Neighborhood green space and childhood obesity during the COVID-19 pandemic: The role of socioeconomic status and urbanicity.

BACKGROUND

Childhood obesity remains a major global public health issue, exacerbated by the COVID-19 pandemic. Neighborhood green space represents a modifiable environmental factor, but its impact during pandemic disruptions and across socioeconomic and urban contexts remains limited. This study aimed to assess whether neighborhood green space exposure was associated with childhood obesity risk during the COVID-19 pandemic and explored effect modification by socioeconomic status (SES) and urbanicity.

METHODS

A longitudinal open cohort study was conducted using electronic health records from primary care providers in the Balearic Islands, Spain, from 2013 to 2022. The study included a total of 21,168 children aged 2-7 years in the pandemic period (2018-2022), 14,211 in the pre-pandemic "control" period (2013-2017), and 42,581 in the overall period (2013-2022). Children were normal weight or overweight at baseline, with obesity onset as the primary outcome. Neighborhood green space exposure was estimated at baseline by the normalized difference vegetation index (NDVI) at census tract level. Cox proportional hazards models assessed NDVI-obesity associations, stratified by area-level SES and urbanicity.

RESULTS

Childhood obesity incidence was 10.4% during the pandemic and pre-pandemic. Increased NDVI exposure was associated with lower obesity risk across all periods (pandemic: HR per interquartile range increase, 0.88 95% CI: 0.80-0.97; pre-pandemic: HR, 0.80, 95% CI: 0.70-0.91; and overall study period: HR, 0.86, 95% CI: 0.80-0.92). Interaction tests showed no statistically significant differences in NDVI-obesity associations between pandemic and pre-pandemic periods. Protective associations were stronger in the least deprived and urban areas. This pattern was consistently observed across periods.

DISCUSSION: In this study, greater neighborhood greenness was consistently associated with lower childhood obesity risk, a benefit that was maintained during the COVID-19 pandemic; however, these protective associations varied across socioeconomic strata and urban contexts, highlighting persistent disparities.