Review - (2022) Volume 12, Issue 6
Type 2 Diabetes Mellitus (T2DM) is a public health issue that must be addressed due to the large number of risk factors that contribute to its emergence. Some environmental risk factors are now described as diabetes predictors, with access to green spaces being an important factor to consider in urban settings. The purpose of this review is to investigate the relationship between exposure to greenspaces and outcomes like diabetes, obesity, and physical activity in the general population. A systematic review was conducted using the databases PubMed, Embase, and LILACS, as well as other sources. The search strategy was implemented between October 2020 and October 2021. There were both cross-sectional and cohort studies included. A pair of reviewers chose the articles, and data extraction was done using a data extraction sheet. A validated tool was used to assess the quality of the included studies. Finally, this review included 19 scientific articles. Evidence suggests that people and communities exposed to green spaces, particularly in their neighbourhoods, are less likely to develop T2DM, are less likely to be obese, and are more likely to engage in physical activity. T2DM can be delayed by using green spaces, increasing physical activity, and lowering the risk of being overweight or obese.
Diabetes mellitus • Physical activity • Obesity • Obesity • Overweight
Without a trace of treatment, Type 2 Diabetes Mellitus (T2DM) is a complex metabolic sickness described by ceaseless hyperglycemia. T2DM, which affects around 90% of diabetics and is characterised by beta-cell brokenness and insulin resistance, is the most well-known sort of diabetes. As per the Global Diabetes League, the worldwide predominance of T2DM in 2020 was 9.3, with a 95% certainty span (CI) (7.4–12.1), and it is projected to increase to 10.9%, with a 95% CI (8.4–14.1) by 2045, influencing 700.2 million individuals around the world. This commonness is projected to be higher in nations where economies move from low-to middle-class pay, revealing the social intricacies that should be considered while concentrating on this illness. T2DM imposes an enormous monetary weight on wellbeing frameworks all over the planet, which can be estimated by direct clinical costs, backhanded costs because of efficiency misfortunes, unexpected losses, and malicious impacts of diabetes on a nation's GDP. Global spending on this disease reached 1.33 trillion dollars in 2015, and by 2030, total spending on T2DM is expected to reach 8.39 trillion dollars [1, 2]. Because of the urbanisation cycle, 310.3 million individuals with T2DM live in metropolitan regions, addressing a commonness of 10.8%, while in rural regions the pervasiveness comes to 7.2%. This anomaly is more noticeable in low and middleincome countries.
Being overweight, obesity and physical inactivity have all been linked to the development of diabetes. T2DM risk factors include ethnicity, gender, socioeconomic status, age, malnutrition, glucose intolerance, and hypertension. Income and social position, education level, working conditions, health service access, and physical environment are structural and social determinants of health outcomes that create various conditions and exposures that have a clear impact on non-communicable chronic diseases such as T2DM, and their recognition enables healthcare workers and stakeholders to work in multidisciplinary spaces to design and implement public policies and health interventions. The authors proposed this theoretical scheme to explain the relationships between environmental, demographic, and health variables that can explain the unequal distribution of T2DM and provide a theoretical basis for the current systematic review.
Other risk factors have emerged to account for the socioeconomic gradients in T2DM prevalence. As a result, preventive measures emerge as a result of multisector work to reduce the prevalence of diabetes risk factors, particularly those that can be modified, such as overweight, obesity, lack of physical activity, and an unhealthy diet, through a combination of fiscal policies, laws, marketing strategy regulation, environmental policies, and urban planning changes, with an emphasis on social and environmental determinants with a multisector, promotional, and preventive approach [3].
T2DM is primarily determined by socioeconomic factors that influence urban exposure. In this regard, the relationship between T2DM prevention and urbanisation processes must be viewed as an environmental health factor. Living in an urban area was associated with a higher T2DM risk: Odds Ratio (OR) = 1.40, 95% CI (1.2-1.6), compared to living in rural areas, according to a meta-analysis that studied the influence of the built environment in urban areas on T2DM. Furthermore, the study found that environmental factors such as neighbourhood green spaces were associated with lower rates of T2DM. Furthermore, exposure to green spaces has been linked to increased physical activity, improved physical and mental health, and lower stress, allowing for increased social capital. Green spaces, in particular, have been studied and proposed as health determinants because their distribution varies across populations and has an impact on the population's health status and wellbeing [4].
Green spaces in the urban context can be defined as open spaces with natural elements such as parks, playgrounds, and recreation areas, both public and private, that the population can use for individual and social activities. These are referred to as "vegetated urban land". Although it is widely acknowledged that urbanisation reduces time spent in contact with nature, green spaces, forests, fields, street trees, and urban parks can play a protective role in the development of non-communicable diseases. In this sense, the possible theoretical pathways of green space exposure and health improvements are based on the reduction of air and noise pollution because greenspaces do not emit pollutants and also provide an acoustic barrier while reducing heat island effects, i.e., urban areas with more buildings than natural landscapes and higher temperatures than outlying areas. Green spaces also reduce stress, increase positive emotions, and allow for fatigue recovery, resulting in increased physical activity and a place for social contact [5].
Although this is not a pandemic study, we cannot ignore the potential effects of green space exposure and urban policy changes that must be discussed in light of the COVID-19 pandemic. In the context of the COVID-19 pandemic, diabetes and other non-communicable diseases have been linked to an increased risk of receiving a positive SARS-CoV-2 test and dying as a result of the virus's complications. T2DM, in particular, was linked to an increased risk of COVID19 relative risk (RR) = 2.38, CI (1.88-3.13) and mortality RR = 2.12, CI (1.44-3.11). Furthermore, T2DM and COVID-19 are referred to as "socially transmitted diseases," and it is widely accepted that environmental factors, such as urban green spaces, play a role in these conditions. Furthermore, it is critical to promote the preservation of green spaces and easily accessible urban park during COVID-19 (and any other pandemic) because it is beneficial to both physical and mental health, taking into account health recommendations to prevent COVID-19 transmission [6].
In this regard, some of the modifiable structural conditions relevant in this context are urban planning policies that can be directed to allow everyone to live in healthier environments and have access to green spaces close to home. Unfortunately, access to green spaces and urban parks is inequitably distributed, reflecting deep social inequalities in urban areas. This evidence suggests that environmental factors such as green spaces may have an impact on the appearance of T2DM. However, the limitations of the studies in terms of quality and quantity prevent us from inferring causality. The following study will examine recent scientific evidence to determine the magnitude of the effect that the exposure variable (green space) has on the prevalence of T2DM. It is worth noting that this study contributes to understanding the onset of T2DM from a socio-spatial perspective, with a focus on social determinants and consideration of the disease's biological mechanisms, such as immunological pathways related to microbial inputs that show a specific inflammatory reaction due to lower levels of Creactive protein and cytokines and higher levels and greater resistance to stress [7]. To the best of our knowledge, this is the first systematic review to investigate the relationship between green space exposure in urban settings and T2DM (and some of its risk factors), with the added benefit of broadening the inclusion criteria to non-English languages such as Spanish and Portuguese, which are frequently overlooked in systematic reviews.
The purpose of this systematic review was to examine the scientific evidence on green space and T2DM as the primary health outcomes, and obesity and physical activity as secondary outcomes. This study discovered various definitions of green space and greenness measurements. Distance to parks, Normalised Difference Vegetation Index (NDVI), used to measure living vegetation by the reflectance levels that the vegetation emits from the photosynthesis process, the density of trees in the neighbourhood, park areas per km2, geographic information system, postal code use, and selfreported questionnaires were all used to measure green space exposure. There is no agreement on which methodology is best for answering this research question [8]. It is critical to discuss the methodology spectrum to assess the validity of the green space measurement. As a result, subjective measures like questionnaires and self-reported data are typically less expensive and easier to implement than objective measurements like NVDI and other georeferenced methods.
Medical records, surveys, and blood tests were used to assess T2DM. Because of the causal pathway between these risk factors and T2DM, secondary outcomes such as physical activity and obesity were included in this systematic review.
In various contexts, the relationship between greenness and greenspaces has been studied. It implies that green spaces play an important role in protecting against air pollution, allowing us to avoid chronic inflammation processes [9]. This relationship's causal pathway also includes demographic factors such as age, gender, ethnicity, and socioeconomic status, as well as living context factors such as cultural factors, safety and infrastructure, local and regional policy, and rural or urban settings. These factors can moderate the opportunities for or barriers to the use of green spaces, which, if available, promote relaxation activities, physical activity, interaction with nature, and social interactions within green spaces, as well as group activities [10]. Furthermore, neighbourhood characteristics, such as green spaces, can help to promote or strengthen the city's social capital.
This systematic review agrees with other studies that focus on the built environment, including green spaces and health-related outcomes, emphasising the role of the urban context in chronic conditions and the importance of addressing inequalities to allow for a more homogeneous distribution of urban green spaces. Other studies have proposed that green spaces promote endocrinological effects and that nature plays a role in the inflammatory response and chronic conditions. There is also evidence supporting the idea that vegetation in the urban context contributes to improving human health and well-being by showing that the majority of people exposed to green spaces have a lower risk of T2DM and other risk factors such as obesity and sedentarism.
More primary studies, taking into account the type of green space exposure and the measurement of main outcomes such as diabetes, but also confounders, risk factors, precursors, and effect modifiers, are needed to properly isolate the effect. Because the findings of this systematic review revealed significant gender differences, these studies must include a gender perspective. Similarly, when analysing the results, ethnicity and other determinants should be taken into account. More research is needed to determine the social and biological links between green spaces and type 2 diabetes mellitus, particularly in low- and middle-income countries; to identify potential barriers to use and distribution inequities, and to encourage stakeholders to develop public policies that take into account urban and health factors to reduce the health impacts of chronic conditions such as T2DM. Using a characterization defined by the authors based on the National Institutes of Health's Quality Assessment Tool for Observational Cohort and Cross-sectional Studies, seven articles were found to be good, seven fair, and five were found to be poor in the quality assessment of the 19 studies included in this systematic review. As a result, the outcomes must be handled with caution.
One of the limitations that this study hoped to address was publication language bias, which was caused by a lack of non-English primary articles in other systematic reviews. Unfortunately, the search strategy used in this study yielded no non-English articles. On the same subject, the search strategy was unable to locate articles conducted in Latin America and Africa. Both of these issues highlight the importance of conducting primary research in those areas, especially given the high levels of inequality in both of these areas. Given a growing body of literature demonstrating its effects on noncommunicable diseases, the current urbanisation process must consider the distribution and protection of urban green spaces (NCDs). When examining the role of green spaces in current urban processes, it is important to recognise their impact on public health because they have a positive effect on the health of nearby residents not only in terms of scale, function, and accessibility, but also in vegetation cover, ecological dimension, and social and environmental quality. Different types of green spaces should be of interest to urban policymakers in terms of prioritising and safeguarding these areas, especially at a time when more research shows the benefits of green spaces, and especially when there are economic actors with a greater interest in large-scale real estate projects that do not consider protecting the exposures to green spaces.
There is substantial evidence that green spaces in urban settings protect against T2DM and other chronic health conditions such as obesity and sedentarism. People and communities who lived in areas with more green space and near parks with sports facilities had a lower risk of developing T2DM. Exposure to green spaces also reduced the likelihood of being obese and increased the likelihood of engaging in physical activity. Communities' access to proximal green spaces is restricted during the COVID-19 pandemic, resulting in poor air quality and high rates of respiratory diseases and other health outcomes, making neighbourhoods more vulnerable to poorer health outcomes and being disproportionately harmed by health costs and economic and social aspects of the COVID-19 pandemic that underpin those neighbourhoods' health conditions.
Citation: Pharasi D. A Systematic Review of the Association of Green Space Exposure with Type 2 Diabetes Mellitus, Physical Activity, and Obesity. Prim Health Care, 2022, 12(6), 445.
Received: 02-Jun-2022, Manuscript No. JPHC-22-75799; Editor assigned: 05-Jun-2022, Pre QC No. JPHC-22-75799(PQ); Reviewed: 17-Jun-2022, QC No. JPHC-22-75799(Q); Revised: 20-Jun-2022, Manuscript No. JPHC-22-75799(R); Published: 27-Jun-2022, DOI: 10.4172/2167-1079.22.12.6.1000455
Copyright: © 2022 Pharasi D.. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
