Article Text

other Versions

Download PDFPDF
Does a physical activity supportive environment ameliorate or exacerbate socioeconomic inequities in incident coronary heart disease?
  1. Pedro Gullon1,2,
  2. Usama Bilal2,3,
  3. Jana A Hirsch2,3,
  4. Andrew G Rundle4,
  5. Suzanne Judd5,
  6. Monika M Safford6,
  7. Gina S Lovasi2,3
  1. 1Public Health and Epidemiology Research Group, Universidad de Alcala de Henares Facultad de Medicina y Ciencias de la Salud, Alcala de Henares, Spain
  2. 2Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
  3. 3Epidemiology and Statistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
  4. 4Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
  5. 5Department of Biostatistics, University of Alabama at Birmingham College of Arts and Sciences, Birmingham, Alabama, USA
  6. 6Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, New York, USA
  1. Correspondence to Dr Pedro Gullon, Universidad de Alcala de Henares Facultad de Medicina y Ciencias de la Salud, Alcala de Henares 28871, Spain; pedro.gullon{at}


Background Efforts to reduce socioeconomic inequities in cardiovascular disease include interventions to change the built environment. We aimed to explore whether socioeconomic inequities in coronary heart disease (CHD) incidence are ameliorated or exacerbated in environments supportive of physical activity (PA).

Methods We used data from the Reasons for Geographic and Racial Differences in Stroke study, which recruited US residents aged 45 or older between 2003 and 2007. Our analyses included participants at risk for incident CHD (n=20 808), followed until 31 December 2014. We categorised household income and treated it as ordinal: (1) US$75 000+, (2) US$35 000–US$74 000, (3) US$20 000–US$34 000 and (4) <US$20 000. We operationalised PA-supportive environments using characteristics within a 1 km residential buffer: walkable destinations density, PA facility density and proportion green land cover. We used Cox proportional hazards models to estimate the adjusted association of income with incident CHD, and tested effect modification by PA-supportive environment variables.

Results We found a 25% (95% CI 1.17% to 1.34%) increased hazard of CHD per 1-category decrease in household income category. Adjusting for PA-supportive environments slightly reduced this association (HR=1.24). The income–CHD association was strongest in areas without walking destinations (HR=1.57), an interaction which reached statistical significance in analyses among men. In contrast, the income–CHD association showed a trend towards being strongest in areas with the highest percentage of green land cover.

Conclusions Indicators of a PA supportive environment show divergent trends to modify socioeconomic inequities in CHD . Built environment interventions should measure the effect on socioeconomic inequities.

  • neighborhood/place
  • cardiovascular disease
  • socio-economic

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @pgullon, @usama_bilal

  • Contributors PG and GL conceived the idea. JAH, AR, MMS and SJ developed the cohort and contextual data. PG and UB carried out the statistical analysis. PG drafted the manuscript. All authors provided critical intellectual contributions. All authors read and approved the final manuscript.

  • Funding The REGARDS research project is supported by cooperative agreement U01 NS041588 cofunded by the National Institute of Neurological Disorders and Stroke (NINDS) and the National Institute on Aging (NIA), National Institutes of Health, Department of Health and Human Service. Representatives of the NINDS were involved in the review of the manuscript but were not directly involved in the collection, management, analysis or interpretation of the data. The authors thank the other investigators, the staff, and the participants of the REGARDS study for their valuable contributions. A full list of participating REGARDS investigators and institutions can be found at: Additionally, the integration and analyses of geographic data were supported by the National Institute of Aging (grants 1R01AG049970, 3R01AG049970-04S1), Commonwealth Universal Research Enhancement (C.U.R.E) program funded by the Pennsylvania Department of Health - 2015 Formula award - SAP #4100072543, the Urban Health Collaborative at Drexel University, and the Built Environment and Health Research Group at Columbia University. PG was supported by Fundación Alfosno Martín Escudero 2018 Postdoctoral fellowship program. UB was supported by the Office of the Director of the National Institutes of Health under award number DP5OD26429.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINDS or the NIA.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The REGARDS study protocol was reviewed and approved by the University of Alabama at Birmingham Institutional Review Board and all participating institutional review boards.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data may be obtained from the REGARDS cohort committee at the University of Alabama at Birmingham on request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.