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. 2025 Apr 18;23(1):228.
doi: 10.1186/s12916-025-04060-8.

The role of environmental access to exercise opportunities in cardiovascular mortality: evidence from a nationwide study

Xiaowen Wang #  1   2 , Yongshi Gu #  3 , Ying Wang #  4 , Yuqing Qiu  3 , Tianling Chen  3 , Philip K Hopke  5   6 , Kai Zhang  7 , Shao Lin  8 , Yanji Qu  9 , Ziqiang Lin  10 , Xinlei Deng  11 , Jie Sun  4 , Shuming Zhu  4 , Xueqing Deng  4 , Sizhe Li  4 , Xian Lin  4 , Zhicheng Du  12 , Yuantao Hao  13 , Wangjian Zhang  14
Affiliations

The role of environmental access to exercise opportunities in cardiovascular mortality: evidence from a nationwide study

Xiaowen Wang et al. BMC Med. .

Abstract

Background: Environmental access to exercise opportunities plays a crucial role in determining the level of physical activity within a population. However, it is unclear how environmental factors contribute to disparities in physical activity and health outcomes. We explored the associations between county-level access to exercise opportunities and cardiovascular disease (CVD) mortality across US counties.

Methods: We conducted an ecological analysis using aggregated data from two primary sources: the County Health Rankings and Roadmaps data and CDC WONDER mortality data. We compared county-level age-adjusted CVD mortality across county-level quartiles of access to exercise opportunities and physical inactivity. Stratification was performed based on age, sex, race, and urbanization variables. The rate ratio (RR) for CVD mortality was also calculated using generalized linear models.

Results: We observed significant variations in CVD mortality across different levels of exercise opportunities access and physical inactivity, which was consistent across all demographic subgroups (P < 0.001). Access to exercise opportunities was significantly associated with a reduced risk of CVD mortality (RR = 0.93 [0.91-0.95]), and the association was most pronounced for acute myocardial infarction (AMI) mortality (RR, 0.80 [0.76-0.85]). The county-level physical inactivity was significantly associated with an increased risk of CVD mortality (RR, 1.16 [1.14-1.17]), especially for ischemic heart disease (IHD) (RR, 1.35 [1.31-1.38]) and AMI (RR, 1.32 [1.25-1.38]). All demographic subgroups demonstrated similar benefits in reducing the risk of CVD by improving the county-level indicators of physical activity.

Conclusions: Counties have the potential to make significant environmental strides in improving the cardiovascular health of their populations by enhancing access to exercise opportunities in the context of urbanization.

Keywords: Access to exercise opportunities; Cardiovascular disease; Nationwide study; Physical inactivity.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: The authors declare no competing interests. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
The US county-level physical activity value and cardiovascular disease. A Counties by access to exercise opportunities index value; B counties by physical inactivity index value; C counties by age-adjusted cardiovascular disease mortality rates per 100,000 among adults. Q indicates quartile
Fig. 2
Fig. 2
Association of A access to exercise opportunities value and B physical inactivity value with age-adjusted mortality rates for specific cardiovascular disease, 4th (highest) value versus 1st (lowest) value. Model 1 was adjusted for year. Model 2 was additionally adjusted for percentage of female, percentage of Hispanic, percentage of rural population, percentage of population over the age of 65 years, percentage of uninsured population, ratio of population to primary care physician, household income inequality, adults smoking prevalence, obesity prevalence, and diabetes prevalence
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