Exposure to Neighborhood Walkability and Residential Greenness and Incident Fracture

Importance: Emerging studies have suggested that environmental factors are associated with fracture. However, little is known about the association of neighborhood walkability and residential greenness with fracture. Objective: To investigate the association of long-term exposure to walkability and greenness with incident fracture and explore the potential interaction effect. Design, Setting, and Participants: This cohort study recruited participants aged 40 years or older in Ningbo, China from June 2015 to January 2018. Participants were observed for outcomes through February 2023, with data analysis conducted in March 2023. Exposures: Neighborhood walkability was measured by a modified walkability calculation method according to a walk score tool. Residential greenness was assessed by satellite-derived normalized difference vegetation index (NDVI) within a 1000-m buffer. Main Outcomes and Measures: Incident fracture was ascertained according to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes via the Yinzhou Health Information System. Cox proportional hazards models were fit, with age as time scale to estimate the associations of walkability and greenness with fracture. Potential effect modification was explored by covariates, as well as the interactive effect of walkability and greenness. Results: A total of 23 940 participants were included in this study with 13 735 being female (57.4%). The mean (SD) age at baseline was 63.4 (9.4) years. During a follow-up period of 134 638 person-years, 3322 incident fractures were documented. In the full adjusted model, every IQR increment in neighborhood walkability and residential greenness was associated with a hazard ratio (HR) of 0.88 (95% CI, 0.83-0.92) and 0.84 (95% CI, 0.80-0.89), respectively, for fracture. Furthermore, the association of greenness and fracture was greater with an increase in walkability. The HR (Q4 vs Q1) for greenness was 0.62 (95% CI, 0.46-0.82) in neighborhoods with the highest quartile of walkability. Conclusions and Relevance: This population cohort study suggested that long-term exposure to neighborhood walkability and residential greenness were both associated with lower risk of incident fracture. The benefits of greenness increased in more walkable areas.