Heal h & Place 78 (2022) 102912
A ailable online 28 Sep embe 2022
1353-8292/© 2022 The Au ho s. Published by Else ie L d. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-
nc-nd/4.0/).
Associa ions o esiden ial g eenspace exposu e and e al g ow h ac oss
ou a eas in Spain
Ma ia To es Toda
a
,
b
, Ma isa Es a lich
c
,
d
,
e
,
*
, Fe an Balles e
c
,
d
,
e
, Mon se a De Cas o
a
,
b
,
e
,
Ana Fe n´
andez-Somoano
e
,
,
g
, Jesús Iba luzea
e
,
h
,
i
,
j
, Ca men I˜
niguez
d
,
e
,
k
, Ai ana Le xundi
e
,
h
,
l
,
Mikel Subiza-Pe ez
h
,
m
,
n
, Jo di Sunye
a
,
b
,
e
, Adonina Ta d´
on
e
,
,
g
, Ma ia Fo as e
a
,
b
,
e
,
1
,
Payam Dad and
a
,
b
,
e
,
l
a
Ba celona Ins i u e o Global Heal h (ISGlobal), D . Aiguade 88, 08003, Ba celona, Spain
b
Pompeu Fab a Uni e si y, Plaça de La Me c`
e 10-12, 08002, Ba celona, Spain
c
Facul y o Nu sing and Chi opody, Uni e si a de Val`
encia, C/Menendez Pelayo S/n, 46010, Val`
encia, Spain
d
Epidemiology and En i onmen al Heal h Join Resea ch Uni , Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Val`
encian Region, FISABIO-
Public Heal h, FISABIO-Uni e si a Jaume I-Uni e si a de Val`
encia, A . Ca alunya 21, 46020, Val`
encia, Spain
e
Spanish Conso ium o Resea ch on Epidemiology and Public Heal h (CIBERESP), A . Mon o e de Lemos, 3-5. Pabell´
on 11, 28029, Mad id, Spain
Unidad de Epidemiología Molecula Del C´
ance , Ins i u o Uni e si a io de Oncología Del P incipado de As u ias (IUOPA) - Depa amen o de Medicina, Uni e sidad de
O iedo, Julian Cla e ía S ee S/n, 33006, O iedo, As u ias, Spain
g
Ins i u o de In es igaci´
on Sani a ia Del P incipado de As u ias (ISPA), Roma A enue S/n, 33001, O iedo, Spain
h
Biodonos ia Heal h Resea ch Ins i u e, En i onmen al Epidemiology and Child De elopmen G oup, 20014, San Sebas ian, Spain
i
Minis y o Heal h o he Basque Go e nmen , Sub-Di ec o a e o Public Heal h and Addic ions o Gipuzkoa, 20013, San Sebas ian, Spain
j
Facul y o Psychology o he Uni e si y o he Basque Coun y, 20018, San Sebas ian, Spain
k
Depa men o S a is ics and Ope a ional Resea ch, Uni e si a de Val`
encia, D . Moline , 50 46100, Val`
encia, Spain
l
Depa men o P e en i e Medicine and Public Heal h o he Uni e si y o he Basque Coun y, UPV/EHU, Leioa, Spain
m
Depa men o Clinical and Heal h Psychology and Resea ch Me hods, Uni e si y o he Basque Coun y UPV/EHU, A enida Tolosa 70, 20018, Donos ia-San
Sebas i´
an, Spain
n
B ad o d Ins i u e o Heal h Resea ch, Temple Bank House, B ad o d Royal In i ma y, Duckwo h Lane, BD9 6RJ B ad o d, Uni ed Kingdom, BD9 6RJ, B ad o d,
Uni ed Kingdom
ARTICLE INFO
Keywo ds:
Na u al en i onmen s
Fe al de elopmen
Ul asound measu emen s
P egnancy
G eenness exposu e
ABSTRACT
An accumula ing body o e idence has associa ed exposu e o g eenspace wi h imp o ed bi h ou comes,
including highe bi h weigh and lowe isk o low bi h weigh ; howe e , e idence on such associa ion wi h in-
u e o e al g ow h is sca ce. We explo ed he in luence o ma e nal exposu e o esiden ial g eenspace and e al
g ow h in ou INMA (In ancia y Medio Ambien e) Spanish bi h coho s (2003–2008), wi h 2,465 pa icipan s.
Residen ial g eenspace was cha ac e ised by he No malised Di e ence Vege a ion Index (NDVI) a e age ac oss
100 m, 300 m, and 500 m bu e s a ound he esidence. Repea ed ul asound measu emen s o he abdominal
ci cum e ence (AC), bipa ie al diame e (BPD), emu leng h (FL), and es ima ed e al weigh (EFW) we e used.
We c ea ed cus omised-gene alised leas squa es models o e alua e associa ions o esiden ial g eenspace
exposu e on each e al g ow h pa ame e , con olled o he ele an con ounde s. The e we e associa ions be-
ween he 500 m bu e and BPD, FL, and AC. We also ound associa ions in he 300 m bu e and FL and AC. The
associa ions in he 100 m bu e we e null. Es ima es we e highe among pa icipan s wi h lowe socioeconomic
s a us. Media ion analyses ound ha ai pollu ion migh explain 15–37% o ou associa ions. Media ion by
physical ac i i y was no obse ed. G eenspace exposu e may be bene icial o e al g ow h.
* Co esponding au ho . Uni e si a de Val`
encia, Uni a mix a FISABIO-Uni e si a Jaume I-Uni e si a de Val`
encia, Menendez Pelayo, 46010, Val`
encia, Spain.
E-mail add esses: [email p o ec ed] (M. To es Toda), [email p o ec ed] (M. Es a lich), [email p o ec ed] (F. Balles e ), mon se a .decas o@
isglobal.o g (M. De Cas o), [email p o ec ed] (A. Fe n´
andez-Somoano), [email p o ec ed] (J. Iba luzea), [email p o ec ed]
(C. I˜
niguez), [email p o ec ed] (A. Le xundi), [email p o ec ed] (M. Subiza-Pe ez), [email p o ec ed] (J. Sunye ), [email p o ec ed]
(A. Ta d´
on), [email p o ec ed] (M. Fo as e ), [email p o ec ed] (P. Dad and).
1
These au ho s con ibu ed equally.
Con en s lis s a ailable a ScienceDi ec
Heal h and Place
jou nal homepage: www.else ie .com/loca e/heal hplace
h ps://doi.o g/10.1016/j.heal hplace.2022.102912
Recei ed 26 Ap il 2022; Recei ed in e ised o m 14 Augus 2022; Accep ed 12 Sep embe 2022
Heal h and Place 78 (2022) 102912
2
1. In oduc ion
An unp eceden ed displacemen om u al o u ban a eas has
occu ed wo ldwide (Uni ed Na ions, 2018). This displacemen is ex-
pec ed o con inue apidly, and by 2050, 68% o he global popula ion
will be u ban (Uni ed Na ions, 2018). A well-planned ci y is a place o
economic, poli ical, and cul u al oppo uni ies and p o ides be e in-
as uc u es, heal h ca e and basic se ices han u al a eas (UN-Ha-
bi a , 2020). Howe e , poo u ban planning may lead o consequences
o he heal h o ci y dwelle s, o example, mo e exposu e o nega i e
en i onmen al ac o s, including ai pollu ion, noise, high empe a u es,
chemicals, poo nu i ion and housing, and lack o g een spaces
(UN-Habi a , 2020; WHO, 2016). In ecen yea s, a g owing body o
s udies has associa ed exposu e o g eenspace wi h posi i e heal h
ou comes (Hu e al., 2021; Nguyen e al., 2021; Rojas-Rueda e al., 2019;
Twohig-Benne and Jones, 2018). O he s udies ha e in es iga ed he
po en ial unde lying pa hways o explain hese bene icial associa ions.
Fo example, exposu e o g eenspace may p omo e physical ac i i y,
enhance social cohesion, es o e s ess and a en ion, and mi iga e
exposu e o nega i e en i onmen al ac o s (i.e., ai pollu an s, noise,
and hea ) (Ma ke ych e al., 2017).
I is known ha humans in he p ena al pe iod a e e y ulne able o
he e ec s o exposu e o en i onmen al ac o s (Ba ouki e al., 2012;
Nieuwenhuijsen e al., 2013). These en i onmen al ac o s may a i e
om he mo he o he e us and may induce changes in g ow h, gene
exp ession, me abolism, ho mones, and o gan s uc u e (Gluckman
e al., 2004). The changes can pe sis and may be de e minan s o
de eloping ad e se heal h ou comes ac oss li e. One o he mos s udied
changes is e al g ow h (Damhuis e al., 2021). Res ic ion in e al
g ow h is associa ed wi h many isks o newbo ns as neona al
mo bidi y and neona al dea h (Ame ican College o Obs e icians and
Gynecologis s, 2019). Mo eo e , e al g ow h es ic ion is associa ed
wi h cogni i e delay (Sacchi e al., 2020) and as hma (Sonnen-
schein-Van De Voo e al., 2016) in childhood, and inc eased isks o
ype 2 diabe es (Kensa a e al., 2005), os eopo osis (Coope e al., 1997),
me abolic synd ome (Rinaudo e al., 2012), and ca dio ascula diseases
(Ba ke and Osmond, 1986; Kensa a e al., 2005) in adul hood.
P e ious s udies ound e idence o a ou able associa ions be ween
g eenspace exposu e and bi h ou comes such as bi h weigh (Agay--
Shay e al., 2019; Aka aci e al., 2021; Yin, 2019), small o ges a ional
age (SGA, bi h weigh below he 10 h pe cen ile o ges a ional age and
sex) (Agay-Shay e al., 2019; Lee e al., 2021; Villeneu e e al., 2022)
and p e e m bi h (ges a ional age <37 weeks) (Aka aci e al., 2021; Lee
e al., 2021; Villeneu e e al., 2022). Howe e , e idence cap u ing an
imp o emen in he e al g ow h in u e o is s ill e y sca ce. In p eg-
nancy, g eenspace may in luence e al heal h by p omo ing mode a e
ma e nal exe cise (Mceachan e al., 2016), enhancing social in e ac ions
(As ell-Bu e al., 2022), educing ma e nal s ess (Ve heyen e al.,
2021) and dep ession (Mceachan e al., 2016), and dec easing ambien
ai pollu an s (Dad and e al., 2012a), noise (Ris o ska e al., 2014), and
hea wa es (Sun e al., 2020).
Cap u ing he e al g ow h in u e o may be ele an because bi h
ou comes some imes may no su icien ly e lec he dynamics o e al
g ow h du ing p egnancy. Impai men in he e al g ow h has been
associa ed wi h ad e se heal h ou comes e en in adul hood and
ega dless o bi h ou comes (Roseboom e al., 2001). Gene ally, bi h
ou comes a e used as a p oxy o wha occu ed in u e o wi h he p ena al
g ow h. Howe e , classi ying newbo ns as e al g ow h- es ic ed using
bi h ou comes may lead o biased es ima es (Damhuis e al., 2021). In
addi ion, he adi ional e alua ion o e al g ow h es ic ion in u e o
was add essed by compa ing es ima ed e al weigh ob ained by ul a-
sound measu emen s wi h speci ic popula ion-based cha s.
Popula ion-based e al g ow h cha s could induce misclassi ica ions o
iden i y pa hological smallness ins ead o cons i u ionally small e uses
and iden i y e uses wi hin he no mal popula ion limi s bu wi h un-
de ec ed e al g ow h es ic ion (Gailla d e al., 2014). This p oblem
may be add essed using cus omised models ha could p o ide indi id-
ual a he han popula ion-based e al g ow h cha s and a e expec ed o
educe he misclassi ica ions men ioned abo e (Mamelle e al., 2001).
We a e awa e o one s udy ha e alua ed ma e nal exposu e o
esiden ial g eenspace and e al g ow h using ul asound measu emen s
in Tongzhou Dis ic (Beijing, China) (Lin e al., 2020). The s udy ound
an inc eased z-sco e o es ima ed e al weigh , abdominal ci cum e -
ence, and head ci cum e ence associa ed wi h he pa icipan s being
mo e exposed o esiden ial g eenspace.
The p esen s udy aims o in es iga e associa ions o exposu e o
ma e nal esiden ial g eenspace on di e en pa ame e s o e al g ow h
du ing p egnancy ac oss ou a eas in Spain, applying cus omised
g ow h models. Ano he aim is o e alua e a po en ial e ec modi ica-
ion o hese associa ions by sex o he child and socioeconomic s a us
(SES). Mo eo e , gi en he po en ial capabili y o g eenspace o educe
exposu e o ai pollu ion (Dad and e al., 2012a) and inc ease physical
ac i i y le els (Mceachan e al., 2016), we aimed o e alua e he ole o
ai pollu ion and physical ac i i y in he associa ions om his s udy, i
any.
2. Ma e ials and me hods
2.1. S udy a ea and popula ion
This s udy was conduc ed as pa o he INMA p ojec (IN ancia y
Medio Ambien e; En i onmen and Childhood), a ne wo k o Spanish
bi h coho s wi h s anda dised me hodologies (Guxens e al., 2012).
The p egnan women we e included in each coho du ing hei
i s - imes e ul asound isi a he hospi al o e e ence and a e
signing a consen o m app o ed by espec i e e hics commi ees.
C i e ia o inclusion we e: (i) o be esiden in one o he s udy a eas, (ii)
o be 16 yea s old minimum, (iii) o ha e a single on-p egnancy, (i ) no
o ha e impedimen s o communica ion, and ( ) o deli e in he co -
esponding e e ence hospi al. Fo ou s udy, we included e uses om
p egnan women ec ui ed om ou a eas ac oss Spain: As u ias
(2004–2006), Gipuzkoa (2006–2008), Sabadell (2004–2006), and
Val`
encia (2003–2005). As u ias and Gipuzkoa a e pa o he Eu o-
sibe ian biogeog aphic egion in no he n Spain, whe eas Val`
encia and
Sabadell, loca ed in eas e n and no h-eas e n Spain, a e pa o he
Medi e anean egion (Alca az-Segu a e al., 2009). The Eu osibe ian
egion is cha ac e ised by a humid clima e, wi h mo e annual p e-
cipi a ions and cold win e s. The Medi e anean egion is cha ac e ised
by a d y clima e, wi h mild win e s and ho summe s (Alca az-Segu a
e al., 2009).
2.2. Cha ac e isa ion o esiden ial g eenspace
We used he No malised Di e ence Vege a ion Index (NDVI) o es-
ima e esiden ial g eenspace in each a ea (Fig. 1). NDVI is a well-known
indica o o ege a ion de i ed om sa elli e image y. Fo his s udy, we
employed images om Landsa 4–5 Thema ic Mappe and Landsa 7
Enhanced Thema ic Mappe Plus da a a 30 m ×30 m esolu ion. The
images we e selec ed on cloud- ee days and he ollowing da es: May
25, 2006 (As u ias), June 14, 2001 (Gipuzkoa), May 18, 2007 (Saba-
dell), and May 29, 2003 (Val`
encia). To achie e maximum exposu e
con as , we used he images co esponding o he g eenes mon h o
each s udy a ea. Values o NDVI a y om −1 o +1, whe e highe
alues ep esen dense and mo e pho osyn he ically ac i e ege a ion
(U.S. Geological Su ey, 2022). Fo each pa icipan , we calcula ed an
a e age o NDVI alues wi hin 100 m, 300 m, and 500 m ci cula bu e s
a ound he esiden ial add ess when he mo he was in he i s imes e
o p egnancy o a oid o e lapping wi h ul asound measu emen s
(Dad and e al., 2012b).
M. To es Toda e al.
Heal h and Place 78 (2022) 102912
3
2.3. Fe al g ow h pa ame e s
Ul asound scans (Voluson 730 P o and 730 Expe ; Siemens Sienna)
we e scheduled a 12, 20, and 34 weeks o ges a ion and pe o med by
obs e icians specialized in conduc ing his ype o examina ions a he
espec i e e e ence hospi als in each coho (I˜
niguez e al., 2016). We
had access o eco ds o any o he ul asounds pe o med on women
du ing p egnancy, which allows us o pe o m wo o eigh alid ul a-
sounds pe woman be ween 7 and 42 weeks o ges a ion. The mea-
su emen o e al g ow h included he ollowing ul asound pa ame e s:
abdominal ci cum e ence, bipa ie al diame e , emu leng h, and es i-
ma ed e al weigh calcula ed using he Hadlock algo i hm (Hadlock
e al., 1984). Ges a ional age was es ablished by c own- ump leng h
measu emen when he da e o he las mens ual pe iod epo ed by he
p egnan women was ≥7 days. To educe po en ial bias, 18 p egnan
women we e excluded because he di e ence be ween c own- ump
leng h and sel - epo ed las mens ual pe iod was mo e han h ee
weeks. Mo eo e , ul asound pa ame e s wi h ±4 SD ou side he mean
we e elimina ed o a oid ex eme ou lie s (n =5 o abdominal
ci cum e ence, n =8 o emu leng h, and n =8 o bipa ie al
diame e ).
2.4. Main analyses
In ou main analysis, e al ul asound pa ame e s we e longi udi-
nally analysed h ough gene alised leas squa es models (gls) (Pinhei o
e al., 2009) because he a iances o he obse a ions we e unequal,
ha is, when he e is he e oscedas ici y o a ce ain deg ee o co ela ion
be ween he obse a ions. The subjec was used as he andom e ec and
adjus ed by cons i u ional de e minan s, in acco dance wi h he me hod
desc ibed in I˜
niguez e al. (2016) (I˜
niguez e al., 2016). Associa ion
es ima es we e exp essed o a 1-in e qua ile ange (IQR) inc ease in
each NDVI bu e o esiden ial g eenspace. Fo each ul asound
pa ame e o he e al g ow h, he associa ion wi h esiden ial g een-
space was assessed by adding he a iable g eenspace in he espec i e
model. A s ep- o wa d algo i hm es ed se e al co a ia es (likelihood
a io es , p- alue<0.05) as po en ial cons i u ional de e minan s. In he
inal models, we included: ma e nal heigh (con inuous, cm), ma e nal
age (con inuous, yea s), pa i y (bina y, yes/no), sex o he child (bina y,
gi l/boy), ma e nal coun y o o igin (bina y, Spain/ou side Spain),
ma e nal social class (ca ego ical, high/medium/low), ma e nal
educa ional le el (ca ego ical, p ima y/high school/uni e si y),
ma e nal smoking du ing p egnancy (bina y, yes/no), wo king s a us
du ing p egnancy (bina y, employed/unemployed), and coho (ca e-
go ical, As u ias/Gipuzkoa/Sabadell/Val`
encia). These co a ia es we e
ob ained om ques ionnai es in he i s and hi d imes e s and
an h opome ic measu emen s by specialized nu ses. Social class was
ob ained om he cu en o la es occupa ion o he mo he and
applying he Spanish classi ica ion sys em (Domingo-Sal any e al.,
2000). Mo he s we e ca ego ised as smoke s du ing p egnancy i hey
epo ed s ill smoking in he hi d- imes e ques ionnai e. Addi ional
modelling de ails could be ound in he Supplemen a y Ma e ials, S1.
S a is ical analyses we e conduc ed in R so wa e, e sion R-4.0.5
(Founda ion o S a is ical Compu ing, Vienna, Aus ia). Le el o s a-
is ical signi icance was se a p- alue <0.05.
As a sensi i i y analysis and o e alua e he obus ness o ou main
indings, we u he adjus ed he main models o alcohol consump ion
du ing p egnancy (bina y, yes/no), pa e nal educa ional le el (ca e-
go ical, p ima y/high school/uni e si y), season o las mens ual
pe iod (ca ego ical, summe /sp ing/au umn/win e ), and an he
models wi hou emo e he da a conside ed ex eme ou lie . We also
e alua ed he change in he e ec o e p egnancy by including an
in e ac ion e m be ween g eenspace and ges a ional age a ul asound
measu emen in he gls models. We c ea ed a baseline model o ep e-
sen he c oss-sec ional associa ion be ween g eenspace and e al g ow h
a he i s isi (12 weeks o p egnancy), and hen, we e alua ed he
e ec modi ica ion by ges a ional age by adding he in e ac ion e m.
2.5. Fu he analyses
2.5.1. E ec modi ica ion by sex, SES, and egion
To be able o de ec an e ec modi ica ion ela ed o he sex o he
child and social class (an indica o o SES), we expanded ou main
models wi h an in e ac ion e m be ween esiden ial g eenspace and sex
o social class. Then, we compa ed ou main models wi h and wi hou
he in e ac ion e m (one a a ime) by applying Wald es s. We in es-
iga ed he associa ions be ween he egions (Eu osibe ian egion:
As u ias and Gipuzkoa, Medi e anean egion; Val`
encia and Sabadell)
by s a i ying ou main models acco ding o he egion. Associa ions
we e epo ed by a 1-IQR inc ease in esiden ial g eenspace as in he
Fig. 1. Landsa NDVI image y and s udy a eas. A =As u ias, B =Gipuzkoa, C =Val`
encia, D =Sabadell.
M. To es Toda e al.
Heal h and Place 78 (2022) 102912
4
main analyses.
2.5.2. In luence o ai pollu ion and physical ac i i y
To explo e he ole o ai pollu ion, we (i) u he adjus ed ou main
models o ai pollu ion and (ii) conduc ed a media ion analysis calcu-
la ing he pe cen age o he associa ions explained by ai pollu ion
(P eache e al., 2011). Ai pollu an s, measu ed as NO
2
le els a he
esidence add ess o each pa icipan in each p egnancy imes e , we e
es ima ed by land-use eg ession (LUR) models. Fu he de ails on hese
LUR models ha e been published p e iously (Es a lich e al., 2011). We
used he ollowing o mula o he media ion pe cen age: (EI/ET) x 100,
whe e ET was he coe icien es ima e o he o al e ec (i.e., ou main
model), and EI was he coe icien es ima e o he indi ec e ec . EI was
calcula ed as EI =ET-ED, whe e ED was he di ec e ec coe icien es-
ima e (i.e., ou main model u he adjus ed o NO
2
). A Jackkni e
app oxima ion was used o calcula e he con idence in e al o he in-
di ec e ec (P eache e al., 2011). To explo e he ole o physical ac-
i i y we conduc ed a media ion analysis calcula ing he pe cen age o
he associa ions explained by physical ac i i y. Physical ac i i y in he
i s imes e was calcula ed based on he o al physical ac i i y
measu ed in me abolic equi alen o asks (METs) hou /day in he
p e ious yea o p egnancy and ob ained h ough ques ionnai es. METs
is a widely used es ima ion o ene ge ic cos pe o med in an
ac i i y- ime, mo e echnically is de ined as he amoun o oxygen
inhaled in a si ing posi ion (1 MET =3.5 ml de O
2
/kg/min) (No man
e al., 2001). We used he same me hodology desc ibed abo e o
calcula e he media ion pe cen age.
3. Resul s
3.1. S udy popula ion and g eenspace
In he s udy, we included 2465 pa icipan s. A de ailed desc ip ion o
ou s udy popula ion cha ac e is ics can be ound in Table 1. Mos o he
mo he s we e nullipa as (56.2%), we e 30–34 yea s old (42.3%), had
high school educa ional le el (41.3%), we e om low social class
(43.6%), we e bo n in Spain (91.8%), wo ked du ing p egnancy
(83.5%), and non-smoked du ing p egnancy (68.4%). The NDVI alues
anged om 0.14 o 0.22 in he Medi e anean egion (Sabadell and
Val`
encia) and om 0.30 o 0.47 in he Eu osibe ian egion (As u ias and
Gipuzkoa) (Supplemen a y Ma e ials, Table S1). Spea man co ela ion
coe icien s be ween NDVI bu e s and NO
2
a e p esen ed in Fig. S1. We
obse ed posi i e co ela ions be ween NDVI bu e s (0.81–0.96) and
nega i e co ela ions be ween NDVI bu e s and NO
2
om −0.62 o
−0.72. O e he p egnancy, we ob ained 1910 comple ed ul asounds in
he i s , 2347 in he second, and 2453 in he hi d imes e s o p eg-
nancy (Supplemen a y Ma e ials, Table S2).
3.2. Main analyses
Table 2 p esen s he adjus ed coe icien es ima es o he associa ions
be ween exposu e o esiden ial g eenspace and each pa ame e o e al
g ow h. We ound associa ions be ween a 1-IQR inc ease o NDVI in 300
m bu e and emu leng h and abdominal ci cum e ence, wi h coe i-
cien es ima es o 0.15 mm (95% CI (Con idence In e al): 0.02, 0.27)
and 0.59 mm (95% CI: 0.06, 1.12), espec i ely. Mo eo e , a 1-IQR in-
c ease o NDVI in 500 m bu e was associa ed wi h an inc eased size in
he bipa ie al diame e [0.17 mm (95% CI: 0.01, 0.35)], emu leng h
[0.15 mm (95%CI: 0.01, 0.31)], and abdominal ci cum e ence [0.83 mm
(95% CI: 0.19, 1.47)]. We did no ind any s a is ically signi ican as-
socia ion be ween esiden ial g eenspace and he es ima ed e al weigh .
Fu he adjus men o he main models o alcohol consump ion,
pa e nal educa ion, and season o las mens ual pe iod did no change
he coe icien es ima es (Supplemen a y Ma e ials, Table S3). The use
o he whole sample wi hou exclusion o ou lie s also did no change he
coe icien es ima es (Supplemen a y Ma e ials, Table S3). The
in e ac ion be ween g een space and ges a ional age was no s a is ically
signi ican (Supplemen a y Ma e ials, Table S4).
3.3. Fu he analyses
Table S5 (Supplemen a y Ma e ials) shows he compa ison be ween
ou main models and models wi h he in e ac ion e m by sex o he
child and SES. The e we e no s a is ically signi ican di e ences in he
models wi h he in e ac ion e m by sex o he child. Howe e , we ound
a s a is ically signi ican in e ac ion by SES in he associa ion be ween
esiden ial g eenspace ac oss 100 m bu e and emu leng h. The e o e,
we conduc ed s a i ied analyses o ou main models by SES (Table 3),
and we ound sugges ions o s onge es ima es in magni ude o hose
pa icipan s pe aining o lowe SES. In pa icula , we ound associa-
ions be ween highe esiden ial g eenspace and he mo e inc eased size
Table 1
Table o he s udy popula ion cha ac e is ics.
Va iable As u ias Gipuzkoa Sabadell Val`
encia All
coho s
Numbe o
pa icipan s
478
(19.3%)
600
(24.3%)
611
(24.7%)
776
(31.4%)
2465
(100.0%)
Ges a ional age
a bi h
(median weeks,
IQR)
39.5(2) 40(1.7) 39.8
(1.8)
39.8
(1.7)
39.8(1.8)
Sex o he child (n, %)
Gi l 227
(47.5%)
296
(49.4%)
305
(50.0%)
368
(47.4%)
1196
(48.5%)
Boy 251
(52.5%)
303
(50.6%)
306
(50.0%)
408
(52.6%)
1268
(51.5%)
P e ious p egnancies (n, %)
No 292
(61.1%)
324
(54.0%)
343
(56.3%)
426
(54.9%)
1385
(56.2%)
Yes 186
(38.9%)
276
(46.0%)
266
(43.7%)
350
(45.1%)
1078
(43.8%)
Ma e nal age (n, %)
24
(5.0%)
13 (2.2%) 54
(8.8%)
88
(11.3%)
179
(7.3%)
25–29 yea s
old
130
(27.2%)
182
(30.3%)
204
(33.4%)
276
(35.6%)
792
(32.1%)
30–34 yea s
old
202
(42.3%)
293
(48.8%)
247
(40.5%)
298
(38.4%)
1040
(42.2%)
122
(25.5%)
112
(18.7%)
105
(17.2%)
114
(14.7%)
453
(18.4%)
Ma e nal educa ional le el (n, %)
P ima y 88
(18.4%)
79
(13.2%)
171
(28.1%)
264
(34%)
602
(24.5%)
High School 213
(44.6%)
212
(35.6%)
261
(42.9%)
330
(42.5%)
1016
(41.3%)
Uni e si y 177
(37%)
307
(51.3%)
176
(29%)
182
(23.5%)
842
(34.2%)
Social class (n, %)
High 152
(31.9%)
265
(44.2%)
187
(30.6%)
169
(21.8%)
773
(31.4%)
Medium 105
(22.0%)
129
(21.5%)
172
(28.2%)
210
(27.0%)
616
(25.0%)
Low 220
(46.1%)
206
(34.3%)
252
(41.2%)
397
(51.2%)
1075
(43.6%)
Coun y o o igin
Spain 461
(96.4%)
576
(96.0%)
536
(88.9%)
683
(88.0%)
2256
(91.8%)
Ou side Spain 17
(3.5%)
24 (4.0%) 67
(11.1%)
93
(12.0%)
201
(8.2%)
Wo king du ing p egnancy (n, %)
No 130
(27.2%)
72
(12.0%)
70
(11.5%)
135
(17.4%)
407
(16.5%)
Yes 348
(72.8%)
528
(88.0%)
541
(88.5%)
641
(82.6%)
2058
(83.5%)
Ma e nal smoking (n, %)
No 321
(71.5%)
445
(76.5%)
418
(69.8%)
456
(59.3%)
1640
(68.4%)
Yes 128
(28.5%)
137
(23.5%)
181
(30.2%)
313
(40.7%)
759
(31.6%)
M. To es Toda e al.
Heal h and Place 78 (2022) 102912
5
o bipa ie al diame e , emu leng h, and abdominal ci cum e ence
among e uses o mo he s wi h lowe SES.
The esul s o s a i ied analyses by egion can be ound in Supple-
men a y Ma e ials, Table S6. The di ec ion o he associa ions was
simila o hose o he main analyses. We did no obse e a consis en
pa e n o s onge es ima es in magni ude o ei he o he egions and
he e ogenei y was no de ec ed (I
2
). The only ema kable di e ence is
ha he associa ions be ween esiden ial g eenspace in 300 m and 500 m
bu e and es ima ed e al weigh we e s onge in As u ias (Eu o-
sibe ian egion). Ne e heless, he associa ions be ween esiden ial
g eenspace in he la ge bu e s and bipa ie al diame e we e s onge in
Val`
encia (Medi e anean egion).
We obse ed smalle associa ion es ima es be ween he g eenspace
exposu e and e al g ow h pa ame e s when we u he adjus ed ou
main models o NO
2
le els (Table 2). The es ima es we e ma ginally
signi ican (p- alues be ween 0.05 and 0.1) o emu leng h in he 300
m NDVI bu e and abdominal ci cum e ence in he 500 m bu e . Fo
he es o he models, he associa ions we e non-signi ican . The esul s
o he media ion analysis a e ep esen ed in Figs. 2 and 3. We conduc ed
he media ion analysis o hose associa ions whe e he o al e ec was
s a is ically signi ican . The pe cen age o he associa ion be ween es-
iden ial g eenspace in 500 m bu e and e al g ow h explained by ai
pollu ion was 37% o bipa ie al diame e , 24% o emu leng h, and
23% o abdominal ci cum e ence. Fu he , he pe cen age media ed by
ai pollu ion o esiden ial g eenspace in 300 m bu e on e al g ow h
was 15% o emu leng h and 26% o abdominal ci cum e ence.
Rega ding physical ac i i y, we did no obse e a media ion.
4. Discussion
This longi udinal s udy explo ed he associa ions be ween ma e nal
esiden ial g eenspace exposu e and e al g ow h pa ame e s. Fo each
pa icipan , sa elli e-image y da a was used o cha ac e ise esiden ial
g eenspace exposu e. We analysed epea ed da a on ul asound pa-
ame e s om ou Spanish bi h coho s wi h ema kably di e en
clima es among he Eu osibe ian and Medi e anean egions. We con-
s uc ed cus omised e al g ow h models o bipa ie al diame e , emu
leng h, abdominal ci cum e ence, and es ima ed e al weigh . We ound
ha mo e esiden ial g eenspace exposu e du ing p egnancy in he 500
m NDVI bu e was associa ed wi h inc eased size in he bipa ie al
diame e , emu leng h, and abdominal ci cum e ence. In addi ion,
mo e exposu e o esiden ial g eenspace in he 300 m bu e was asso-
cia ed wi h enhanced measu es o emu leng h and abdominal
ci cum e ence. We did no ind associa ions o esiden ial g eenspace in
100 m bu e wi h any ul asound pa ame e s o e al g ow h and any
bu e s wi h he es ima ed e al weigh . We did no ind an e ec
modi ica ion by sex. Howe e , we ind an e ec modi ica ion by SES in
he associa ion be ween g eenspace exposu e in 100 m bu e and emu
leng h. S a i ica ion by SES showed s onge es ima es in magni ude o
hose pa icipan s om lowe SES. A e s a i ica ion o ou main ana-
lyses by egion, he associa ions did no show a consis en pa e n. Once
we u he adjus ed ou main models o ai pollu ion, we obse ed a
weakening o he associa ion es ima es, and hose s a is ically signi i-
can associa ions men ioned abo e disappea ed o emained ma ginal.
Ou media ion analyses we e sugges i e o a po en ial media o y ole o
ai pollu ion in he associa ion be ween g eenspace exposu e and e al
g ow h. Media ion by physical ac i i y was no obse ed.
Ou esul s we e in line wi h hose om p e ious s udies. A ecen
s udy in Beijing (China) ound ha e uses om pa icipan s wi h mo e
esiden ial g eenspace exposu e (i.e., 500 m NDVI bu e abo e he
Table 2
Gene alised leas squa es models o 1-IQR inc ease o each bu e o esiden ial
su ounding g eenspace and di e ence in he a e age o e al g ow h (mm)
measu emen s and co esponding 95% con idence in e als (CI).
Main e ec
a
Adjus ed o ai pollu ion
b
Be a coe icien
(95% CI)
P
alue
Be a coe icien
(95% CI)
P
alue
Bipa ie al diame e
NDVI 100 m
bu e
−0.01 (−0.12,
0.11)
0.89 −0.05 (−0.17,
0.07)
0.41
NDVI 300 m
bu e
0.13 (−0.02, 0.27) 0.08 0.08 (−0.08, 0.24) 0.32
NDVI 500 m
bu e
0.17 (0.01, 0.35) 0.05* 0.11 (−0.09, 0.31) 0.27
Femu leng h
NDVI 100 m
bu e
0.05 (−0.04, 0.15) 0.29 0.03 (−0.07, 0.14) 0.51
NDVI 300 m
bu e
0.15 (0.02, 0.27) 0.02* 0.12 (−0.01, 0.26) 0.07
NDVI 500 m
bu e
0.15 (0.01, 0.31) 0.04* 0.12 (−0.05, 0.29) 0.17
Abdominal Ci cum e ence
NDVI 100 m
bu e
0.19 (−0.22, 0.59) 0.36 0.07 (−0.37, 0.51) 0.75
NDVI 300 m
bu e
0.59 (0.06, 1.12) 0.02* 0.44 (−0.15, 1.02) 0.14
NDVI 500 m
bu e
0.83 (0.19, 1.47) 0.01* 0.64 (−0.07, 1.36) 0.07
Es ima ed Fe al Weigh
NDVI 100 m
bu e
0.09 (−0.39, 0.56) 0.72 0.02 (−0.49, 0.53) 0.94
NDVI 300 m
bu e
0.26 (−0.35, 0.87) 0.40 0.15 (−0.53, 0.82) 0.66
NDVI 500 m
bu e
0.23 (−0.50, 0.97) 0.53 0.05 (−0.77, 0.88) 0.90
*p <0.05.
a
The main models we e adjus ed o : ma e nal heigh , ma e nal age, pa i y,
coun y o o igin, social class, ma e nal smoking, ma e nal educa ion, sex o he
child, wo king du ing p egnancy, and coho .
b
The models we e u he adjus ed o
a
and NO
2
.
Table 3
Gene alised leas squa es models
(a)
o 1-IQR inc ease o each bu e o esi-
den ial su ounding g eenspace and di e ence in he a e age o e al g ow h
(mm) measu emen s and co esponding 95% CI, s a i ied by SES (social class).
High Medium Low
Bipa ie al diame e
NDVI 100 m
bu e
−0.09 (−0.29,
0.11)
0.10 (−0.12,
0.32)
−0.02 (−0.19,
0.16)
NDVI 300 m
bu e
0.02 (−0.24,
0.28)
0.22 (−0.06,
0.51)
0.15 (−0.08,
0.38)
NDVI 500 m
bu e
0.03 (−0.28,
0.34)
0.21 (−0.13,
0.55)
0.25 (-0.03,
0.54)
Femu leng h
NDVI 100 m
bu e
−0.06 (−0.23,
0.11)
0.09 (−0.10,
0.28)
0.13 (-0.02,
0.28)
NDVI 300 m
bu e
0.12 (−0.11,
0.34)
0.14 (−0.10,
0.38)
0.18 (-0.02,
0.37)
NDVI 500 m
bu e
0.15 (−0.13,
0.42)
0.14 (−0.15,
0.43)
0.17 (−0.07,
0.42)
Abdominal Ci cum e ence
NDVI 100 m
bu e
−0.03 (−0.72,
0.67)
0.21 (−0.62,
1.05)
0.37 (−0.27,
1.01)
NDVI 300 m
bu e
0.49 (−0.43,
1.41)
0.65 (−0.42,
1.72)
0.65 (−0.18,
1.48)
NDVI 500 m
bu e
0.79 (−0.33,
1.92)
0.65 (−0.63,
1.93)
0.99 (0.03, 2.00)
Es ima ed Fe al Weigh
NDVI 100 m
bu e
0.09 (−0.71,
0.89)
0.23 (−0.75,
1.20)
0.07 (−0.69,
0.83)
NDVI 300 m
bu e
0.53 (−0.54,
1.60)
0.02 (−1.20,
1.24)
0.18 (−0.78,
1.14)
NDVI 500 m
bu e
0.74 (−0.56,
2.04)
−0.32 (−1.76,
1.12)
0.02 (−1.15,
1.19)
*p <0.05.
(a)The models we e adjus ed o : ma e nal heigh , ma e nal age, pa i y, coun y
o o igin, ma e nal smoking, ma e nal educa ion, sex o he child, wo king
du ing p egnancy, and coho .
M. To es Toda e al.
Heal h and Place 78 (2022) 102912
6
Fig. 2. Pe cen age explained o media ion o he associa ion be ween esiden ial su ounding g eenspace and e al g ow h by ai pollu ion (NO
2
).
Fig. 3. Pe cen age explained o media ion o he associa ion be ween esiden ial su ounding g eenspace and e al g ow h by physical ac i i y.
M. To es Toda e al.
Heal h and Place 78 (2022) 102912
7
median) had inc eased z-sco es in es ima ed e al weigh o 0.05 (95%
CI: 0.02, 0.08), in he abdominal ci cum e ence o 0.04 (95% CI: 0.01,
0.08), and he head ci cum e ence o 0.05 (95% CI: 0.02, 0.09) (Lin
e al., 2020). In ou s udy, we did no ind a s a is ically signi ican as-
socia ion o any o he bu e s o esiden ial g eenspace on es ima ed
e al weigh , bu he di ec ions o he es ima es we e posi i e. Ou
abdominal ci cum e ence esul s we e compa able o hei s, and we also
ound associa ions in he la ge bu e sizes.
The p e ious s udy on g eenspace exposu e and e al g ow h (Lin
e al., 2020) did no obse e in e ac ions by sex o he child o SES in
hei models. Simila ly, ou s udy did no ind an in e ac ion by sex o
he child. These indings may indica e ha associa ions wi h esiden ial
g eenspace may no depend on child sex. Howe e , we ound an in e -
ac ion by SES in he associa ion be ween esiden ial g eenspace (100 m
NDVI bu e ) and emu leng h. A e s a i ica ion o he main models
by SES, we obse ed some sugges ions o mo e inc eased size o bipa -
ie al diame e , emu leng h and abdominal ci cum e ence associa ed
wi h highe esiden ial g eenspace among e uses o mo he s wi h lowe
SES. O he s udies on g eenspace exposu e and bi h ou comes ound a
pa e n o mo e bene i s o hose babies wi h mo he s/ a he s wi h he
lowes ma e nal educa ion, ano he indica o o SES (Dad and e al.,
2012c; Lau en e al., 2019). These indings a e impo an because
people om lowe SES ha e an inc eased isk o poo e al g ow h and
wo se heal h (Ball e al., 2013; Vos e al., 2014) compa ed o hose om
highe SES. Exposu e o g eenspace may ha e he capabili y o educe
his gap in heal h among people wi h di e en socioeconomic le els.
The eby, p omo ing g eenspace in ou ci ies can be a a ge o u ban
planne s and policymake s o educe heal h inequali ies and inc ease
en i onmen al jus ice, especially in dep i ed a eas. The p esen s udy
was conduc ed ac oss ou a eas in Spain wi hin wo di e en biogeo-
g aphic egions. The associa ions ac oss he speci ic a eas we e com-
pa able, sugges ing ha hese associa ions a e no egion-speci ic.
We a e no awa e o any o he s udy besides he one by Lin e al.
(2020), ha e alua ed g eenspace exposu e and e al g ow h pa ame-
e s. Howe e , al hough bi h ou comes may no co ec ly e lec he
dynamics o e al g ow h in u e o, s udies on ma e nal exposu e o
g eenspace and posi i e bi h ou comes a e one o he mos consis en
associa ions ound in s udies abou he heal h bene i s o g eenspace
(Yang e al., 2021). Ou esea ch g oup p e iously in es iga ed he as-
socia ion be ween esiden ial g eenspace and bi h weigh , bi h head
ci cum e ence, and ges a ional age a bi h (Dad and e al., 2012b). A
1-IQR inc ease in esiden ial g eenspace was associa ed wi h inc eases
in bi h weigh [44.2 g (95% CI: 20.2, 68.2)] and head ci cum e ence
[1.7 mm (95% CI: 0.5, 2.9)] bu no wi h ges a ional age. A sys ema ic
e iew by Dzhambo e al. (2014) ound ha la ge bu e sizes o NDVI
had a mo e no iceable imp o emen in bi h weigh , while smalle
bu e sizes ended o ha e mo e inconsis en esul s. Al hough in ou
s udy we analysed e al g ow h pa ame e s, bi h weigh is widely used
as an indica o o impai ed e al g ow h, and hose indings we e simila
compa ed o ou s. A po en ial explana ion o his could be ha he
social and physical ac i i y unc ion o esiden ial g eenspace e lec ed
in la ge bu e s a he han s ess educ ion by isualisa ion in sho e
bu e s migh be mo e ele an mechanisms unde lying hese associa-
ions. Al hough in ou analyses no signi ican media ion by physical
ac i i y was ound.
The mechanisms unde lying he heal h bene i s o g eenspace
exposu e a e ye o be es ablished, bu an eme ging body o e idence has
shed ligh on a numbe o hem. Fo example, he abili y o g eenspace o
educe s ess and dep ession (Ve heyen e al., 2021), inc ease physical
ac i i y (Mceachan e al., 2016), and mi iga e exposu e o ai pollu ion
(Dad and e al., 2012a) could unde lie ou obse ed associa ions be-
ween g eenspace exposu e and e al g ow h. In ou s udy, he s a is i-
cally signi ican associa ions disappea ed a e u he inclusion o NO
2
in ou main models sugges ing a po en ial media o y ole o NO
2
. We
hen conduc ed a media ion analysis o NO
2
, and we ound ha his ai
pollu an could explain 15–37% o ou obse ed associa ions. We could
no compa e hese indings o hose o he p e ious s udies wi h ul a-
sound measu emen s gi en he una ailabili y o such a media ion
analysis. Howe e , hese indings a e in line wi h a ious p e ious
s udies e alua ing g eenspace exposu e and bi h ou comes (e.g., bi h
weigh , SGA, and low bi h weigh ) (Dad and e al., 2012b; Lau en
e al., 2019; Lee e al., 2021). A p e ious s udy showed ha pa icula e
ma e (PM) media ed app oxima ely 5–19% o he associa ion be ween
i s and hi d imes e g eenspace and p e e m bi h and media ed
app oxima ely 15–37% o he associa ion be ween g eenspace and SGA
(Lee e al., 2021). We did no obse e a media ion by physical ac i i y.
We a e awa e o ano he s udy on g eenspace and e al g ow h ha
ound an inc ease in he dis ance om ou doo i ness equipmen
explained 14% o he associa ions, used as a p oxy o physical ac i i y
(Agay-Shay e al., 2019). Fo ou media ion analyses, we used ano he
a iable o physical ac i i y ha p obably could explain hese di e -
ences on he esul s i we compa e he wo s udies. Mo eo e , ou
physical ac i i y a iable was calcula ed based on he p e ious yea o
p egnancy and his inaccu acy migh be explaining ou null esul s.
Mo eo e , he applica ion o cus omised models is a g owing a ea o
esea ch. These models migh imp o e he dis inc ion be ween small
e uses ha ha e achie ed hei g ow h po en ial and small e uses
because o a eal pa hological g ow h es ic ion (Gailla d e al., 2014).
Fe uses iden i ied as g ow h- es ic ed by popula ion-based e e ence
cha s may include e uses wi h in au e ine g ow h es ic ion wi h a
highe isk o su e ing ad e se heal h ou comes and also cons i u ion-
ally small bu no mal-g ow h e uses (Gailla d e al., 2014).
Some limi a ions o ou s udy should be conside ed. To begin wi h,
we did no ha e da a on o he impo an aspec s o he g eenspace
exposu e, such as he ime spen in g een spaces, isual access o
g eenspace, o quali y cha ac e is ics o he g eenspace. A p e ious
s udy by ou esea ch g oup ound ha isual access and ime spen in
g een spaces we e associa ed wi h highe bi h weigh (To es Toda
e al., 2020a). Quali y cha ac e is ics o g eenspace a e also impo an o
conside , gi en ha an una ac i e and unsa e g eenspace may be
discou aging o p egnan women o isi . To calcula e ou NDVI alues,
we elied on images om Landsa , a sa elli e ha has be e spa ial
esolu ion compa ed o o he s (i.e., MODIS) bu wi h he p ice o losing
some empo al esolu ion. Howe e , some s udies showed ha NDVI
alues in sho pe iods do no a y signi ican ly (Dad and e al., 2012b;
To es Toda e al., 2020b), and he e o e we belie ed ha o ou s udy
pe iod ha ing mo e spa ial esolu ion would be be e . Al hough i is a
common p ac ice in g eenspace and heal h s udies, ano he limi a ion
was o ely on a single sa elli e image pe s udy a ea which always is
p one o some misclassi ica ion. We sugges o he u u e s udies o y o
o e come his limi a ion. Al hough we did no ha e in o ma ion abou
p e ious esiden ial mobili y and p econcep ional exposu e o g een-
space, we expec a minimal e ec on esul s gi en ha only 1–6% o
INMA pa icipan s mo ed du ing p egnancy (Es a lich e al., 2011).
Mo eo e , ou sample size was limi ed, and ou s a i ied analyses we e
possibly unde powe ed. Finally, a s udy compa ing SGA classi ica ion
om popula ion-based models and cus omised models in 8162 p egnan
women (Gailla d e al., 2011) ound 16–25% di e ences be ween he
wo models. Howe e , ma e nal and e al cha ac e is ics used o cus-
omisa ion may no s ongly p edic e al g ow h indi idually. Mo e
s udies a e needed o cha ac e ise hese cus omised models o epide-
miological and clinical u ilisa ion. We ecommend using la ge sample
sizes o u u e s udies while accoun ing o da a on he quali y and ype
o g eenspace. Fo u u e s udies, we also ecommend he e alua ion o
o he po en ial mechanisms unde he associa ion be ween g eenspace
and e al g ow h, such as s ess le els.
To conclude, ou esul s suppo he hypo hesis ha esiden ial
g eenspace may posi i ely in luence e al g ow h in u e o and shed ligh
on a po en ial media o y ole o ai pollu ion on his associa ion.
Imp o ing and implemen ing g eenspace in u ban a eas could help o
p omo e heal h in ea ly li e and educe heal h inequali ies among
di e en SES.
M. To es Toda e al.
Heal h and Place 78 (2022) 102912
8
Funding
We a e g a e ul o all he pa icipan s o hei gene ous collabo a-
ion. A ull os e o he INMA P ojec ounde s can be ound a : h ps://
www.p oyec oinma.o g/p oyec o-inma/ inanciado es/. Ma ia To es
Toda is unded by a PFIS (Con a o P edoc o al de Fo maci´
on en
In es igaci´
on en Salud) ellowship (FI17/00128) awa ded by Ins i u o
de Salud Ca los III. Ma ia Fo as e is bene icia y o an AXA Resea ch
Fund g an . ISGlobal acknowledges suppo om he Spanish Minis y o
Science and Inno a ion and S a e Resea ch Agency h ough he “Cen o
de Excelencia Se e o Ochoa 2019–2023” P og am (CEX2018-000806-
S), and suppo om he Gene ali a de Ca alunya h ough he CERCA
P og am.
Decla a ions o compe ing in e es
None.
Da a a ailabili y
The da a ha has been used is con iden ial.
Acknowledgemen s:
The au ho s would pa icula ly like o hank all he pa icipan s o
hei gene ous collabo a ion.
Appendix A. Supplemen a y da a
Supplemen a y da a o his a icle can be ound online a h ps://doi.
o g/10.1016/j.heal hplace.2022.102912.
Re e ences
Agay-Shay, K., Michael, Y., Basaga˜
na, X., Ma ínez-Solanas, `
E., B oday, D., Lensky, I.M.,
Rudol , M., Rubin, L., Ken , R., Le y, N., Haklai, Z., G o o, I., 2019. Mean and
a iance o g eenness and p egnancy ou comes in Tel A i du ing 2000–14:
longi udinal and c oss-sec ional app oaches. In . J. Epidemiol. 48 (4), 1054–1072.
h ps://doi.o g/10.1093/ije/dyy249.
Aka aci, S., Feng, X., Suesse, T., Jalaludin, B., As ell-Bu , T., 2021. G eene
neighbou hoods, heal hie bi h ou comes? E idence om Aus alia. En i on. Pollu .
278, 116814 h ps://doi.o g/10.1016/j.en pol.2021.116814.
Alca az-Segu a, D., Cabello, J., Pa uelo, J., 2009. Baseline cha ac e iza ion o majo
Ibe ian ege a ion ypes based on he NDVI dynamics. Plan Ecol. 202 (1), 13–29.
h ps://doi.o g/10.1007/s11258-008-9555-2.
Ame ican College o Obs e icians and Gynecologis s, 2019. Clinical Managemen
Guidelines o Obs e ician-Gynecologis s. Numbe 227. h p://jou nals.lww.com/
g eenjou nal.
As ell-Bu , T., Ha ig, T., Ecke mann, S., Nieuwenhuijsen, M., McMunn, A., F umkin, H.,
Feng, X., 2022. Mo e g een, less lonely? A longi udinal coho s udy. In . J.
Epidemiol. 51 (1), 99–110. h ps://doi.o g/10.1093/ije/dyab089.
Ball, S., Jacoby, P., Zub ick, S., 2013. Socioeconomic s a us accoun s o apidly
inc easing geog aphic a ia ion in he incidence o poo e al g ow h. In . J. En i on.
Res. Publ. Heal h 10 (7). h ps://doi.o g/10.3390/ije ph10072606, 2606–2020.
Ba ke , W.D., Osmond, C., 1986. In an mo ali y, childhood nu i ion, and ischaemic
hea disease. Lance .
Ba ouki, R., Gluckman, P.D., G andjean, P., Hanson, M., Heindel, J.J., 2012.
De elopmen al O igins o Non-communicable Disease: Implica ions o Resea ch and
Public Heal h. En i onmen al Heal h. h p://www.ehjou nal.ne /con en /11/1/42.
Coope , C., Fall, C., Egge , P., Hobbs, R., Eas ell, R., Ba ke , D., 1997. G ow h in in ancy
and bone mass in la e li e. Ann. Rheum. Dis. 56 (1), 17–21. h ps://doi.o g/
10.1136/a d.56.1.17.
Dad and, P., de Nazelle, A., T igue o-Mas, M., Schemba i, A., Ci ach, M., Amoly, E.,
Figue as, F., Basaga˜
na, X., Os o, B., Nieuwenhuijsen, M., 2012a. Su ounding
g eenness and exposu e o ai pollu ion du ing p egnancy: an analysis o pe sonal
moni o ing da a. En i on. heal h Pe spec . 120 (9), 1286–1290. h ps://doi.o g/
10.1289/ehp.1104609.
Dad and, P., Sunye , J., Basaga˜
na, X., Balles e , F., Le xundi, A., Fe n´
andez-
Somoano, A., Es a lich, M., Ga cía-Es eban, R., Mendez, M.A., Nieuwenhuijsen, M.J.,
2012b. Su ounding g eenness and p egnancy ou comes in ou Spanish bi h
coho s. En i on. heal h Pe spec . 120 (10), 1481–1487. h ps://doi.o g/10.1289/
ehp.1205244.
Dad and, P., de Nazelle, A., Figue as, F., Basaga˜
na, X., Su, J., Amoly, E., Je e , M.,
V ijheid, M., Sunye , J., Nieuwenhuijsen, M.J., 2012c. G een space, heal h
inequali y and p egnancy. En i on. In . 40 (1), 110–115. h ps://doi.o g/10.1016/j.
en in .2011.07.004.
Damhuis, S., Ganze oo , W., Go dijn, S., 2021. Abno mal Fe al G ow h, Small o
Ges a ional Age, Fe al G ow h Res ic ion, La ge o Ges a ional Age: De ini ions and
Epidemiology. Obs e Gynecol Clin N Am. h ps://doi.o g/10.1016/j.
ogc.2021.02.002.
Domingo-Sal any, Regido , Alonso, Al a ez-Da de , 2000. P oposal o a Social Class
Measu e. Wo king G oup o he Spanish Socie y o Epidemiology and he Spanish
Socie y o Family and Communi y Medicine [in Spanish]. A enci´
on P ima ia.
Dzhambo , A.M., Dimi o a, D.D., Dimi ako a, E.D., 2014. Associa ion be ween
esiden ial g eenness and bi h weigh : sys ema ic e iew and me a-analysis. U ban
Fo . U ban G een. 13 (4), 621–629. h ps://doi.o g/10.1016/j.u ug.2014.09.004.
Es a lich, M., Balles e , F., Aguile a, I., Fe n´
andez-Somoano, A., Le xundi, A., Llop, S.,
F ei e, C., Ta d´
on, A., Bas e echea, M., Sunye , J., I˜
niguez, C., 2011. Residen ial
exposu e o ou doo ai pollu ion du ing p egnancy and an h opome ic measu es a
bi h in a mul icen e coho in Spain. En i on. heal h Pe spec . 119 (9), 1333–1338.
h ps://doi.o g/10.1289/ehp.1002918.
Gailla d, R., de Ridde , M.A.J., Ve bu g, B.O., Wi eman, J.C.M., MacKenbach, J.P.,
Moll, H.A., Ho man, A., S eege s, E.A.P., Jaddoe, V.W.V., 2011. Indi idually
cus omised e al weigh cha s de i ed om ul asound measu emen s: he
Gene a ion R S udy. Eu . J. Epidemiol. 26 (12), 919–926. h ps://doi.o g/10.1007/
s10654-011-9629-7.
Gailla d, R., Jaddoe, V., XX, XX, ., 2014. Assessmen o e al g ow h by cus omized
g ow h cha s. Sou ce: Ann. Nu . Me ab. 65 (3), 149–155. h ps://doi.o g/10.2307/
48514525.
Gluckman, P., Hanson, M., XX, XX, 2004. De elopmen al o igins o disease pa adigm: a
mechanis ic and e olu iona y pe spec i e. In: Pedia ic Resea ch, ol. 56. Lippinco
Williams and Wilkins, pp. 311–317. h ps://doi.o g/10.1203/01.
PDR.0000135998.08025. Issue 3, FB.
Guxens, M., Balles e , F., Espada, M., Fe n´
andez, M.F., G imal , J.O., Iba luzea, J.,
Olea, N., Rebaglia o, M., Ta d´
on, A., To en , M., Vioque, J., V ijheid, M., Sunye , J.,
2012. Coho p o ile: he INMA-IN ancia y Medio Ambien e-(en i onmen and
childhood) p ojec . In . J. Epidemiol. 41 (4), 930–940. h ps://doi.o g/10.1093/ije/
dy 054.
Hadlock, F.P., Ha is , R.B., Ca pen e , R.J., De e , R.L., Pa k, S.K., 1984. Sonog aphic
es ima ion o e al weigh : he alue o emu leng h in addi ion o head and
abdomen measu emen s. Radiology.
Hu, C.Y., Yang, X.J., Gui, S.Y., Ding, K., Huang, K., Fang, Y., Jiang, Z.X., Zhang, X.J.,
2021. Residen ial g eenness and bi h ou comes: a sys ema ic e iew and me a-
analysis o obse a ional s udies. En i on. Res. 193, 110599 h ps://doi.o g/
10.1016/j.en es.2020.110599.
I˜
niguez, C., Esplugues, A., Sunye , J., Bas e echea, M., Fe n´
andez-Somoano, A.,
Cos a, O., Es a lich, M., Aguile a, I., Le xundi, A., Ta d´
on, A., Guxens, M.,
Mu cia, M., Lopez-Espinosa, M.J., Balles e , F., 2016. P ena al exposu e o NO2 and
ul asound measu es o e al g ow h in he Spanish INMA coho . En i on. heal h
Pe spec . 124 (2), 235–242. h ps://doi.o g/10.1289/ehp.1409423.
Kensa a, O.A., Woo on, S.A., Phillips, D.I., Pa el, M., Jackson, A.A., Elia, M., 2005. Fe al
p og amming o body composi ion: ela ion be ween bi h weigh and body
composi ion measu ed wi h dual-ene gy X- ay abso p iome y and an h opome ic
me hods in olde Englishmen 1-3. The Ame ican Jou nal o Clinical Nu i ion. h ps
://academic.oup.com/ajcn/a icle/82/5/980/4607681.
Lau en , O., Benma hnia, T., Milesi, C., Hu, J., Kleeman, M.J., Cockbu n, M., Wu, J.,
2019. Rela ionships be ween g eenness and low bi h weigh : in es iga ing he
in e ac ion and media ion e ec s o ai pollu ion. En i on. Res. 175, 124–132.
h ps://doi.o g/10.1016/j.en es.2019.05.002.
Lee, P.C., Wu, C. da, Tsai, H.J., Tsai, H.Y., Lin, S.H., Wu, C.K., Hung, C.Y., Yao, T.C.,
2021. Residen ial g eenness and bi h ou comes: e alua ing he media ion and
in e ac ion e ec s o pa icula e ai pollu ion. Eco oxicol. En i on. Sa . 211 h ps://
doi.o g/10.1016/j.ecoen .2021.111915.
Lin, L., Li, Q., Yang, J., Han, N., Chen, G., Jin, C., Xu, X., Liu, Z., Liu, J., Luo, S., Raa , H.,
Guo, Y., Wang, H., 2020. The associa ions o esiden ial g eenness wi h e al g ow h
in u e o and bi h weigh : a bi h coho s udy in Beijing, China. En i on. In . 141
(Ap il), 105793 h ps://doi.o g/10.1016/j.en in .2020.105793.
Mamelle, N., Coche , V., Cla is, O., 2001. De ini ion o e al g ow h es ic ion acco ding
o cons i u ional g ow h po en ial. In: Biol Neona e, ol. 80. www.ka ge .com.
Ma ke ych, I., Schoie e , J., Ha ig, T., Chudno sky, A., Hys ad, P., Dzhambo , A.M., de
V ies, S., T igue o-Mas, M., B aue , M., Nieuwenhuijsen, M.J., Lupp, G.,
Richa dson, E.A., As ell-Bu , T., Dimi o a, D., Feng, X., Sadeh, M., S andl, M.,
Hein ich, J., Fue es, E., 2017. Explo ing pa hways linking g eenspace o heal h:
heo e ical and me hodological guidance. En i on. Res. 158 (Feb ua y), 301–317.
h ps://doi.o g/10.1016/j.en es.2017.06.028.
Mceachan, R.R.C., P ady, S.L., Smi h, G., 2016. The associa ion be ween g een space and
dep essi e symp oms in p egnan women: mode a ing oles o socioeconomic s a us
and physical ac i i y. J. Epidemiol. Communi y Heal h 70, 253–259. h ps://doi.
o g/10.1136/jech.
Nguyen, P.Y., As ell-Bu , T., Rahimi-A dabili, H., Feng, X., 2021. G een space quali y
and heal h: a sys ema ic e iew. In: In e na ional Jou nal o En i onmen al Resea ch
and Public Heal h, ol. 18. MDPI. h ps://doi.o g/10.3390/ije ph182111028. Issue
21.
Nieuwenhuijsen, M.J., Dad and, P., G ellie , J., Ma inez, D., V ijheid, M., 2013.
En i onmen al isk ac o s o p egnancy ou comes: a summa y o ecen me a-
analyses o epidemiological s udies. In: En i onmen al Heal h : a Global Access
Science Sou ce, ol. 12. h ps://doi.o g/10.1186/1476-069X-12-6.
No man, A, Bellocco, R, Be gs ¨
om, A, Wolk, A, 2001. Validi y and ep oducibili y o sel -
epo ed o al physical ac i i y–di e ences by ela i e weigh . In . J. Obes. Rela .
Me ab. Diso d. 25 (5), 682–688. h ps://doi.o g/10.1038/sj.ijo.0801597.
Pinhei o, J., Ba es, D., XX, XX, 2009. In: Mixed-E ec s Models In S and S-PLUS (2009.
Sp inge Science & Business Media.
M. To es Toda e al.
Heal h and Place 78 (2022) 102912
9
P eache , K., Kelley, K., XX, XX, 2011. E ec size measu es o media ion models:
quan i a i e s a egies o communica ing indi ec e ec s. Psychol. Me hods.
h ps://doi.o g/10.1037/a0022658.supp.
Rinaudo, P., Wang, E., XX, XX, 2012. Fe al p og amming and me abolic synd ome. Annu.
Re . Physiol. 74, 107–130. h ps://doi.o g/10.1146/annu e -physiol-020911-
153245.
Ris o ska, G., Laszlo, H.E., Hansell, A.L., 2014. Rep oduc i e ou comes associa ed wi h
noise exposu e - a sys ema ic e iew o he li e a u e. In: In e na ional Jou nal o
En i onmen al Resea ch and Public Heal h, ol. 11. MDPI, pp. 7931–7952. h ps://
doi.o g/10.3390/ije ph110807931, 8.
Roseboom, T.J., an de Meulen, J.H., Ra elli, A.C., Osmond, C., Ba ke , D.J., Bleke , O.
P., 2001. E ec s o p ena al exposu e o he Du ch amine on adul disease in la e
li e: an o e iew. Mol. Cell. Endoc inol. 185 (1–2), 93–98. h ps://doi.o g/10.1016/
s0303-7207(01)00721-3.
Rojas-Rueda, D., Nieuwenhuijsen, M.J., Gascon, M., Pe ez-Leon, D., Mudu, P., 2019.
G een spaces and mo ali y: a sys ema ic e iew and me a-analysis o coho s udies.
Lance Plane . Heal h 3 (11), e469–e477. h ps://doi.o g/10.1016/S2542-5196(19)
30215-3.
Sacchi, C., Ma ino, C., Nosa i, C., Vieno, A., Visen in, S., Simonelli, A., 2020. Associa ion
o in au e ine g ow h es ic ion and small o ges a ional age s a us wi h childhood
cogni i e ou comes A sys ema ic e iew and me a-analysis. JAMA Pedia .
Sonnenschein-Van De Voo , A.M.M., Gailla d, R., de Jongs e, J.C., Ho man, A.,
Jaddoe, V.W.V., Duij s, L., 2016. Foe al and in an g ow h pa e ns, ai way
esis ance and school-age as hma. Respi ology 21 (4), 674–682. h ps://doi.o g/
10.1111/ esp.12718.
Sun, Y., Ilango, S.D., Schwa z, L., Wang, Q., Chen, J.C., Law ence, J.M., Wu, J.,
Benma hnia, T., 2020. Examining he join e ec s o hea wa es, ai pollu ion, and
g een space on he isk o p e e m bi h in Cali o nia. En i on. Res. Le . 15 (10)
h ps://doi.o g/10.1088/1748-9326/abb8a3.
To es Toda, M., Mi i, M., Alonso, L., G´
omez-Roig, M.D., Fo as e , M., Dad and, P.,
2020a. Exposu e o g eenspace and bi h weigh in a middle-income coun y.
En i on. Res. 189 (July) h ps://doi.o g/10.1016/j.en es.2020.109866.
To es Toda, M., Anabi a e Riol, A., Ci ach, M., Es a lich, M., Fe n´
andez-Somoano, A.,
Gonz´
alez-Sa on , L., Guxens, M., Jul ez, J., Ria˜
no-Gal´
an, I., Sunye , J., Dad and, P.,
2020b. Residen ial su ounding g eenspace and men al heal h in h ee Spanish
a eas. In e na ional jou nal o . En i on. Res. Pub. Heal h 17 (16), E5670. h ps://
doi.o g/10.3390/ije ph17165670.
Twohig-Benne , C., Jones, A., 2018. The heal h bene i s o he g ea ou doo s: a
sys ema ic e iew and me a-analysis o g eenspace exposu e and heal h ou comes.
En i on. Res. 166, 628–637. h ps://doi.o g/10.1016/j.en es.2018.06.030.
UN-Habi a , 2020. In eg a ing Heal h in U ban and Te i o ial Planning: A Sou cebook.
h ps://unhabi a .o g/si es/de aul / iles/2020/05/1- inal_high es_20002_in eg a in
g_heal h_in_u ban_and_ e i o ial_planning_a_sou cebook.pd .
Uni ed Na ions, 2018. Wo ld U baniza ion P ospec s 2018. Uni ed Na ions, 12. h ps://p
opula ion.un.o g/wup/.
U.S. Geological Su ey, 2022. Landsa No malized Di e ence Vege a ion Index. U.S.
Geological Su ey. h ps://www.usgs.go /landsa -missions/landsa -no malized
-di e ence- ege a ion-index.
Ve heyen, V.J., Remy, S., Lamb ech s, N., Go a s, E., Colles, A., Poelmans, L.,
Ve ach e , E., Le eb e, W., Monsieu s, P., Vanpoucke, C., Nielsen, F., an den
Eeden, L., Jacquemyn, Y., Schoe e s, G., 2021. Residen ial exposu e o ai pollu ion
and access o neighbo hood g eenspace in ela ion o hai co isol concen a ions
du ing he second and hi d imes e o p egnancy. En i on. Heal h: Global Access
Sci. Sou ce 20 (1). h ps://doi.o g/10.1186/s12940-021-00697-z.
Villeneu e, P.J., Lam, S., Tjepkema, M., Pinaul , L., C ouse, D.L., Oso nio-Va gas, A.R.,
Hys ad, P., Je e , M., La igne, E., S ieb, D.M., 2022. Residen ial p oximi y o
g eenness and ad e se bi h ou comes in u ban a eas: indings om a na ional
Canadian popula ion-based s udy. En i on. Res. 204, 112344 h ps://doi.o g/
10.1016/j.en es.2021.112344.
Vos, A.A., Pos humus, A.G., Bonsel, G.J., S eege s, E.A.P., Denk as¸, S., 2014. Dep i ed
neighbo hoods and ad e se pe ina al ou come: a sys ema ic e iew and me a-
analysis. In: Ac a Obs e icia e Gynecologica Scandina ica, ol. 93. Wiley-Blackwell
Publishing L d, pp. 727–740. h ps://doi.o g/10.1111/aogs.12430. Issue 8.
WHO, 2016. U ban G een Space In e en ions and Heal h: A Re iew o Impac s and
E ec i eness, ol. 80. WHO Regional O ice o Eu ope. h p://www.eu o.who.in /p
ub eques %0Ah p://www.eu o.who.in /pub eques %0Ah p://www.eu o.who.in /
__da a/asse s/pd _ ile/0005/321971/U ban-g een-spaces-and-heal h- e iew-e ide
nce.pd ?ua=1.
Yang, B.-Y., Zhao, T., Hu, L.-X., B owning, M.H.E.M., Hein ich, J., Dha mage, S.C.,
Jalaludin, B., Knibbs, L.D., Liu, X.-X., Luo, Y.-N., James, P., Li, S., Huang, W.-Z.,
Chen, G., Zeng, X.-W., Hu, L.-W., Yu, Y., Dong, G.-H., 2021. G eenspace and human
heal h: an umb ella e iew. Inno a ion 2 (4), 100164. h ps://doi.o g/10.1016/j.
xinn.2021.100164.
Yin, P., 2019. Compa ison o g eenness measu es in assessing he associa ion be ween
u ban esiden ial g eenness and bi h weigh . U ban Fo es y &. U ban G eening
46, 126519. h ps://doi.o g/10.1016/j.u ug.2019.126519.
M. To es Toda e al.
