that have been studied in relation to CVD incidence. There are accumulating evidence regarding the relationship among the supermarkets, healthier eating and lower prevalence rates of hypertension, obesity, and diabetes. According to the report of the division of Nutrition, Physical Activity, and Obesity of the US National Center for Chronic Disease Prevention and Health Promotion (NCCPHP), the location of full-service grocery stores is encouraged, especially in neighbourhoods where such stores are not found (2). It has been observed that residents with access to full-service grocery stores tend to eat more fruits and vegetables, tend to have lower risk of overweight and obesity, whereas these metabolic disorders are significantly higher in areas where food is mostly available through small stores and fast-food outlets. (1) One of the first studies in Europe that used spatial epidemiological techniques to evaluate the association between built environment and CVD risk and related factors, the Attica epidemiological Study (2002-2022), revealed the role of food-related environment in the development of a series of cardiometabolic disorders. The observed beneficial role of the higher density and frequency of street markets and supermarkets, together with the lower frequency of ready-to-eat or street-food markets or fast-foods within neighbourhoods in reducing CVD risk and related disorders, agrees with other observational studies, highlighting that better health outcomes are greatly influenced by individuals’ access to healthy food environments. (2) Nevertheless, all these research hypotheses should be further studied and evaluated in a variety of environments. 

At what extent which food sources may provide healthier food options remains a matter of debate and concern. What is evident is that in areas of lower socio-economic status, nutrition and health education messages regarding healthier dietary behaviours cannot be effectively disseminated and implemented to the population. (3) Therefore, the concept of health and nutrition literacy comes once again into the front. In line with all these findings, the World Health Organization supported the concept of the Healthy Cities, according to which a healthy city is the “one that continually creates and improves its physical and social environments and expands the community resources that enable people to mutually support each other in performing all the functions of life and developing to their maximum potential”.

Individualized prevention and treatment approaches are now considered as the basis in decreasing the burden of CVDs, worldwide. Accumulating data suggest that environmental modifications that promote healthy behaviours seems to be a cornerstone for achieving better health. According to the current European health policy developments, the transformation of public health actions to local authorities, could provide input for policy makers to better understand how individuals’ health is affected by the environmental characteristics of their residential area.


Demosthenes Panagiotakos commented on:

Liu M, Meijer P, Lam TM, Timmermans EJ, Grobbee DE, Beulens JWJ, Vaartjes I, Lakerveld J. The built environment and cardiovascular disease: an umbrella review and meta-meta-analysis. Eur J Prev Cardiol. 2023 Nov 9;30(16):1801-1827.

Additional references:

  1. Koohsari MJ, McCormack GR, Nakaya T, Oka K. Neighbourhood built environment and cardiovascular disease: knowledge and future directions. Nat Rev Cardiol. 2020 May;17(5):261-263.
  2. Tsiampalis T, Faka A, Psaltopoulou T, Pitsavos C, Chalkias C, Panagiotakos DB. The relationship of the built and food environments with the metabolic syndrome in the Athens metropolitan area: a sex-stratified spatial analysis in the context of the ATTICA epidemiological study. Hormones (Athens). 2021 Dec;20(4):723-734.
  3. Zhang K, Brook RD, Li Y, Rajagopalan S, Kim JB. Air Pollution, Built Environment, and Early Cardiovascular Disease. Circ Res. 2023 Jun 9;132(12):1707-1724. 

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.