Identifying Co-occurring Neighbourhood Environmental Patterns and Their Association with Health Behaviours in a Dutch Urban Population at High Cardiometabolic Risk

Background Most studies examine environmental determinants of health in isolation, neglecting the complex interplay between neighbourhood characteristics. Furthermore, research has primarily focused on general populations, leaving a gap in understanding how environmental factors relate to health behaviours in high-risk groups. This study aimed to (1) identify patterns of co-occurring neighbourhood characteristics related to the food environment, green space and walkability in a highly urbanised Dutch city; and (2) explore whether these neighbourhood patterns are associated with weight status, diet quality and physical activity among patients at high cardiovascular risk. Methods This cross-sectional study used baseline data from the Healthy Heart study in The Hague, Netherlands (N = 475 participants from 73 postal codes). Twenty-three indicators across food environment, green space and walkability domains were assessed at two spatial scales. Correlation analyses examined intercorrelations among indicators and with contextual characteristics. Neighbourhood patterns were identified using principal component analysis (PCA), and associations with health outcomes were examined using multivariable regression, adjusted for individual and neighbourhood confounders. Results Several environmental indicators were strongly intercorrelated and closely linked to contextual neighbourhood characteristics, particularly population density and absolute food retailer densities, even within the most highly urbanised areas. PCA identified four neighbourhood patterns. Only the “Relative food environment advantage” pattern was robustly associated with lower odds of being overweight, but also counterintuitively with lower fruit and vegetable diet quality. There was some indication of effect modification by neighbourhood socioeconomic position for this pattern. Conclusions Neighbourhood characteristics cluster into structured patterns in urban settings. Food environment measures remained coupled to population density even within high-density areas, fundamentally challenging independent effect estimation. Modest, paradoxical associations suggest limited environmental influence on lifestyle behaviours and weight in medically supervised high-risk populations.