Alice Dalton UK Researcher: Your Heart and Greenspace


Today it is my pleasure to introduce to you Alice Dalton. 

Alice is a Senior Research Associate working in the Norwich Medical School at the University of East Anglia in the UK. Alice is a geographer and she is interested in understanding the health implications of how we interact with the environment around us. Recently, she has been exploring the role that neighbourhood green space may play in protecting people from certain health outcomes, such as cardiovascular disease.

Welcome Alice Dalton so nice you have you here with us. Would you like to tell us a little about where you are located in the UK Alice?

I am in a city called Norwich (which rhymes with porridge!). We are on the most eastern tip of England. It is a beautiful place. It is the most complete medieval city in England, and it is a very creative, vibrant, and fun place to live. It has been rated as one of the best places to live in the UK for the last three years by The Times newspaper.  We are lucky to be surrounded by the most beautiful country and cityscapes – we’ve got green and blue spaces, woodlands, open spaces, and the waterways of the Broads National Park, and many beaches nearby on the coast. It is a good place to be.

 

Would you please tell us your story Alice?

 

As you have said, I am a geographer, and working with a small team here in the Medical School at the university. We are really interested in population health. It is a discipline that is interested in promoting well-being and preventing ill health across populations and groups within those populations – as opposed to focusing on individuals and diagnosing and treating illness in those individuals.

 

We are interested in how people interact with their environment around them and the impact this has on their health. By environment I mean anything green, such as an urban park or woodland, and we are also interested in looking at anything built, such as the street networks, buildings and cycle networks.

 

I have always been interested in geography and how we interact with the planet. I did an undergraduate degree at the University of Reading in England. When I was finished there I worked for an engineer, out and about mapping things outside… along rivers…that was brilliant fun. And while I was there, I did a Master’s degree in more mapping and science. And during that time, I developed an interest in research. I liked to go out and investigate, to explore a problem, and a research question. 

 

Then I decided to do a PhD at the University of Bristol (so that is the other side of England) on the western side of England. That was in sustainable urban development. While I was doing that I decided that, ‘yes, a research career is for me’. This is definitely really interesting.

 

I applied to an advert here for a job at the University of East Anglia. That was ten years ago now. I was interested in applying what I had learned into population health behavior and eventually moving to the Medical School and looking at public health.

 

I can see how a medical school would really value your knowledge and the tools that you use as a geographer. Could you tell us a little bit about those?

 

We have a range of tools at our fingertips here. The main thing that I use is called “geographic information systems (GIS)”. We use these systems to understand how we interact with our environment.

 

Now that sounds like a bit of a mouth full, but the first example of GIS was a British physician called John Snow back in the 19th century. He lived in Soho in London and he was very interested in the causes of the cholera outbreak in Soho. There were lots of deaths and he was trying to work out what was going on here on a population level. What he did was map the location of all the streets and houses in this area. Then he mapped the locations of water sources – where people went to collect their fresh water. He noticed that there was a cluster around one particular water pump. He could attribute the cholera cases to this one pump. The map that he created is known as the “map that changed the world.” He created this link between water borne disease and public health for the first time. Dr John Snow was considered one of founders of epidemiology as a result. Epidemiology is the study of patterns of health and disease at the population level…rather than at the individual level. So that is an early example of how you can use a map to overlay different aspects to explore a problem and potentially come up with a solution.

 

Of course, these days we have very sophisticated software and big data sets where you can overlay layers of mapping. You can analyze and use statistics to look different aspects of the problem. 

 

 

Another tool that I use is GPS. By fitting people with GPS trackers, or these days even mobile phones have GPS trackers built into them, you can then find out where people are going and how long they stay there. You can bring together these two tools. You have your system of storing and analyzing all this data.  When you bring these two systems together (GIS and GPS) you can really begin to understand human behavior. You can use this to inform future strategies to encourage healthier behaviors. Finding these patterns can be really exciting.

 

Thank you for explaining the usefulness of geography and of GIS and GPS for looking at disease patterns Alice. What compelled you to get involved in this work Alice?

 

Our team at UEA (University of East Anglia), we specialize in how people interact with their environment. We look at the social, the natural, the cultural – everything around this – and the impact that this might have on their mental and physical health. And as I have said, I am interested in using these tools GPS and GIS to understand this a bit more… to help better design the environments around us.

 

 

There is a lot of research out there that suggests that living near greenspace may improve out mental health and reduce the risk of developing various health conditions such as cardiovascular disease and diabetes.

 

However, a lot of the research is based on cross sectional comparisons: a snapshot in time, or an end point, such as deaths from cardiovascular disease at a particular time. It is difficult to draw conclusions on that data because you can’t explain what exposures that they have had or what kind of experiences in their lifetime that may have led to that health outcome. It is very difficult to say why things are happening. We had access to a large longitudinal cohort study.

 

I love that your research followed over 25 thousand people (women and men) over a 14-year period of time. Especially when you look back and see that women and older adults might have been missed out in these research studies in the past…very valuable. Will you tell us about your study?

 

The study that we looked at was called the “European Prospective Investigation of Cancer.” So, this was a large multi-centre European study with eleven different countries involved. Each country carried out its sub-analysis and collection of data.

 

The study was primarily interested in looking at diet and lifestyle factors in older people with cancer. The study is still ongoing now. It has followed the same people since the early 1990s.

 

Norfolk in England was chosen as one of the areas, partly because fewer people in older age groups are moving out of this county. We have a relatively stable population. Also there is one main general hospital that serves the population so it is a bit easier to follow up people when you can coordinate it from one central place.

 

The aim of the project overall was to provide data-based evidence for health policies. We can work out how to prevent disease onset and help maintain health and independence in older people.

 

We were not involved when that project was first set up, but over time we became involved because we saw this huge dataset… like you said, there were over 25 thousand people who were recruited in the beginning. We thought, well, this would be a really good opportunity to explore patterns and changes in physical activity in older people. …we could look at what determines those patterns and the consequences of those patterns.

 

Together with Cambridge University, which was involved in setting up the project initially, we went to the National Institute for Health Research – which is the research arm of the National Health Service (NHS) – we requested and received funding for what we called “The Life-Long Health and Well Being Project.” 

 

Some of the original research that we did showed that there was an association with people living in greener areas with physical activity. People who lived in greener areas experienced less of a decline in physical activity as they got older. We thought this is very interesting. The next stage we wanted to look at health outcomes – what type of a role greenspace and physical activity might play.

 

We looked at two health outcomes: diabetes and cardiovascular disease. We have some really good robust measures for those in the dataset, which were hospital verified. We had data on incident disease, so we knew the dates when people developed those diseases. We could do some complex modelling rather than just looking at the date that a person died. This way you can look at when a disease happens in the life course.

 

We had this data and we had information about where people lived, and we could objectively look at the amount of green space around the neighborhood. We chose this as a measure because previous studies had suggested that greenspace in people’s immediate living environment was important. We were able to map that using our geographic information systems (GIS). And then we looked at disease outcomes in these people, and by conducting something called “survival analysis” we were able to explore time to disease onset and exposure to green space. And we looked at physical activity as a potential mediator in that relationship; i.e. a potential mechanism by which somebody may or may not have different chances of developing a disease. You know, if someone is more active, might this reduce their chance of having a disease?

 

When we looked at this, our conclusions were that greenspace offered a protective role but this was not via the mechanism of physical activity.

 

What do you find interesting about that?

 

Participants living in the greenest locations have a 7% lower relative risk of developing cardiovascular disease at follow-up when compared to people living in the least green areas.

 

What is particularly interesting, is that that result remained even after we considered potential factors such as age, gender, body mass index, prevalent diabetes, and socioeconomics. So even after we considered all those different factors, green space still continued to have a protective role.

So, that was really exciting because a lot of this is often associated with other kinds of risk factors, but we were able to allow for all of that and say “hey, greenspace is still important here.”

 

Fascinating. Wonderful work.

 

The thing that we found surprising with this study is we thought, well, this association might be with physical activity because if someone lives in a greener area, they might be more physically active there. So maybe they might go out for a walk or a run. We thought that that might be the mechanism that was leading to the health outcomes. But when we tested physical activity as a mediator, we found that it didn’t explain those associations. So that did surprise us.

 

Some of the research before showed that physical activity was a mediator and other research showed that it wasn’t – so we were not sure how this was going to go.

 

So, it wasn’t people being active that led to a decrease in developing cardiovascular disease.

 

Therefore, this opens up the question, what is it about greenspace that reduces the likelihood of developing cardiovascular disease? And that is the million-dollar question.

 

Now you Alice are in a medical school, is this information trickling down into doctor’s offices?

 

We know that green open spaces are important for health and well-being. The evidence is overwhelming. There is an association between greenspace and health and well-being. In research, there are a variety of hypotheses about why this might be the case. As we found out from this study, our research shows that physical activity is not one of those mechanisms, but it is really difficult to drill down to what it is and what is out there. There is a vast array of studies out there, all using different types of measurement, drawing different types of conclusions, and looking at groups of people, and these relationships are very complex, and to generalize is very difficult. That has proved a challenge.

 

Mechanisms might be different for certain areas or groups. People with different long-term conditions might have different requirements from greenspace, which might not be applicable elsewhere. I suppose the tricky thing is without knowing what specific mechanisms are, it is difficult for health professionals to give out the best evidence-based advice. The same is true for giving out advice to planners and local authorities to design better environments.

 

This research suggests that other meditators might be present. We need to understand, for example, if seeing greenspace is the thing that is most beneficial, then we might need to enable people to see greenspace more. So that might be done by improving viewpoints or aesthetics for example.

 

Or perhaps on the other hand, it is that greenspace offers the biggest benefit because it strengthens our immune system so therefore maybe we need to increase access to places that are rich in biodiversity. Or maybe it is that greenspace gives people the opportunity to get out and meet people and talk to each other to reduce social isolation, so we might need to create opportunities for that. And it may be that not just one of these is at play, there might be a whole range of mediators and they may be dependent on each other…they might be intertwined. And you have the complication of mediators counteracting each other. Perhaps someone has green space on their door-step, but they might associate crime with it or allergy or perhaps gentrification has made that greenspace less usable for them. These might all be in competition with the positive mediators. So, I suppose this is the first thing to say is that this is very complex and it is difficult for health professionals to know exactly what the best thing to do is. And that remains a challenge.

 

And I did mention earlier that how these things are measured is key. That makes a difference in what we can conclude. Different researchers have used different types of measurement. For example, how you measure someone’s physical activity – we used leisure and work-based activity on a four-point scale – from very low to very high activity. Other studies might have a continuous scale where you get the number of steps that someone has made in a day. We face these complexities as well.

 

The thing that was interesting was that we had our objective measure of greenspace, so we mapped exactly how much greenspace was available on someone’s doorstep, but perhaps what might be important is how people perceive that greenspace. They might see it as a very pleasant area, but on the other hand, they might not.

 

But as far as all this complexity exists, we do know that greenspace is important and it should be preserved. This does remain a challenge as well. Developers in the UK are required to provide a certain amount of greenspace when they build new housing. This may not always work as it should. For all of us, parks and greenspaces are vulnerable to local authority cuts, and lack of spending.

 

There are signs of promise here because the UK government recently has put funding into supporting and maintaining greenspaces by government pots of money or lottery funding.

 

I think that COVID has really highlighted the importance of how having access to local green spaces plays a really important role in people’s lives. Securing that funding is key.

 

If we step back, something that is underpinning all of this, which is of concern to doctors and public health, is regarding health inequalities – differences in health that are unjust or preventable. These inequalities might be by place of residence, ethnicity, occupation, gender, religion, and so on. Often the people that stand to gain the most from using greenspace, might be the least likely to use these places.

 

Whatever we do or whatever doctors prescribe or the national organizations suggest, we have got to be really careful not to widen these inequalities. We have to make sure that those who are most in need can benefit.

 

An example here is walking groups in here in England. Walking groups have been funded by two national charities here. Different groups go out and walk together for the health benefits. Originally this was based on a model where you have people who were less likely to go out walking and might have long-term conditions, and they might get taken out for a short walk – to start to build that confidence and ability up. But then recently, and this is something that we have discovered in Norfolk, that there were groups of keener people that were getting fitter and fitter and they are potentially leaving the less able and slower people behind. So, the model in Norfolk has been completely turned on its head and we are completely rethinking the way that these are run. So maybe these become more of a befriending service than a walking group. That is showing some really positive signs because that leads on to the potential for social prescribing rather than going through primary care for solving problems.

 

Using social prescribing to sign post people to local walking groups or other outdoor activities, that has real potential reduce the burden of disease on the population and the health care system.

 

Great ideas.  We started a walking group in our seniors’ centre. We all started out in one group but now new and old friends are going out that are at the same walking level.  That just evolved. But it is nice to hear you say the same things, and you recognize patterns.

 

There is so much pressure on GP time that these processes have to be nice and efficient and quick. And you really need buy-in from GPs as well. I think there is some evidence that that is happening – that these processes are being streamlined – but we do have a way to go.

 

That is great – maybe we are looking at support groups that a primary physician can refer to in the future. What excites you about the future and what are the next steps in this study Alice?

 

As part of the collection process for these people in Norfolk, they are on their fifth health check. They come in to see the nurse and they are assessed on different elements. In health check four, there were four thousand people in the study who wore GPS receivers and activity tracking monitors. This was at the twenty year follow up – so twenty years into the study they wore these devices. Having those two devices, we are able to see where people have been going and how active they were. We can see what type of locations people are using, and where people are active, so this gives us an incredibly rich dataset. There aren’t many datasets out there that can tell us this much information.

 

We have just finished putting all that information together. We know where people are active and how they interact with their local areas. This will give us further insight into how the neighborhood green space is used and how it might be supported for people’s health and well- being. And then we can think about how we might support healthy behaviors as people age. This guides the advice that public health professionals and national organizations might give out. So, it is really exciting that we are able to do this with the data.

It is exciting…really exciting what you are doing.

So, watch this space! 

 

Before I give your research contact information is there anything that you would like to add before we close Alice?

This research is constantly evolving. People are very interested in green space and interested in how we use it, so there is new research being published all the time. This is a fast-moving field.

We will be following your research.

Brilliant. Thank you.

Listeners if you would like to follow Alice Dalton’s research you can find her at

https://people.uea.ac.uk/a_dalton

Her email is A.Dalton@uea.ac.uk

You can find her paper ‘Residential neighbourhood greenspace is associated with reduced risk of cardiovascular disease: A prospective cohort study’, here: https://doi.org/10.1371/journal.pone.0226524

Thank you again Alice. In spite of all the complexities of research, thanks to your work we know that we are getting 7% goodness by just being outside in greenspace. Listeners, please check out my book and workbook Take Back Your Outside Mindset: Live Longer, Prevent Dementia, and Control Your Chronic Illness and look for this episode’s show notes on my website Treesmendus.com. 

Listeners thank you for listening to the end. Please rate this episode if you have a minute to show your support for this show. Maybe next time you are outside place your hand on your heart, think of all the ways you might be helping your heart by just being outside close to trees, shrubs, and grass. Remind yourself that there are innovative researchers like Alice Dalton who are using many state- of – the art tools to help shape our understanding of how our minds and bodies to respond to natural places … This is a good thing, because if you ask me, we all need a little more of Your Outside Mindset.