Abstract
Background.
Extant evidence links neighborhood walkability with obesity-related health in the general population. This association likely exists in cancer survivors, but research is limited. Further, disproportionate obesity burden in African American cancer survivors warrants subgroup-specific analyses.
Methods.
We analyzed data from 2089 African American cancer survivors participating in the Detroit Research on Cancer Survivors (ROCS) cohort. Using built environment data summarized within 1-km radial buffers around Census block centroids, we constructed a multidimensional Neighborhood Walkability Index (NWI). We geocoded survivors’ residential addresses at Detroit ROCS enrollment and linked addresses to NWI scores via Census block of residence. At study enrollment, survivors reported height and weight; we used these data to calculate their BMI. We evaluated associations between NWI quartiles and body mass index (BMI), overall and by cancer type, biologic sex, and physical activity engagement.
Results.
We found BMI to be inversely associated with increasing NWI quartile (p-trend:<0.01). We observed this inverse relationship in men (p-trend:<0.01) and in survivors reporting any regular physical activity (p-trend:<0.01).
Conclusion.
Our findings suggest that among African American cancer survivors, higher neighborhood walkability is associated with lower BMI. As health care systems in the United States increasingly consider the role of the neighborhood environment on their patients’ health, these findings provide additional evidence supporting health systems’ incorporation of neighborhood walkability as an obesity-related health indicator for this cancer survivors subgroup and potentially for cancer survivors from other vulnerable populations.
Keywords: African American, survivorship, neighborhood, walking, obesity
Precis:
We evaluated the relationship between neighborhood walkability and body size in a population-based sample of African American cancer survivors in Metropolitan Detroit. We found a cross-sectional link between higher neighborhood walkability and lower body mass index (BMI).
INTRODUCTION
Increasingly, health care systems in the United States (US) are becoming stakeholders in local and regional urban design and infrastructure planning processes, and are considering how neighborhood environments can support community and patient population health in health system catchment areas.1, 2 To this end, health systems are working alongside community partners to improve alignment and delivery of local resources as well as contracting with planning firms to create Health District Plans that develop urban infrastructure promoting healthy lifestyles1, 2 Further, in response Affordable Care Act provisions, health systems are beginning to incorporate neighborhood-level data in electronic health records (EHR) as patient “vital signs.”3, 4 However, justifying health systems’ collection of neighborhood features data requires robust evidence from patient populations. And while extant literature indicates associations between urban form and health in general populations, few studies explore these relationships in specific patient populations – including African American cancer survivors.5–10
Previous studies indicate neighborhood built environment characteristics that support walking and other forms of physical activity to be related to lower body mass index (BMI) in the general population.8, 11 Neighborhood walkability is likely similarly associated with obesity in cancer survivor populations, thereby influencing a range of obesity-related cancer survivorship outcomes, including disease progression, recurrence, quality of life, and prognosis.5, 6, 11–15 Cancer survivors, particularly those diagnosed with hormonally or metabolically driven cancer types such as breast, colorectal, or prostate, are at heightened risk of weight gain after their diagnosis;16, 17 they are susceptible to the energy-balance-related causes of weight gain common in the general population as well as to cancer treatment-related weight gain.14, 16 Further, recent analyses show that obesity prevalence over the last two decades has increased more rapidly in cancer survivors than in the general population, and more so among African American versus non-Hispanic White cancer survivors.16 Yet despite a growing awareness that neighborhood walkability influences obesity risk in the general population,8, 11 and regardless of evidence that obesity poses additional health hazards for cancer survivors,12, 16 there have been only two studies on links between neighborhood walkability and body size among cancer survivors, neither of which found evidence of an overall association.5, 6 Moreover, only one study estimated relationships for African American survivors separately from other groups.6
Prior research suggested that urban form features that support pedestrian activity (e.g. increased population density, public transit access, intersection density, and number of walkable destinations) are associated with higher levels of physical activity and lower BMI among residents in the general population.11, 18 However, these associations significantly vary by race/ethnicity, with some studies not finding the expected relationships between greater neighborhood walkability and lower BMI in African Americans.8, 11, 19 As a result of historic and contemporary residential segregation, African Americans are more likely than non-Hispanic whites to live in low socioeconomic status (SES) neighborhoods.11 Low SES neighborhoods may have greater physical disorder and be perceived by residents as having more crime- and traffic-related safety concerns than higher SES neighborhoods;11 conversely, based on singular common walkability measures (e.g., street connectivity), low SES neighborhoods may also be deemed more walkable than higher SES neighborhoods.20, 21 Yet, despite the high walkability of socioeconomically disadvantaged neighborhoods, poor perceptions of aesthetics and safety could result in residents, especially women, choosing to not engage with local urban form for healthy daily living activities.8, 11
The two existing survivorship studies of neighborhood walkability and body size assessed the influence of multiple built environment features related to walkability elements (e.g., street connectivity, population density, traffic density, or walkable destinations) on obesity in female breast cancer survivors.5, 6 However, these investigations considered singular walkability construct elements, rather than using a single measure incorporating multiple elements, and their analyses were limited to survivors of a single cancer type and biologic sex.22 Furthermore, neither study focused on African American cancer survivors. As such, additional evaluation of neighborhood walkability as an obesity-related health vital sign is warranted within this patient subgroup.5, 6, 11, 14, 20, 23
The goal of the current analysis was to examine the cross-sectional association between a residential neighborhood walkability index (NWI) score and BMI in a population-based sample of African American cancer survivors in Metropolitan Detroit. We explored these associations for all survivors, and by cancer type and physical activity engagement. Since both built environment use and obesity prevalence often differ between men and women, we also assessed sex-specific relationships.11
MATERIALS AND METHODS
Study population
Our study population included cancer survivors who were diagnosed with a first primary invasive breast, prostate, or colorectal cancer and participated in the Detroit Research on Cancer Survivors (ROCS) study. A detailed description of Detroit ROCS, including recruitment and methodology, has been previously published.24, 25 Briefly, Detroit ROCS enrolls African Americans diagnosed with breast, colorectal, lung, or prostate cancer on or after January 1, 2013. Cancer survivors were identified from the Metropolitan Detroit Cancer Surveillance System (MDCSS) cancer registry, a founding participant in the National Cancer Institute (NCI)’s Surveillance, Epidemiology and End Results (SEER) program. Eligible cancer survivors included both survivors in active treatment and those who completed treatment, consistent with the NCI definition of survivor.26 Other Detroit ROCS enrollment criteria included self-identification as African American or Black; an age between 20–79 years at cancer diagnosis; residence at diagnosis in Wayne, Oakland, or Macomb County, Michigan; and being alive at study contact.
Since prior evidence shows that lung cancer survivors often experience significant weight loss after diagnosis,27 and often experience severe limitations in physical activity due to their diagnosis,25 we excluded survivors of this cancer from analyses.
Study measures
Neighborhood measures
To create the NWI, we assessed four dimensions of urban form suggested by planners and designers to promote walking as a mode of transport: population density; access to public transit, as measured by bus-stop density; street connectivity, as measured by the density of 3- and 4-way street intersections; and destination accessibility, as measured by the density of daily living destinations (e.g., restaurants, grocery stores, retail locations, religious centers).22 We measured each of these measures within 1-kilometer (1km) radial buffers around the centroid of each 2010 Census block in Metropolitan Detroit (n=68,472 Census blocks in Macomb, Oakland, and Wayne counties, Michigan), z-score transformed each measure, and then summed z-scored measures together. In the final index, higher NWI scores indicated greater neighborhood walkability.22
Within the 1-km radial buffers, we also evaluated neighborhood crime risk as measured by the validated25 ESRI total crime risk index score (Redlands, CA) as well as six SES measures from the American Community Survey (ACS) 2013–2017 five-year estimates: “proportion of residents 25 years or older who completed high school or better”, “proportion of residents 25 years or older who completed college or better”, “proportion of residents living in poverty,” “median household income”, “per capita income”, and “proportion of residents who were African American.” Based on a prior study of prostate cancer survivors in Metropolitan Detroit, we expected, and subsequently found via Spearman Rank Correlation analyses, ACS measures of SES and racial composition to be highly correlated with each other.28 We applied principal component analyses to the six ACS measures to estimate a comprehensive index of neighborhood-level SES.28 These analyses identified one factor with an eigenvalue greater than 1, which accounted for 76% of the variance in neighborhood-level SES measures. As in the prior work, we labeled this factor “Neighborhood SES Index” (NSESI); a higher NSESI score reflected higher neighborhood SES.
We geocoded the residential address at the time of study enrollment of each Detroit ROCS cancer survivor, identified their Census block of residence, and linked them to their Census block’s NWI score and other neighborhood-level variables. For statistical analyses, we classified survivors into neighborhood measure quartiles based on the distribution of those neighborhood measures in Detroit ROCS survivors.
Body mass index (BMI)
At Detroit ROCS enrollment, participating survivors completed a survey collecting information on demographics, socioeconomic characteristics, health behaviors, health care access, and health-related quality of life.24, 25 As part of the survey, survivors self-reported height and current weight. We divided weight (in kilograms[kg]) by height (in meters squared[m2]) to calculate BMI.
Statistical analysis
Linear generalized estimating equation (GEE) models clustered on participant residential neighborhoods were used to estimate associations between quartiles of NWI scores and mean BMI at enrollment. For survivors living within the City of Detroit, models accounted for clustering in 2017 City designated neighborhoods; for those living outside city limits, models accounted for clustering on 2010 town administrative boundaries. These GEE models yield population average estimates of associations with robust standard error estimates accounting for non-independence of observations within larger neighborhood and town areas in the Tri-County area.29 Separate GEE models estimated these relationships in the overall study population, by cancer type, by sex, and by recent engagement in regular physical activity. Final model estimates were adjusted for potential confounders found in Table 1, and we selected these confounders using a directed acyclic graph. We estimated p-values for trends across NWI scores by performing a Wald test on the ordinal version of that variable; we estimated the statistical significance of interactions of NWI quartiles with (separately) cancer type, sex, and physical activity engagement using a Wald test of the interaction coefficient compared with zero. We conducted all analyses in STATA/SE 16.1 (College Station, TX) and considered two-sided tests statistically significant at the α=0.05 level.
Table 1.
Variations in mean body mass index (BMI) in Detroit ROCS cancer survivors (N=2089)
| BMI, in kg/m2 |
||
|---|---|---|
| No.(%) | Mean (25th,75th Percentiles) | |
|
|
||
| Overall | 2089 (−) | 30.8 (26.0,34.3) |
| Age at diagnosis, in years | ||
| <50 | 356 (17) | 32.2 (27.0,36.5) |
| 50-59 | 687 (33) | 31.1 (26.4,34.7) |
| 60-69 | 748 (36) | 30.1 (25.4,33.7) |
| 70-79 | 298 (14) | 29.9 (26.1,33.2) |
| Sex | ||
| Men | 992 (47) | 29.2 (25.1,32.1) |
| Women | 1097 (53) | 32.1 (27.1,36.3) |
| Marital status | ||
| Married/Live-in partner | 799 (38) | 30.6 (26.5,34.0) |
| Widowed | 211 (10) | 30.1 (25.2,34.3) |
| Divorced | 320 (16) | 30.9 (26.6,34.3) |
| Separated | 232 (11) | 31.0 (25.8,35.3) |
| Never married | 527 (25) | 31.0 (25.1,35.3) |
| Household income | ||
| <$20K | 831 (40) | 30.3 (25.0,34.3) |
| $20–39K | 448 (21) | 31.4 (26.6,34.9) |
| $40–59K | 289 (14) | 31.4 (27.2,34.5) |
| ≥$60K | 378 (18) | 30.6 (27.0,33.8) |
| Missing | 143 (7) | 30.2 (25.8,34.5) |
| Education | ||
| <High school degree | 210 (10) | 30.0 (24.4,34.2) |
| High school degree/GED | 607 (29) | 29.9 (25.2,32.9) |
| Some college | 527 (25) | 31.3 (26.6,34.5) |
| Two-year college degree | 258 (12) | 31.7 (26.8,36.2) |
| ≥Four-year college degree | 487 (24) | 31.1 (26.6,34.5) |
| Time since diagnosis | ||
| 2-11 months | 491 (24) | 31.2 (26.3,35.2) |
| 12-23 months | 675 (32) | 30.5 (25.8,33.8) |
| ≥24 months | 923 (44) | 30.7 (26.3,34.4) |
| Cancer site | ||
| Breast | 955 (46) | 32.3 (27.3,36.6) |
| Prostate | 866 (41) | 29.5 (25.5,32.3) |
| Colorectal | 268 (13) | 29.2 (24.4,32.9) |
| Physical activity engagement in the last month | ||
| Regular participation | 1347 (65) | 30.4 (25.8,33.8) |
| No regular participation | 739 (35) | 31.5 (26.6,35.3) |
| Missing | 3 (<1) | 30.9 (24.4,41.1) |
| Neighborhood walkability index (NWI) score | ||
| Quartile 1(low NWI score) | 542 (26) | 31.6 (26.9,35.4) |
| Quartile 2 | 518 (25) | 30.7 (26.3,34.2) |
| Quartile 3 | 513 (24) | 30.4 (25.8,34.0) |
| Quartile 4(high NWI score) | 516 (25) | 30.1 (25.1,33.8) |
| Neighborhood SES index (NSESI) score | ||
| Quartile 1(low SES) | 514 (25) | 30.1 (25.1,33.4) |
| Quartile 2 | 528 (25) | 30.4 (25.4,33.9) |
| Quartile 3 | 523 (25) | 31.4 (26.6,35.4) |
| Quartile 4(high SES) | 524 (25) | 31.2 (26.9,35.3) |
| Neighborhood crime risk index score | ||
| Quartile 1(low crime risk score) | 556 (27) | 31.0 (26.6,34.4) |
| Quartile 2 | 519 (25) | 31.5 (26.8,35.1) |
| Quartile 3 | 504 (24) | 30.2 (25.1,34.0) |
| Quartile 4(high crime risk score) | 513 (24) | 30.2 (25.5,33.9) |
RESULTS
Our analyses included data from 2089 cancer survivors, including 955 women with breast cancer, 866 men with prostate cancer, and 268 colorectal cancer survivors (142 women, 126 men) (Table 1). The median age at diagnosis was 60 years (range:27–79 years), the median time since diagnosis was 20 months (range:2–78 months), and the median BMI at enrollment was 29.5 kg/m2 (range:14.6–66.2 kg/m2). Approximately 53% of survivors were women, 38% reported being married or living in a marriage-like relationship, 40% listed their annual household income as less than $20K, and 65% reported participating in any regular physical activity for physical fitness in the last month. Mean BMI was greater among younger versus older, women versus men, and breast versus prostate or colorectal cancer survivors.
After adjusting estimates for survivor- and neighborhood-level characteristics, survivor BMI in neighborhoods in the highest NWI score quartile was 1.70 kg/m2 lower (95% CI:−2.76,−0.65) than that of survivor BMI in neighborhoods in the lowest NWI score quartile (p-trend:<0.01;Table 2). We noted similar trends in prostate cancer survivors (p-trend:0.02) and, though not statistically significant, in colorectal cancer survivors (p-trend:0.09); in breast cancer survivors there was no apparent trend of lower BMI with higher NWI (p-trend:0.39). Overall associations and type-specific findings were likely driven by sex-specific associations. Among men, pooling prostate and colorectal cancer survivors, we found a strong trend of lower BMI associated with higher quartile of NWI score (p-trend:<0.01). In women, pooling breast and colorectal cancer survivors, we observed only a statistically significant difference of lower BMI for those living in neighborhoods in the 2nd versus 1st quartiles of NWI score (β:−1.84, 95% CI: 3.44,−0.24); breast cancer survivors accounted for 87% of the women included. Overall relationships were likely also fueled by physical activity engagement-specific findings; we noticed a significant trend of lower BMI given higher NWI score among survivors reporting recent participation in regular physical activity (p-trend:<0.01), but did not observe a trend for survivors reporting no regular participation (p-trend:0.79). However, we did not find any statistically significant interactions terms in stratified analyses.
Table 2.
Associations of neighborhood walkability index (NWI) score with mean body mass index (BMI) in Detroit ROCS cancer survivors, overall and by cancer type, sex, and physical activity engagementa
| Overall | Cancer |
Sex |
Physical activity engagementb |
|||||
|---|---|---|---|---|---|---|---|---|
| N=2089 β(95% CI) | Breast N=955 β(95% CI) | Prostate N=866 β(95% CI) | Colorectal N=268 β(95% CI) | Men N=992 β(95% CI) | Women N=1097 β(95% CI) | Regular participation N=1347 β(95% CI) | No regular participation N=739 β(95% CI) | |
|
|
|
|
|
|||||
| Neighborhood walkability index (NWI) score | ||||||||
| Quartile 1(low NWI score) | Ref | ref | ref | ref | ref | ref | ref | ref |
| Quartile 2 | −1.14 (−2.10,−0.18) | −1.95 (−3.56,−0.35) | −0.04 (−1.20,1.13) | −1.98 (−4.39,0.44) | −0.35 (−1.42,0.72) | −1.84 (−3.44,−0.24) | −1.45 (−2.55,−0.34) | −0.31 (−1.96,1.34) |
| Quartile 3 | −1.31 (−2.28,−0.34) | −1.01 (−2.70,0.67) | −0.99 (−2.28,0.29) | −2.37 (−4.80,0.06) | −1.22 (−2.41,−0.04) | −1.30 (−2.95,0.35) | −1.47 (−2.76,−0.18) | −0.56 (−1.98,0.86) |
| Quartile 4(high NWI score) | −1.70 (−2.76,−0.65) | −1.33 (−3.12,0.46) | −1.43 (−2.84,0.01) | −2.94 (−5.88,0.01) | −1.55 (−2.80,−0.30) | −1.70 (−3.42,0.02) | −2.23 (−3.55,−0.92) | −0.26 (−2.05,1.54) |
| P for trend | <0.01 | 0.39 | 0.02 | 0.09 | <0.01 | 0.11 | <0.01 | 0.79 |
Estimates adjusted for age at diagnosis, sex, education, household income, marital status, time since diagnosis, NSESI score, and neighborhood crime risk index score
Interaction terms between NWI quartiles and (separately) cancer type, sex, and physical activity engagement were calculated using Wald tests. There were no statistically significant interaction terms
Three survivors missing physical activity engagement data
DISCUSSION
Among African American cancer survivors living in Metropolitan Detroit, greater neighborhood walkability was associated with lower BMI. Stratified findings indicated that this overall relationship likely reflected an association in men, suggesting that the influence of neighborhood walkability on post- diagnosis body size may differ by gender11, 30, as well as a relationship among survivors regularly engaged in physical activity. However, in formal tests of whether the association of NWI score with BMI differed by cancer type, sex, or regular engagement in physical activity, we did not observe evidence of statistically significant differences. While these relationships are cross-sectional, and require additional research to tease out underlying mechanisms, our findings still provide further evidence supporting health systems’ collection of neighborhood walkability data for their African American cancer survivor patient populations. 5, 6, 11, 14
We believe this to be the first survivorship investigation of neighborhood walkability and body size to focus solely on African Americans, to include survivors of more than one obesity-related cancer, to incorporate men, and to use a multidimensional walkability index. Our findings for women are consistent with findings from two previous studies, both set in women breast cancer survivor cohorts in California.5, 6 In the Pathways study, the authors observed marginal-to-null relationships between multiple singular aspects of neighborhood walkability (e.g., traffic density, street connectivity, population density, density of walkable destinations) and overweight/obesity prior to diagnosis.5 Likewise, in the California Breast Cancer Survivorship Consortium, singular walkability elements (e.g., street connectivity, business density, public park density) were not associated with BMI at the time of diagnosis.6
Conceptually and statistically, common neighborhood walkability elements overlap – for example, neighborhoods with greater street connectivity likely have higher population density, and these characteristics likely affect each other over time.8, 11, 20 As such, walkability aspects are rarely assessed in isolation from one another as health indicators.11 By using a multidimensional index, we expect to have better expressed, compared to past studies, the construct of overall neighborhood walkability that prior urban planning theory and research suggests is most relevant to general population obesity-related health outcomes.11, 19, 21, 22 However, consistent with previous findings described above, we did not observe an association between our walkability measure and BMI among women with cancer. Our findings and null findings from previous breast cancer research could be explained by important gender-specific associations. It is possible that the urban form walkability construct captured by common walkability elements, including those incorporated in the NWI, relates to lower BMI in African American men diagnosed with cancer but not in African American women cancer survivors.11, 30 A different set of neighborhood characteristics not accounted for by the NWI score, such as perceptions of crime- and traffic-related safety, may be of more relevance to obesity-related health in African American women with cancer.11
The cancer survivorship consequences of obesity have prompted multiple organizations to issue clinical practice guidelines for weight management as part of cancer care and follow-up.13, 31 However, these guidelines all emphasize survivor-level interventions such as clinic- or home-based weight loss programs.14, 16, 32–34 This is in contrast to neighborhood- and other systems-level approaches to maintaining healthy weight in the general population that are currently receiving funding and are also of increasing interest to health care systems.2, 8, 10, 11, 35 In order to reframe the dialogue around weight management for cancer survivors to include both contextual- and survivor-level perspectives, particularly for African American cancer survivors and survivors from other vulnerable populations, further evidence is needed to support health systems’ routine collection of neighborhood features data.1, 5, 11, 16, 19 Our findings supply a piece of this evidence, highlighting neighborhood walkability as a neighborhood-level obesity-related health vital sign in African Americans cancer survivors.
Our findings should be interpreted in light of key limitations. First, this assessment is cross-sectional in nature, thus limiting our ability to explore mechanisms. However, cohort follow-up is ongoing and future analyses will incorporate longitudinal data.25 Second, height and weight data are based on self-report, but potential error in our outcome assessment is unlikely to alter the conclusions of the analyses. Previous research indicates that self-reported anthropometric data and measured anthropometric data produce near identical estimates in health effects studies, especially if estimates are adjusted for individual-level sociodemographic factors known to be associated with measurement error from self-report.36 Third, neighborhoods were defined as 1-km radial buffers, which are small areas surrounding survivors’ residences and are standard neighborhood definitions in this area of research.15, 22 However, survivors’ perception of neighborhood boundaries and activity spaces likely differ from this neighborhood definition, leading to measurement error in exposure assessment.5, 15 Further, data were not available on how participants actually engaged or were able to engage with built environment features. In choosing a purely urban form construct of walkability, our measures did not capture how cancer survivors perceive the aesthetics and safety of their surroundings – which may be especially relevant for African American women.5, 8, 11 Finally, even with a relatively large sample size, we lacked enough survivors to further stratify analyses, including by survivor-level socioeconomic factors, such as household income, which may modify the accessibility of neighborhood walkability features. However, future investigations in this cohort will have access to a greater sample size.
Our findings contribute to the understanding of the relationship between urban form and obesity-related health in African American cancer survivors. Future research is critical and should be performed in African American cancer survivor populations from different geographic regions. Additionally, since both obesity burden and the influence of neighborhood walkability features on obesity-related health likely differ between men and women in this patient population, a better understanding of gender-by-environment interactions and driving mechanisms may be crucial to producing truly translational findings and to supporting health systems’ neighborhood-level engagement with cancer survivors and their surrounding community.11, 12
Acknowledgments
This work was supported by the National Cancer Institute (grants T32 CA094061-18 , U01CA199240, U01CA-199240-02, U01CA-199240-03), and also, in part, by the Epidemiology Research Core and National Institutes of Health Center Grant P30CA022453 awarded to the Karmanos Cancer Institute at Wayne State University.
Footnotes
Conflict of interest disclosures: The authors make no disclosures
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