# Is objectively measured exposure to built and natural environment associated with population-level cardiovascular disease mortality in Great Britain?

## TL;DR

This study explores how the built and natural environment in Great Britain affects cardiovascular disease mortality, finding that air pollution increases risk while walkability and tree cover may reduce it.

## Contribution

The study uniquely examines multiple built environment features and their interactions with socioeconomic factors to assess cardiovascular disease mortality at a population level.

## Key findings

- Higher air pollution is linked to increased CVD mortality in both sexes.
- Walkability reduces female CVD mortality, and tree cover reduces male CVD mortality.
- Air pollution and 'bads' increase male CVD mortality in deprived areas.

## Abstract

Cardiovascular disease (CVD) causes one-third of global mortality, with modifiable risk factors such as unhealthy diet, sedentary behaviour, tobacco/alcohol use contributing to 80 % of CVD deaths. The built environment (BE) can influence CVD risk indirectly by shaping health behaviours and directly through environmental exposures like air pollution. While research has established connections between isolated environmental features and CVD, this study addresses significant research gaps in understanding how multiple BE characteristics influence CVD mortality across socioeconomic contexts, aiming to inform neighbourhood design to reduce both CVD and inequalities.

We modelled, for small areas across GB, tree cover, air pollution, walkability, densities of health-detrimental amenities (‘bads’) (e.g. fast-food outlets) and health-promoting amenities (‘goods’) (e.g. gyms), and income deprivation. Generalised linear models were used to assess associations between small area features and (sex-stratified) age-standardised CVD mortality rates (i.e. ICD-10 codes I00–I99), controlling for deprivation, urban-rural, country, and local authority. Combined models (i.e. models mutually adjusted for all BE features) identified the unique contribution of each feature while accounting for those that ‘co-located’. Interaction analysis was performed to examine variations by income deprivation.

A slight increase in CVD mortality risk was associated with greater ‘goods’ densities (female mortality ratio (MR):1.005 (CIs:1.003–1.007), p < 0.001, male MR:1.005 (CIs:1.003–1.006), p < 0.001), and higher air pollution (female MR:1.006 (CIs:1.003–1.009), p < 0.001, male MR:1.008 (CIs:1.005–1.009), p < 0.001). A slight decrease in CVD mortality was associated with higher walkability for females (MR:0.996 (CIs:0.992–0.999), p = 0.034) and tree cover for males (MR:0.999 (CIs:0.998–0.999), p = 0.007). Higher air pollution levels and ‘bads’ were associated with higher male CVD mortality in deprived areas.

Findings have clear policy implications, suggesting prioritisation of reductions in air pollution—particularly in deprived areas—while promoting walkability and tree cover to reduce health inequalities. Unexpected positive associations between ‘goods’ and mortality highlight that complex neighbourhood effects warrant further study.

•Built environment (BE) influences CVD risk via behaviours and exposures.•Study models multiple BE features across small areas in Great Britain.•Higher air pollution linked to increased CVD mortality in both sexes.•Walkability (females) and tree cover (males) linked to lower CVD mortality.•Air pollution and amenity ‘bads' raised male CVD mortality in deprived areas.

Built environment (BE) influences CVD risk via behaviours and exposures.

Study models multiple BE features across small areas in Great Britain.

Higher air pollution linked to increased CVD mortality in both sexes.

Walkability (females) and tree cover (males) linked to lower CVD mortality.

Air pollution and amenity ‘bads' raised male CVD mortality in deprived areas.