Modifying effect of urban parks on socioeconomic inequalities in diabetes prevalence: a cross-sectional population study of Madrid City, Spain

Background Evidence has shown contradicting results on how the density of urban green spaces may reduce socioeconomic inequalities in type 2 diabetes ( equigenic hypothesis ). The aim of this study is to test whether socioeconomic inequalities in diabetes prevalence are modified by park density. Methods We designed a population-wide cross-sectional study of all adults registered in the primary healthcare centres in the city of Madrid, Spain (n=1 305 050). We obtained georeferenced individual-level data from the Primary Care Electronic Health Records, and census-tract level data on socioeconomic status (SES) and park density. We modelled diabetes prevalence using robust Poisson regression models adjusted by age, country of origin, population density and including an interaction term with park density, stratified by gender. We used this model to estimate the Relative Index of Inequality (RII) at different park density levels. Findings We found an overall RII of 2.90 (95% CI 2.78 to 3.02) and 4.50 (95% CI 4.28 to 4.74) in men and women, respectively, meaning that the prevalence of diabetes was three to four and a half times higher in low SES compared with high SES areas. These inequalities were wider in areas with higher park density for both men and women, with a significant interaction only for women (p=0.008). Interpretation We found an inverse association between SES and diabetes prevalence in both men and women, with wider inequalities in areas with more parks. Future works should study the mechanisms of these findings, to facilitate the understanding of contextual factors that may mitigate diabetes inequalities. Data may be obtained from a third party and are not publicly available. Data are not publicly available as it contains information from Electronic Medical Records. Upon reasonable request to the Heart Healthy Hoods project, data could be available for researchers.