See Article by Jones et al

Zoning is not an obvious intervention to improve cardiovascular outcomes, but, as the primary method of land use planning, it is important for population health. If we hope to achieve health equity and improve the health of all populations, we must look beyond the usual suspects. Zoning policies determine what goes where and for what purposes land can be used. These policies shape built environments and the distribution of and access to health-promoting resources.¹ For example, zoning can be health promoting when it is used to create dense walkable communities that foster physical activity and social connectedness. On the other hand, zoning policies have also disproportionately placed landfills and commercial hazardous waste facilities near communities of color increasing their exposure to environmental toxins that are harmful to their health.

Most of the zoning and health literature has focused on zoning’s relationship to built environments and physical activity or exposure to environmental hazards due to zoning. Less attention has been paid to how zoning influences health through its ability to shape housing environments. Zoning determines what types of and how many homes can be built in a neighborhood by outlining minimum lot sizes, minimum square footage requirements, building height limits, and other related factors. Zoning policy has spatially concentrated both poverty and wealth in certain neighborhoods, decreased access to affordable housing, and created racial residential segregation.² The contribution to residential segregation is especially important given that racial residential segregation, a product of structural racism, is a root cause of racial disparities in cardiovascular outcomes.³

Zoning policy has been cited as a major barrier to increasing the supply of affordable housing.⁴ Lack of access to affordable housing is associated with a decreased ability to pay for health care and other essential needs as well as poorer physical and mental health outcomes.⁵ Because of decreased federal and state funding for affordable housing programs, local governments are increasingly burdened with providing funding for and increasing the supply of affordable housing.⁶ Inclusionary zoning (IZ) policies are one policy tool used by local governments to increase the share of affordable housing in their jurisdictions. In addition to creating more affordable housing, IZ policies may have larger social benefits such as socioeconomic integration, increased access to healthy food, and less exposure to environmental toxins and gun violence.⁷ Through their ability to increase access to affordable housing and influence other health determinants, IZ policies can affect modifiable risk factors important for improved cardiovascular outcomes. Although zoning is recognized as being important for health, there is little empirical research on the population health effects of IZ and other zoning policies.

In this issue of Circulation: Cardiovascular Quality and Outcomes, Jones et al⁸ build on this important area of research by exploring the association between IZ policies and cardiovascular outcomes at the city-level. In this study, the authors found that the presence of an IZ policy was associated with a 0.18 percentage point lower prevalence of high blood pressure, 0.59 percentage point lower high cholesterol prevalence, and a 0.27 percentage-point lower prevalence of taking blood pressure medication. IZ policies are not homogenous and vary greatly across programs. The authors utilize this variation to examine which characteristics of IZ programs are associated with cardiovascular outcomes. The authors found that mandatory IZ programs, the amount of fees collected, focus on rental development, not providing developer incentives, the ability to preserve and rehab housing, and devoting a larger percentage of development to affordable housing were significantly associated with cardiovascular outcomes.

Jones et al also determined that cities that implemented IZ policies were different from cities that did not in significant ways. The authors found that cities with IZ policies had better cardiovascular outcomes, higher labor force participation, lower poverty rates, and higher median incomes. Previous research has also found that cities that adopt IZ policies have higher shares of rent-burdened households, smaller populations, higher housing densities, younger and more college educated populations, and state policy environments that mandate, authorize, or allow localities to implement IZ policies.⁹ State-level policies around IZ are particularly important given that state preemption of local IZ policies is significantly associated with poorer health outcomes.¹⁰ The Jones et al study only accounted for the share of rent-burdened households in their study. An important limitation of the study is the inability to determine if the relationship between IZ and cardiovascular outcomes is explained by some of these unobserved factors that prompted the adoption and implementation of IZ policies. Future work should incorporate some of these unobserved factors to better understand how and why IZ relates to cardiovascular outcomes.

People of color are disproportionately burdened by poor health outcomes, rising rents, and housing policies that impede their ability to obtain safe, quality, and affordable housing.¹¹ The authors note that their findings bolster support for the importance of affordable housing policies as a tool for reducing or eliminating racial and socioeconomic disparities in cardiovascular disease, but their analysis did not explore the racialized effects of IZ policies. They controlled for the proportion of residents that are racial minorities in each city and did not include any variables related to racial residential segregation. However, their study does provide evidence for the role of income inequality in the relationship between IZ and cardiovascular health by including the Gini index in their multivariate models. The authors found that rising income inequality was associated with a higher percentage point prevalence of high blood pressure, high cholesterol, taking high blood pressure medicine, and higher CHD. Future work should explicitly examine how the presence and characteristics of IZ policies are related to racial disparities in cardiovascular outcomes.

Jones et al have made an important contribution to the literature about the social benefits of IZ policies and laid the groundwork for future research exploring how IZ policies and broader zoning policy can be used to improve cardiovascular health. The positive associations between the presence of IZ policies and better cardiovascular outcomes, as well as significant differences between cities that adopt and implement IZ policies and cities that do not, highlight the importance of looking upstream to improve health. Zoning and land use regulation policy deserve more attention as modifiable policy levers for improving cardiovascular outcomes and reducing racial and socioeconomic health inequity.

Disclosures None.

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

For Disclosures, see page 954.

见琼斯等人的文章

分区不是改善心血管结果的明显干预措施，但作为土地利用规划的主要方法，它对人口健康很重要。如果我们希望实现健康公平并改善所有人群的健康，我们必须超越通常的怀疑。分区政策决定了土地的用途和用途。这些政策塑造了建筑环境以及促进健康资源的分配和获取。¹例如，当分区用于创建促进体育活动和社会联系的密集步行社区时，它可以促进健康。另一方面，分区政策也将垃圾填埋场和商业危险废物设施不成比例地放置在有色人种社区附近，增加了他们接触对他们健康有害的环境毒素的机会。

大多数分区和健康文献都集中在分区与建筑环境和身体活动或由于分区而暴露于环境危害的关系上。对分区如何通过塑造住房环境的能力影响健康的关注较少。分区通过概述最小地块大小、最小平方英尺要求、建筑高度限制和其他相关因素来确定社区中可以建造的房屋类型和数量。分区政策在空间上集中了某些社区的贫困和财富，减少了获得经济适用房的机会，并造成了种族居住隔离。²鉴于种族居住隔离是结构性种族主义的产物，是心血管结果中种族差异的根本原因，因此对居住隔离的贡献尤为重要。³

分区政策被认为是增加经济适用房供应的主要障碍。⁴无法获得负担得起的住房与支付医疗保健和其他基本需求的能力下降以及身心健康状况较差有关。⁵由于联邦和州政府对经济适用房项目的资金减少，地方政府在为经济适用房提供资金和增加供应方面的负担越来越重。⁶包容性分区 (IZ) 政策是地方政府用来增加其辖区内经济适用房份额的一种政策工具。除了创造更多负担得起的住房外，IZ 政策还可能带来更大的社会效益，例如社会经济融合、增加获得健康食品的机会以及减少接触环境毒素和枪支暴力的机会。⁷通过增加获得负担得起的住房和影响其他健康决定因素的能力，IZ 政策可以影响对改善心血管结果很重要的可修改风险因素。尽管分区被认为对健康很重要，但很少有关于 IZ 和其他分区政策对人口健康影响的实证研究。

在本期循环：心血管质量和结果中，Jones 等人⁸通过探索城市级别的 IZ 政策与心血管结果之间的关联，以这一重要研究领域为基础。在这项研究中，作者发现 IZ 政策的存在与高血压患病率降低 0.18 个百分点、高胆固醇患病率降低 0.59 个百分点以及服用降压药的患病率降低 0.27 个百分点相关。IZ 政策不是同质的，并且因项目而异。作者利用这种变化来检查 IZ 计划的哪些特征与心血管结果相关。作者发现强制性的 IZ 计划，收取的费用数额，侧重于租赁开发，而不是提供开发商激励，保护和修复住房的能力，

Jones 等人还确定，实施 IZ 政策的城市与没有明显不同的城市。作者发现，拥有 IZ 政策的城市有更好的心血管结局、更高的劳动力参与、更低的贫困率和更高的收入中位数。先前的研究还发现，采用 IZ 政策的城市有更高的租金负担家庭比例、较少的人口、更高的住房密度、更年轻和更多受过大学教育的人口，以及授权、授权或允许地方实施 IZ 政策的国家政策环境. ⁹鉴于州对地方 IZ 政策的抢占与较差的健康结果显着相关，因此围绕 IZ 的州级政策尤为重要。¹⁰Jones 等人的研究仅考虑了他们研究中的租金负担家庭的份额。该研究的一个重要限制是无法确定 IZ 与心血管结果之间的关系是否可以用这些未观察到的因素来解释，这些因素促使采用和实施 IZ 政策。未来的工作应该结合其中一些未观察到的因素，以更好地了解 IZ 如何以及为何与心血管结果相关。

有色人种因健康状况不佳、租金上涨以及阻碍他们获得安全、优质和负担得起的住房的能力的住房政策而承受不成比例的负担。¹¹作者指出，他们的研究结果支持经济适用房政策作为减少或消除心血管疾病种族和社会经济差异的工具的重要性，但他们的分析并未探讨 IZ 政策的种族化影响。他们控制了每个城市中少数民族居民的比例，并且不包括任何与种族居住隔离相关的变量。然而，他们的研究确实通过在他们的多变量模型中包含基尼指数，为收入不平等在 IZ 与心血管健康之间的关系中的作用提供了证据。作者发现，收入不平等加剧与高血压、高胆固醇、服用高血压药物和冠心病的患病率增加有关。

Jones 等人对有关 IZ 政策的社会效益的文献做出了重要贡献，并为未来探索 IZ 政策和更广泛的分区政策如何用于改善心血管健康的研究奠定了基础。IZ 政策的存在与更好的心血管结果之间的正相关，以及采用和实施 IZ 政策的城市与不实施 IZ 政策的城市之间的显着差异，突出了向上游看以改善健康的重要性。分区和土地使用监管政策作为改善心血管结果和减少种族和社会经济健康不平等的可修改政策杠杆，值得更多关注。

披露无。

本文中表达的观点不一定是编辑或美国心脏协会的观点。

有关披露，请参见第 954 页。