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Background: The food environment has been hypothesized to influence cardiovascular diseases (CVD) such as hypertension and coronary heart disease (CHD). This study determines the relation between fast-food outlet density (FFD) and the individual risk for CVD, among a nationwide Dutch sample.Methods: After linkage of three national registers, a cohort of 2,472,004 adults (≥35 year), free from CVD at January 1st 2009, and living at the same address for ≥15 years was constructed. Participants were followed for one year to determine incidence of CVD, including CHD, stroke and heart failure. FFD within 500m, 1000m and 3000m from residential addresses was related to CVD using logistic regression, stratifying models by degree of urbanisation and adjusting for age, sex, ethnicity, marital status, comorbidity, neighbourhood-level income and population density.Results: In urban areas, fully adjusted models indicated that the incidence of CVD and CHD was significantly higher within 500m buffers containing one or more fast food outlets compared to areas without outlets. An elevated FFD within 1000m was associated with a significantly increased incidence of CVD and CHD. Evidence was less pronounced for 3000m buffers, or for stroke and heart-failure incidence.Conclusions: Elevated FFD in the urban residential environment (≤1000m) was related with an increased incidence of CVD and CHD. To better understand how FFD is associated with CVD, future studies should account for a wider range of lifestyle and environmental confounders than was achieved in this study.