Moving into the neighborhood: thinking beyond individuals to improve cardiovascular health.

1 To achieve this ambitious goal, there is an appropriate strong focus on counseling and educating our patients about hyper-tension, diabetes mellitus, and healthy behaviors. However, there is an additional opportunity that may ultimately be critical to our success. Too often neglected, contextual factors also have a strong influence on cardiovascular risk. By contex-tual variables, we mean the environment in which we live, to include the structural or built environment (eg, buildings, sidewalks , parks, recreational facilities) and the social environment (ie, the trust and bonds between community members). Emerging research is showing that these factors may influence risk through their effect on health behaviors and risk factors, as well as through other pathways. Importantly, these factors may be essential in efforts to shift the risks and improve the health of populations. In this issue of Circulation: Cardiovascular Quality and Outcomes, we have an example of the emerging literature directing our attention toward contextual factors associated with cardiovascular health. Unger et al 2 report the association of a range of neighborhood characteristics with a global measure of cardiovascular health using data from the Multi-Ethnic Study of Atherosclerosis (MESA). The MESA is well designed to examine the environmental context on health because it includes a cohort of both sexes and 4 race/ ethnic groups without clinical cardiovascular disease at the time of enrollment from 6 communities in different regions of the United States and captures information about the par-ticipants' cardiovascular risk and perception of their neighborhood along with current and prior addresses that can be used to identify elements of the neighboring structural environment. Although initial studies from MESA focused mainly on methods to identify subclinical cardiovascular disease, more recent studies from this group report the relationship between the environment and cardiovascular disease. Although previous MESA studies mostly addressed the relationship between the structural and economic environment and specific disease or risk factors, such as hyper-tension, 3 obesity, 3 coronary disease, 4 or physical activity, 5 Unger et al 2 advance the research further by examining the association between the American Heart Association's comprehensive construct of cardiovascular health and multiple facets of a neighborhood, including the built, social, and economic environments. Their cross-sectional analysis revealed that density of stores selling healthy foods, density of recreational facilities, perceived walkability, and neighborhood socioeconomic status were associated with cardiovascular health, independent of individual sociode-mographic characteristics. These findings may help explain why the National Research …