title: Residential neighbourhood greenspace is associated with reduced risk of incident diabetes in older people: a prospective cohort study.
abstract: Three cross sectional studies suggest that neighbourhood greenspace may protect against incident diabetes. This study uses data from a longitudinal study with a large sample size to investigate the association between greenspace and the occurrence of incident diabetes over time.
  
  
  
  Data was from the European Prospective Investigation of Cancer Norfolk, UK, cohort, recruitment 1993-2007 (N = 23,865). Neighbourhoods were defined as 800 m circular buffers around participants' home locations, according to their home postcode (zip code). Greenspace exposure was defined as the percentage of the home neighbourhood that was woodland, grassland, arable land, mountain, heath and bog, according to the UK Land Cover Map. Cox proportional hazards regression examined the association between neighbourhood greenspace exposure and incident diabetes. The population attributable fraction assessed the proportion of diabetes cases attributable to exposure to least green neighbourhoods. Mediation analysis assessed if physical activity explained associations between greenspace and diabetes. Interaction analysis was used to test for the modifying effect of rurality and socio-economic status on the relationship between greenspace and diabetes. Models were adjusted for known and hypothesised confounders.
  
  
  
  The mean age of participants was 59 years at baseline and 55.1% were female. The mean follow-up time was 11.3 years. Individuals living in the greenest neighbourhood quartile had a 19% lower relative hazard of developing diabetes (HR 0.81; 95% CI 0.67, 0.99; p = 0.035; linear trend p = 0.010). The hazard ratio remained similar (HR 0.81; 95% CI 0.65, 0.99; p = 0.042) after adjusting for age, sex, BMI, whether a parent had been diagnosed with diabetes and socio-economic status at the individual and neighbourhood level. A HR of 0.97 was attributed to the pathway through physical activity in a fully adjusted model, although this was non-significant (95% CI 0.88, 1.08; p = 0.603). The incidence of diabetes in the least green neighbourhoods (with 20% greenspace on average) would fall by 10.7% (95% CI -2.1%, 25.2%; p = 0.106) if they were as green as the average neighbourhood observed across the whole cohort (59% greenspace on average). There were no significant interactions between rurality or socio-economic status and level of greenspace.
  
  
  
  Greener home neighbourhoods may protect against risk of diabetes in older adults, although this study does not support a mediation role for physical activity. Causal mechanisms underlying the associations require further investigation.
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK. a.dalton@uea.ac.uk.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Dalton
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Jones
authors.affiliation: Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Sharp
authors.affiliation: Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK.
authors.forename: Andrew J M
authors.initials: AJ
authors.lastname: Cooper
authors.affiliation: Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Griffin
authors.affiliation: Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Wareham
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000209:etiology*; D004777:Environment; D015444:Exercise; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012111:Residence Characteristics; D012307:Risk Factors; D012424:Rural Population / Q000706:statistics & numerical data; D012923:Social Class; D012959:Socioeconomic Factors; D006113:United Kingdom / Q000453:epidemiology
keywords: Greenspace exposure; Incident diabetes; Older adults; Physical activity