Inequities in access to exercise facilities and relationship with diabetes burden from an equity perspective in Madrid, Spain
- Autores: Luis Cereijo Tejedor
- Directores de la Tesis: Manuel Franco Tejero (dir. tes.), Hannah Badland (codir. tes.), David Valadés Cerrato (codir. tes.)
- Lectura: En la Universidad de Alcalá ( España ) en 2023
- Idioma: inglés
- Tribunal Calificador de la Tesis: Palma Chillón Garzón (presid.), Francisca Sureda Llull (secret.), Stephanie E. Coen (voc.)
- Programa de doctorado: Programa de Doctorado en Epidemiología y Salud Pública por la Universidad Autónoma de Madrid; la Universidad de Alcalá y la Universidad Rey Juan Carlos
- Materias:
- Enlaces
- Resumen
- español
Introducción: La actividad física, y especialmente el ejercicio, ejerce una influencia sobre la incidencia y la prevalencia de grandes problemas de salud, como la obesidad, la diabetes o las enfermedades cardiovasculares. Entre los diferentes recursos urbanos, la disponibilidad de instalaciones deportivas es importante como apoyo en la práctica de actividad física; sin embargo, las ciudades presentan una distribución de las instalaciones deportivas que no es equitativa. Hay una débil evidencia publicada sobre la asociación entre la disponibilidad de instalaciones deportivas en el barrio y los resultados de salud, especialmente la Diabetes Mellitus Tipo 2 (DMT2), debido a la falta de atención que ha recibido en la investigación en salud pública.
Objetivos: La presente tesis doctoral examina la relación entre la disponibilidad de instalaciones deportivas, la carga de DMT2, el nivel socioeconómico del área (NSE) el sexo en Madrid, España, a través de tres objetivos, presentados en tres estudios diferentes. Los objetivos son: (1) investigar la relación entre el NSE y la accesibilidad y la disponibilidad de instalaciones deportivas; (2) estudiar la asociación entre la disponibilidad de instalaciones deportivas y la prevalencia de obesidad y DMT2 en la población adulta; y (3) examinar la relación entre la disponibilidad de instalaciones deportivas y la incidencia de DMT2 y sus complicaciones.
Métodos: Fueron identificadas todas las instalaciones deportivas en Madrid, y clasificadas en cuatro grupos: públicas, privadas, low-cost, e instalaciones sesionales. Las instalaciones fueron geolocalizadas usando Google Maps. La accesibilidad fue operacionalizada como la distancia por la red de calles a la instalación deportivas más cercana desde cada una de los 125.427 portales residenciales de Madrid. La disponibilidad de instalaciones deportivas fue definida como el número de instalaciones en un área de 1.000 metros a través de la red de calles desde cada portal. El NSE fue medido usando un índice compuesto basado en siete indicadores sociodemográficos. Las variables de salud fueron obtenidas de las historias clínicas electrónicos de más del 90% de los residentes en Madrid de entre 40 y 75 años, usando datos de 2017 para los análisis transversales (N=1.270.512) y de 2015 a 2018 (N=1.412.759) para los análisis longitudinales. Los datos de salud estudiados fueron obesidad, DMT2, y las complicaciones macrovasculares (isquemia cardíaca e isquemia cerebral) y microvasculares (enfermedad renal crónica, retinopatía, y enfermedad vascular periférica) de la DMT2. Para el primer estudio realicé modelos de regression lineal multinivel y modelos de regresión zero-inflated Poisson para estudiar la asociación entre el NSE y la accesibilidad y disponibilidad de instalaciones deportivas en Madrid. Para el segundo estudio llevé a cado modelos de regresión Poisson con errores estándar agrupados a nivel de sección censal para obtener ratios de prevalencia de la disponibilidad de instalaciones deportivas (terciles) con obesidad y DMT2. Asimismo, se examinaron interacciones por NSE y sexo. Para el tercer studio llevé a cabo modelos de regresión Poisson con errores estándar agrupados a nivel de sección censal para obtener el riesgo relativo de la asociación entre la disponibilidad de instalaciones deportivas y la incidencia de DMT2 y sus complicaciones. Se llevaron a cabo análisis con interación por NSE y sexo para identificar una potencial modificación del efecto.
Resultados: El primer estudio mostró que los residentes en Madrid que viven en las áreas más desfavorecidas tienen la distancia media más pequeña a la instalación deportivas más cercana, especialmente para instalaciones públicas y low-cost. Mientras, aquellos que viven en áreas menos desfavorecidas tienen una mayor disponibilidad de instalaciones deportivas, especialmente privadas y sesionales, comparado con los residentes de áreas más desfavorecidas.
- English
Introduction: Physical activity, specifically exercise, exerts influence on the incidence and prevalence of major health problems, such as obesity, diabetes, and cardiovascular diseases. Among urban built environment resources, the availability of exercise facilities is important for supporting physical activity engagement; however inequitable distribution of exercise facilities exists throughout many cities. The empirical evidence for the associations between the neighbourhood exercise facility environment and health outcomes, especially Type 2 Diabetes Mellitus (T2DM), are weak and has received relatively little attention in public health research.
Objectives: This thesis examines the relationship between exercise facility availability, T2DM burden, and area-level socioeconomic status (SES) in in Madrid, Spain through three aims, presented as separate studies. The aims are to: (1) investigate the relationship between area-level socioeconomic status (SES) and accessibility to, and availability of, exercise facilities; (2) study the association between the availability of exercise facilities and the likelihood of obesity and T2DM in the adult population; and (3) examine the relationships between exercise facility availability and incidence of T2DM and its complications.
Methods: All exercise facilities in Madrid were identified and classified them into four types: public, private, low-cost, and sessional facilities. Facilities were geocoded using Google Maps and accessibility was operationalised as the street network distance to the nearest exercise facility from each of the 125,427 residential building entrances in Madrid. Exercise facility availability was defined as the count of exercise facilities in a 1000 m street network buffer around each portal. Area-level SES was measured using a composite index based on seven sociodemographic indicators. Health outcome data were obtained from electronic medical records (EMRs) from more than 90% of Madrid residents aged 40-75 years, using data from 2017 for the cross-sectional studies (n=1,270,512) and 2015-2018 (n=1,412,759) for the longitudinal study. Health outcomes studied were obesity, T2DM, and macrovascular (cardiac ischemia and stroke) and microvascular (chronic kidney disease, retinopathy, and peripheral vascular disease) complications of T2DM. For the first study, I carried out a multilevel linear regression and a zero-inflated Poisson regression analysis to assess the association between arealevel SES and exercise facility accessibility and availability in Madrid. For the second study, I used Poisson regression with standard errors clustered at census tract level to assess prevalence ratios (PR) of exercise facility availability (tertiles) with obesity and T2DM. Interactions by area-level SES and sex were also examined. For the third empirical study, I carried out Poisson regression models using robust standard errors clustered at the census tract level to estimate the relative risk (RR) for the association between exercise facilities and each health outcome. Analyses of interactions by area-level SES and sex were undertaken to identify potential effect modification.
Results: The first study showed that Madrid residents living in more disadvantaged areas had the shortest mean street network distance to the closest exercise facility, especially for accessing public and low-cost exercise facilities. Meanwhile those living in less disadvantaged areas had higher availability of exercise facilities, especially for private and sessional exercise facilities, compared with those more disadvantaged. The second study showed people living in areas with lower availability of exercise facilities had a higher prevalence of obesity and T2DM compared with those who had a higher availability of exercise facilities. Stratified analysis found an effect modification by arealevel SES, with stronger associations for residents living in low-SES areas, and strongest for women living in low SES neighbourhoods. The third study found that residents living in areas with lower exercise facility availability presented with higher risk of T2DM and macrovascular and microvascular T2DM complications compared with those living in areas with higher availability of exercise facilities. Analysis showed stronger associations for those living in low SES areas with the lowest tertile of exercise facility availability and incidence of T2DM and its microvascular complications compared with those residents from high SES areas.
Conclusions: This thesis draws two main conclusions. First, exercise facility accessibility and availability are related to T2DM burden, not only for T2DM itself, but also for its main risk factor (obesity) and macrovascular and microvascular T2DM complications. Second, this set of studies have exposed how socioeconomic inequities play a role in these relationships, by conditioning harmful effects for residents from low SES areas in Madrid. This research generated new knowledge that can help shape exercise-based interventions to reduce health inequities, including increasing availability of exercise facilities in more disadvantaged areas alongside ensuring that the facilities are affordable and gender-appropriate.
- español
