Low walkability in neighborhoods associated with higher heart disease risk

Low neighborhood walkability is associated with increased risk of cardiovascular disease (CVD), according to research presented today at ESC Preventive Cardiology 2025, a scientific congress of the European Society of Cardiology (ESC). 

The health benefits of physical activity are well established and yet more than a quarter of adults do not meet the recommended guideline of 150 minutes of moderate-intensity physical activity per week.

Neighborhoods designed to be walkable may help residents to choose active transportation, such as commute walking, rather than sedentary modes of travel like driving, and allow increased physical activity to be incorporated into daily life."

Dr. Erik Timmermans, presenter of University Medical Center Utrecht, Utrecht, Netherlands

Neighborhood walkability can be defined as a composite measure of built environment characteristics that facilitate walking, with consideration of factors including land use mix, population density and green space density. "Evidence on the relationship between walkability and CVD is scarce and largely relies on cross-sectional studies. We conducted a longitudinal study to capture changes in walkability over time and relate them to CVD incidence in later years," noted Dr. Timmermans. 

The analysis included data from Statistics Netherlands for all 3,019,069 Dutch residents aged 40 years or older at baseline (2009), without a history of CVD and who did not move house after baseline. A nationwide, objectively measured walkability index was calculated for 500 m areas around their residential addresses. In this study, the walkability index consisted of six components: population density, retail and service density, land use mix, intersection density, green space density and sidewalk density, with geographical data provided by the Geoscience and Health Cohort Consortium. Latent class trajectory modelling was used to assess walkability changes over a 13-year period, from 1996 to 2008. 

Data on the incidence of CVD from 2009 to 2019 was collected from the Dutch Hospital Discharge Register and the National Cause of Death Register. Cox proportional hazards modelling was used to analyse associations between walkability trajectories and subsequent CVD incidence, adjusted for individual- and area-level sociodemographic characteristics. 

The median age of the study population at baseline was 57 years (interquartile range, 49 to 65 years). Four distinct trajectories of neighbourhood walkability were observed: a stable but relatively low walkability trajectory (91.1%), a stable but relatively higher walkability trajectory (0.6%), a relatively higher initial neighbourhood walkability that decreased over time (1.7%), and a relatively lower initial neighbourhood walkability that increased over time (6.5%). During a median follow-up of 11.0 years, 21.4% of individuals developed CVD. Among CVD outcomes, there were 81,600 deaths due to any CVD (2.7%). 

Compared with stable high walkability, individuals exposed to stable low walkability had a 5.1% higher risk of any CVD (hazard ratio [HR] 1.051; 95% confidence interval [CI] 1.011–1.093). Individuals exposed to increasing walkability had a 4.9% higher risk of any CVD compared with those exposed to stable high walkability (HR 1.049; 95% CI 1.008–1.092). Similar associations were observed for coronary heart disease and stroke but were not statistically significant. No significant associations were found for heart failure and CVD mortality. 

Dr. Timmermans summarized the findings: "Adults exposed to low walkability over time – which was most individuals in our study – had a higher risk of CVD compared to those in stable high walkability neighborhoods. Increasing walkability was also associated with higher CVD risk, which is likely due to the overall lower cumulative walkability during the exposure period that could have led to ingrained activity patterns or cardiometabolic risks that were not immediately reversible, even after walkability improved. Our results highlight the importance of long-term urban planning for cardiovascular health."