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Peer-reviewedCC BY-NC-NDEnvironmental research

Neighborhood Walkability, Green Space, and Incident Hip Fracture among Older U.S. Adults: The Cardiovascular Health Study

  • Rachel E. Elam1,2
  • Petra Bůžková3
  • Howard A. Fink4,5
  • Joshua I. Barzilay6
  • Eric J. Roseen7
  • Jane A. Cauley8
  • John A. Robbins9
  • Laura D. Carbone1,2
  • Gina S. Lovasi10
  • Kenneth J. Mukamal11
11 affiliations
  1. 1Division of Rheumatology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
  2. 2Edward Hines, Jr. VA Health Care System, Hines, IL, USA
  3. 3Department of Biostatistics, University of Washington, Seattle, WA, USA
  4. 4Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, MN, USA
  5. 5Department of Medicine, University of Minnesota, Minneapolis, MN, US
  6. 6Division of Endocrinology, Kaiser Permanente of Georgia, Atlanta, GA, USA
  7. 7Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
  8. 8Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
  9. 9Department of Medicine, University of California Davis, Davis, CA, USA
  10. 10Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
  11. 11Department of Medicine, Beth Israel Deaconess Medical Center, Brookline, MA, USA
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Abstract

PURPOSE: Neighborhood walkability and green space are associated with walking behavior and physical activity, but evidence linking them to fracture is limited and inconsistent, and potential sex differences remain understudied. We evaluated associations of neighborhood walkability and green space with incident hip fracture in older, community-dwelling U.S. adults. METHODS: We conducted a prospective cohort study of adults aged ≥65 years from the Cardiovascular Health Study (CHS). Neighborhood exposures were defined using 1-km radial buffers around geocoded residential addresses from 1992 to 1993 (baseline). Walkability was the sum of standardized population and walkable destination densities. Green space was the proportion of satellite-derived green land cover. Hip fractures were prospectively ascertained over 12 years using International Classification of Diseases, Ninth Revision (ICD-9) codes from hospital discharge abstracts. Cox hazard models adjusted for individual-level (age, sex, race, weight, height, smoking status, current heavy alcohol use, medication use, diabetes, renal function, marital status, education level, annual household income) and neighborhood-level (median household income, median value of owner-occupied housing, proportion of persons in managerial/professional occupations) covariates evaluated associations, overall and by sex. RESULTS: Among 3676 participants (58% women), 359 experienced hip fracture over a median 10-years observation. Greater neighborhood walkability was significantly associated with lower hip fracture incidence among women (hazard ratio per 1 standard deviation increase of 0.72 [95% confidence interval, 0.53-0.98]), but not overall or among men. Neighborhood green space was not significantly associated with hip fracture. CONCLUSION: Greater neighborhood walkability, but not green space, was associated with lower hip fracture risk among older women.

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Cite

BibTeXRIS
BibTeX
@article{elam2026neighborhood,
  title = {{Neighborhood Walkability, Green Space, and Incident Hip Fracture among Older U.S. Adults: The Cardiovascular Health Study}},
  author = {Rachel E. Elam and Petra Bůžková and Howard A. Fink and Joshua I. Barzilay and Eric J. Roseen and Jane A. Cauley and John A. Robbins and Laura D. Carbone and Gina S. Lovasi and Kenneth J. Mukamal},
  journal = {Environmental research},
  year = {2026},
  month = oct,
  doi = {10.1016/j.envres.2026.125875},
  url = {https://doi.org/10.1016/j.envres.2026.125875},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Neighborhood Walkability, Green Space, and Incident Hip Fracture among Older U.S. Adults: The Cardiovascular Health Study
AU  - Rachel E. Elam
AU  - Petra Bůžková
AU  - Howard A. Fink
AU  - Joshua I. Barzilay
AU  - Eric J. Roseen
AU  - Jane A. Cauley
AU  - John A. Robbins
AU  - Laura D. Carbone
AU  - Gina S. Lovasi
AU  - Kenneth J. Mukamal
PY  - 2026
DA  - 2026/10/10
JO  - Environmental research
DO  - 10.1016/j.envres.2026.125875
UR  - https://doi.org/10.1016/j.envres.2026.125875
AB  - PURPOSE: Neighborhood walkability and green space are associated with walking behavior and physical activity, but evidence linking them to fracture is limited and inconsistent, and potential sex differences remain understudied. We evaluated associations of neighborhood walkability and green space with incident hip fracture in older, community-dwelling U.S. adults. METHODS: We conducted a prospective cohort study of adults aged ≥65 years from the Cardiovascular Health Study (CHS). Neighborhood exposures were defined using 1-km radial buffers around geocoded residential addresses from 1992 to 1993 (baseline). Walkability was the sum of standardized population and walkable destination densities. Green space was the proportion of satellite-derived green land cover. Hip fractures were prospectively ascertained over 12 years using International Classification of Diseases, Ninth Revision (ICD-9) codes from hospital discharge abstracts. Cox hazard models adjusted for individual-level (age, sex, race, weight, height, smoking status, current heavy alcohol use, medication use, diabetes, renal function, marital status, education level, annual household income) and neighborhood-level (median household income, median value of owner-occupied housing, proportion of persons in managerial/professional occupations) covariates evaluated associations, overall and by sex. RESULTS: Among 3676 participants (58% women), 359 experienced hip fracture over a median 10-years observation. Greater neighborhood walkability was significantly associated with lower hip fracture incidence among women (hazard ratio per 1 standard deviation increase of 0.72 [95% confidence interval, 0.53-0.98]), but not overall or among men. Neighborhood green space was not significantly associated with hip fracture. CONCLUSION: Greater neighborhood walkability, but not green space, was associated with lower hip fracture risk among older women.
SN  - 0013-9351
SN  - 1096-0953
ER  -