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An Update of the Literature Supporting the Well-Being
Bene¢ts of Plants: Part 2 Physiological Health Bene¢ts
1
Charles R. Hall and Melinda J. Knuth
2
Abstract
This paper focused on providing evidence from the literature regarding the physiological health benefits associated with plants,
thereby influencing the physiological, psychological, and cognitive well-being constructs affecting quality of life. These benefits are
segmented and discussed using the following categories: better sleep, increased birthweights, decreased diabetes, decreased ocular
discomfort, enhanced immunity, improved circadian functioning, improved rehabilitation, decreased cardiovascular and respiratory
disease, decreased mortality, improved digestion, decreased allergies, increased physical activity, and improved cognitive
development. This research should be strategically incorporated into both industry-wide and firm-specific marketing messages that
highlight the quality of life value proposition in order to maintain the industry’s sense of value and relevance to residential landscape
consumers of the future. These findings also present evidence that municipal leaders and policymakers can use in justifying green
infrastructure-related funding decisions, as well as grounds for the construction industry using biophilic design principles in ensuring
the built environment offers opportunities for green space interactions. The green industry can play a pivotal role not only in
providing plants of high quality for these applications but educating stakeholders regarding the benefits discussed herein.
Index words: benefits of plants, emotional health, mental health.
Significance to the Horticulture Industry
This paper is the second of a four-part series that
provides a review of the substantial body of peer-reviewed
research that has been conducted regarding the economic,
environmental, and health and well-being benefits of green
industry products and services. While the first article
focused on the emotional and mental health benefits that
plants provide, this article focuses specifically on the
physiological health benefits provided by plants. These
benefits include better sleep, increased birthweights,
decreased incidence of diabetes, decreased ocular discom-
fort, enhanced immunity, improved circadian functioning,
improved rehabilitation from illnesses, decreased likeli-
hood of cardiovascular and respiratory disease, decreased
mortality, improved digestive functioning, decreased
susceptibility to allergies, and improved cognitive devel-
opment. This research should be strategically incorporated
into both industry-wide and firm-specific marketing
messages that highlight how quality of life dimensions
are affected in order to enhance the perceived value and
relevance of green industry products for gardening and
landscaping consumers in the future.
Introduction
In 2011, Hall and Dickson published a forum article in
the Journal of Environmental Horticulture (JEH) that
summarized the economic, environmental, and health and
well-being benefits associated with people-plant interac-
tions. The proposition put forth in that article was that
green industry firms needed to focus on these types of
functional benefits in their marketing messages to con-
sumers rather than simply base their value proposition on
the features and benefits of the plants themselves (e.g.
aesthetic characteristics, insect and/or disease resistance,
cold or heat tolerance, salt tolerance, drought resistance,
etc.). By doing so, the end consumer would better
understand the inherent ways in which plants improve the
quality of their lives and begin perceiving plants to be a
necessity in their lives rather than a mere luxury they could
cast aside during economic downturns, as they did during
the ‘‘Great Recession’’ of 2008-2009.
Since 2011, there has been a plethora of additional
research studies conducted regarding these functional plant
benefits. A total of 1,348 citations have been compiled in
total and about two-thirds of those have been conducted
since 2011. These voluminous studies provide compelling
evidence that warrants further attention. Thus, this new
series of forum articles attempts to update the findings
summarized in the original article by Hall and Dickson by
focusing on the research on plant benefits that has been
conducted since 2011. By doing so, this new information
provides the basis for even more innovative green industry
marketing efforts, which, in turn, may positively influence
the price elasticity of demand for plants in general.
The second topic in the four-part series, physiological
health benefits of plants, is one that has been shown to
resonate with consumers of all demographic segments
(Hall and Dickson 2011). These benefits are segmented and
discussed using the following categories: better sleep,
increased birthweights, decreased diabetes, decreased
ocular discomfort, enhanced immunity improved circadian
functioning, improved rehabilitation, decreased cardiovas-
cular and respiratory disease, decreased mortality, im-
proved digestion, decreased allergies, increased physical
activity, and improved cognitive development.
Many of these benefits can be experienced during
exposure to plants in both the built environment and the
natural environment. The built environment includes all
human-made spaces in which people live, work, and play
including buildings, gray infrastructure (e.g. utilities,
transportation networks, etc.), and improved landscapes
(outdoor landscape spaces that have been ‘‘improved’’
1
Received for publication May 7, 2019; in revised form June 10, 2019.
2
Professor and Graduate Student, respectively, Texas A&M University,
College Station, Texas 77843-2133. Corresponding author: Charles
Hall (c-hall@tamu.edu).
J. Environ. Hort. 37(2):63–73. June 2019 Copyright 2019 Horticultural Research Institute 63
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aesthetically). The term ‘‘ green spaces’’ has been used
extensively to refer to areas of urban vegetation including
public and private parks and gardens, residential land-
scapes, and urban forests and other municipal landscapes.
However, with urbanization and global migration into
urban centers, exposure to outdoor green spaces is
becoming less frequent in people’s everyday life, prompt-
ing the use of biophilic design principles to offer exposure
to the elements of natural environments within the built
environment. For example, ‘‘green buildings’’ often
incorporate green walls, green roofs, water features, natural
lighting, and natural materials that emulate nature.
Better Sleep
Getting inadequate amounts of sleep can heighten risks
for obesity, chronic disease, and mortality (Cappuccio et al.
2011, Cappuccio et al. 2008, Chaput et al. 2007, Hislop and
Arber 2003, Hublin et al. 2007). Time spent in natural
settings and improved landscapes can decrease multiple
issues with sleep (Morita et al. 2011). For example, short
sleep syndrome is less common in ‘‘greener’’ (e.g. more
plants incorporated) residential surroundings (Astell-Burt
et al. 2013). Experiencing indoor and outdoor natural
environments helps transition individuals from a state of
stress towards a state of relaxation and subconscious
activity enabling better sleep (El-Sheikh et al. 2013),
reflected by an improvement in common measures of sleep
quality (Astell-Burt et al. 2013, Grigsby-Toussaint et al.
2015, Morita et al. 2011).
Birthweight
Residential greenness during pregnancy is associated
with healthier birth weights and lowered risk of small-for-
gestational-size infants (Dadvand et al. 2012a, Dadvand et
al. 2012b, Donovan et al. 2011, Hystad et al. 2014). Birth
outcomes may be influenced by noise and pollution but
results from a recent study found that birth outcomes can
also be heavily influenced by psychosocial and psycholog-
ical factors (Nicole 2014). Positive birth outcomes were
associated with ‘‘greenness thresholds’’ above 0.15 (scores
under 0.15 are considered dense urban areas along major
roadways, etc.) (Nicole 2014).
Specifically, greater exposure to plants affects birth
outcomes by altering increasing maternal levels of physical
activity, reducing maternal stress, enhancing social con-
tacts among mothers, reducing maternal noise and air
pollution exposure, and moderating ambient temperatures
(Dadvand et al. 2012a). Studies that used birth registries to
link the mother’s address at birth to a measure of greenness
(most commonly, the normalized difference vegetation
index or NDVI), found consistent positive associations
between greenness and birth weight (Agay-Shay et al.
2014, Dadvand et al. 2012a, Dadvand et al. 2014a, Hystad
et al. 2014, Markevych et al. 2014).
Other studies found that higher greenness exposure was
linked to lower odds of a child being small for gestational
age or preterm (Hystad et al. 2014), larger head
circumferences (Dadvand et al. 2012a), and lower infant
mortality risk, although these findings were not replicated
across all studies because some birth registry studies were
not able to account for alcohol or tobacco use (Agay-Shay
et al. 2014) or maternal income or education (Hystad et al.
2014). However, most analyses were able to adjust for
these factors and also model complex environmental
exposures including air pollution (Dadvand et al. 2012a,
Hystad et al. 2014), neighborhood walkability, and noise
(Hystad et al. 2014). Stronger associations between
greenness and birth outcomes were observed among those
whose parents had lower levels of education and lower
socio-economic status (Agay-Shay et al. 2014, Dadvand et
al. 2012a, Markevych et al. 2014).
Decreased Diabetes
Interacting with plants also counters the adverse effects
of stress on energy metabolism, insulin secretion,
inflammatory pathways (Bhasin et al. 2013), and ulti-
mately diabetes and obesity (Astell-Burt et al. 2014,
Bodicoat et al. 2014, Lachowycz and Jones 2011,
Thiering et al. 2016). Walking in natural areas or
improved landscapes (outdoor landscape spaces that have
been ‘‘improved’’ aesthetically) results in healthier levels
of the hormone didehydroepiandrosterone in the blood-
stream (DHEA) (Ohtsuka 1998). DHEA has cardio-
protective, anti-obesity, and anti-diabetic properties
(Bjørnerem et al. 2004). Thus, regular exposure to natural
areas helps protect against obesity, type 2 diabetes,
hypertension, and coronary heart disease.
Even brief exposure to plants has a number of positive
short-term effects, which suggests that regular nature
exposure could improve diabetes outcomes significantly
by stimulating the release of anti-diabetic hormones
adiponectin and DHEA, modulating insulin by way of its
effects on parasympathetic activity (Bhasin et al. 2013),
and normalizing elevated blood glucose. In diabetic
patients, monthly nature walks were sufficient to reduce
glycated hemoglobin (HbA1c) to just below the threshold
value for a diabetes diagnosis. Not surprisingly then,
diabetes mellitus (Type 1 or 2) is less prevalent among
individuals living in greener surroundings (Astell-Burt et
al. 2014, Maas et al. 2009) and among public park users
than non-park-users (Tamosiunas et al. 2014).
Decreased Ocular Discomfort
Being around plants indoors results in decreased ocular
(eye) discomfort (French et al. 2013, Guggenheim et al.
2012). A cohort of sixth grade students at two newly
constructed elementary schools performed a self-assess-
ment of ocular discomfort symptoms in association with
indoor air quality. While indoor plant additions made little
difference in air temperature and relative humidity, the
plants did stabilize levels of carbon dioxide and decreased
indoor concentrations of volatile organic compounds such
as toluene and xylene, which may lead to ocular
discomfort. Students in classrooms without indoor plants
experienced an increase in ocular discomfort symptoms,
those in classrooms with indoor plants demonstrated a
decrease in frequency (He et al. 2015).
64 J. Environ. Hort. 37(2):63–73. June 2019
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Enhanced Immunity
Immunity is generally referred to as the body’s ability to
ward off disease or withstand infection. Recent studies
show that immunity from illnesses can be enhanced by
viewing, interacting with, or even being in the vicinity of
plants. Kuo (2015) and Song et al. (2016) both found that
being in nature improves immune function in several ways.
First, consistent with the ‘‘hygiene hypothesis,’’ contact
with microbial and other antigens in natural settings during
particular developmental windows may modify (improve)
immune function over the lifespan (Hanski et al. 2012,
Kondrashova et al. 2013, Nicolaou et al. 2005, Rook 2013,
Ruokolainen et al. 2015, Stiemsma et al. 2015), perhaps
operating through effects on the microbiome (Lee and
Mazmanian 2010). Second, short-term exposure to natural
substances (such as phytoncides from trees) have been
associated with improved natural killer (NK) cell activity
(Li 2010, Li and Kawada 2011, Li et al. 2008a, Li et al.
2008b, Li et al. 2006). NK cells play important protective
roles against cancer, viral infections, and inflammatory
cytokines that have been implicated in diabetes, cardio-
vascular disease, depression, and other negative health
outcomes (Cesari et al. 2003, Dowlati et al. 2010, Orange
and Ballas 2006, Wellen and Hotamisligil 2005).
These natural killer cells (also known as NK cells, K
cells, and killer cells) are a type of lymphocyte (a white
blood cell) and a component of innate immune systems.
Stress recovery and immune function mechanisms may not
be distinct because of reciprocal relationships between
these two physiologic systems (Irwin and Cole 2011,
Nusslock and Miller 2016). Fantuzzi (2013) also found that
adiponectin levels in the body increase while in nature and
improved landscapes (Li and Kawada 2011), which helps
protect against atherosclerosis, acute urinary tract infec-
tions, infectious diseases of the intestinal canal, and upper
respiratory tract infections.
Illnesses associated with failing immunoregulation and
poorly-regulated inflammatory responses, manifested as
chronically raised levels of C-reactive protein and proin-
flammatory cytokines, are mitigated through exposure to
plant-filled nature, reducing the levels of these inflamma-
tory cytokines (Mao et al. 2012). There is another theory
that the ‘‘ awe’’ experienced with viewing impressive
landscape settings helps with immunity (Stellar et al.
2015). Regular experiences of awe are tied to healthier,
lower levels of inflammatory cytokines (Stellar et al. 2015).
Moreover, extended time in nature decreased inflammatory
cytokines implicated in chronic disease by roughly one-
half (Mao et al. 2012).
Environmental biodiversity has been proposed to
contribute to human commensal microbiota, the ‘‘ good
bacteria’’ living on or in the human body (Rook 2013, Von
Hertzen et al. 2011). Commensal microbiota play a role in
the immune system’s ability to tolerate rather than attack
non-threats (Kuo 2013). In one study, the abundance of one
particular commensal microorganism on the skin was
correlated with levels of an anti-inflammatory cytokine
playing a key role in immunologic tolerance (IL-10)
(Hanski et al. 2012). The more access that children have to
natural settings in which to play, the more proteobacteria
on their skin and the more diverse their gamma-
proteobacteria (Hanski et al. 2012, Ruokolainen et al.
2015).
Epidemiological studies suggest that living close to the
natural environment is associated with long-term health
benefits including reduced death rates, reduced cardiovas-
cular disease, and reduced psychiatric problems (Rook
2013). This is often attributed to psychological mecha-
nisms boosted by exercise, social interactions, and sunlight.
Compared with urban environments, exposure to green
spaces does indeed trigger rapid psychological, physiolog-
ical, and endocrinological effects.
Improved Autonomic Nervous System and
Parasympathetic Activity
The autonomic nervous system is a control system that
acts largely unconsciously and regulates bodily functions
such as the heart rate, digestion, respiratory rate, pupillary
response, urination, and physical arousal. This system is
the primary mechanism in control of the fight-or-flight
response. The sympathetic nervous system is the part of the
autonomic nervous system that prepares the body to react
to stresses such as threat or injury. It causes muscles to
contract and heart rate to increase. The parasympathetic
nervous system is the part of the autonomic nervous system
that controls functions of the body at rest. It helps maintain
homeostasis in the body. It causes muscles to relax and
heart rate to decrease.
Window views and images of green spaces in nature
reduce sympathetic nervous activity and increase parasym-
pathetic activity (Brown et al. 2013, Gladwell et al. 2012),
These sympathetic and parasympathetic effects drive
immune system behavior (Kenney and Ganta 2011) with
long-term health consequences (van den Berg et al. 2015b).
As little as five minutes of exposure to images of trees,
grass, and fields in a laboratory setting is enough to
increase parasympathetic nervous activity and decrease
heart rate (Brown et al. 2013, Gladwell et al. 2012).
Relaxation has important implications for health, and,
when used regularly, relaxation techniques have docu-
mented dose-response effects on immune functioning
(Kang et al. 2011). Deep states of relaxation counter the
adverse effects of stress on energy metabolism, insulin
secretion, and inflammatory pathways (Bhasin et al. 2013)
with potential implications for diabetes, cardiovascular
disease, and other inflammatory disorders. Parasympathetic
dominance also appears to play an important role in sleep
quality (El-Sheikh et al. 2013).
Improved Rehabilitation
Many older people in senior living facilities suffer from
complex health problems (DelSesto 2017). The total effect
of green spaces on self-perceived health has been shown to
be positive and significant by generating a sense of being
‘‘away’’ from the facility, enhancing the level of interest
associated with their day, and fostering an environment that
encourages visitation from family and friends (Dahlkvist et
al. 2016).
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Field experiments in hospitals show much faster post-
operative healing and a reduced need for pain medication
in patients with rooms whose windows look out on trees
and other elements in the landscape (Mehaffy and
Salingaros 2015, Park et al. 2013). To examine the health
benefits of a bedroom window view to natural surround-
ings, coronary and pulmonary patients were divided in half
(Raanaas et al. 2012) and patients were placed either in a
private bedroom with a panoramic view to natural
surroundings or in a room with a view that was partially
or entirely blocked by buildings. For women, a blocked
view appeared to negatively influence change in physical
health, whereas for men, a blocked view appeared to
negatively influence change in mental health (Raanaas et
al. 2012). Pulmonary patients with a panoramic view
showed greater improvement in mental health than
coronary patients without such a view. Those with a
panoramic view to nature more often chose to stay in their
bedroom when they wanted to be alone than those with a
blocked view (Raanaas et al. 2012).
Lower Cardiovascular Disease Risk and Blood Pressure
Contact with nature and improved landscapes has been
tied to both short- and long-term outcomes related to
cardiovascular disease (Ray and Jakubec 2014). Walks in
these settings have a number of positive short-term effects
on the cardiovascular system by raising serum levels of
adiponectin – which is antiatherogenic, and DHEA – which
is cardio protective. In addition, in hypertensive patients,
walks in nature decrease serum levels of a number of
factors associated with high blood pressure: endothelin-1,
homocysteine, renin, angiotensin II type 1 receptor, and
angiotensin II type 2 receptor (Mao et al. 2012). Not
surprisingly then, these walks lower blood pressure in
young and middle-aged adults (Li 2010, Park et al. 2010)
as well as older adults with hypertension (Mao et al. 2012).
When experienced regularly, these short-term effects
appear to promote cardiovascular health: individuals living
in greener surroundings have lower blood pressure on
average (Markevych et al. 2014a), lower rates of
cardiovascular disease (Maas et al. 2009, Pereira et al.
2012, Tamosiunas et al. 2014), lower rates of cardiovas-
cular mortality (Coutts et al. 2010, Donovan et al. 2013,
Mitchell and Popham 2008, Richardson et al. 2010,
Villeneuve et al. 2012), and higher survival rates after
ischemic stroke (Wilker et al. 2014). A handful of studies,
generally comparing larger geographical units, found a
positive, but not statistically-significant relationship, be-
tween greener areas and cardiovascular outcomes (Coutts
et al. 2010, Mitchell et al. 2011, Richardson et al. 2010).
The gap between the natural setting, for which our
physiological functions are adapted, and the highly
urbanized and artificial setting that we inhabit is a
contributing cause of the ‘‘stress state’’ in modern people
(Song et al. 2016). Walking in and viewing nature can
lower blood pressure and heart rate (Brown et al. 2013,
Duncan et al. 2014, Haluza et al. 2014, Markevych et al.
2014, Shanahan et al. 2016). It also can help with
circulatory and heart disease risks (Maas et al. 2009).
Walking in nature also increases serum levels of adipo-
nectin (Li and Kawada 2011) and regular walks could
potentially protect against obesity, type 2 diabetes,
hypertension, and coronary heart disease (Song et al.
2017).
Heart rate is a significant indicator of stress response and
serves as a flag for high risk of cardiovascular disease.
Average heart rates of low-income African American
males when walking past landscaped sites went from 103.3
beats per minute (bpm) before greening to 107.2 bpm after
greening for a total increase of 3.9 bpm (South et al. 2015).
When in view of non-landscaped vacant lots, average heart
rate went from 99.6 bpm in the pre-intervention period to
109.1 bpm in the post-intervention period for a total
increase of 9.5 bpm. The final estimate between landscaped
and non-landscaped vacant lots was lower with a heart rate
of ~5.6 bpm (South et al. 2015). While the physiological
effects of natural (rural and urban) environments on the
cardiovascular system of coronary artery disease (CAD)
patients are not fully understood, reductions in cortisol
levels (a stress hormone) after outdoor walks were greater
in city parks than in urban street settings (Grazuleviciene et
al. 2016).
Decreased Mortality
The amount of ‘‘green’’ landscaped spaces in neighbor-
hoods also has an impact on all-cause mortality (Coutts et
al. 2010, Gascon et al. 2015, James et al. 2016, Mitchell et
al. 2011, van den Berg et al. 2015a, Villeneuve et al. 2012).
People living in neighborhoods with a higher density of
trees on their streets reported significantly higher percep-
tions of overall health and significantly less cardio-
metabolic conditions such as diabetes, high cholesterol,
heart disease, and stroke. Having 10 or more trees on a city
block improved health perception in ways comparable to
being 7 years younger or having a higher annual personal
income of $10,000 (Takano et al. 2002).
A natural experiment is an empirical study in which
individuals (or clusters of individuals) are exposed to the
experimental and control conditions that are determined by
nature or by other factors outside the control of the
investigators. A natural experiment, which provides
stronger evidence of causality, was used to test whether a
major change to the natural environment has influenced
mortality related to cardiovascular and lower-respiratory
diseases (Donovan et al. 2013). Emerald ash borer, an
invasive forest pest, has caused the loss of approximately
100 million trees in the United States. Two fixed-effects
regression models were used to estimate the relationship
between emerald ash borer presence and county-level
mortality from 1990 to 2007 in 15 U.S. states, while
controlling for a wide range of demographic covariates.
There was an increase in mortality related to cardiovascular
and lower-respiratory-tract illness in counties infested with
the emerald ash borer. The magnitude of this effect was
greater as the infestation progressed and in counties with
above-average median household income (Donovan et al.
2013). Across the 15 states in the study area, the loss of
trees from the ash borer was associated with 6,113 deaths
related to lower-respiratory-system illnesses and 15,080
cardiovascular-related deaths. These results suggest that
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loss of trees to the emerald ash borer (or any other cause)
will increase mortality related to cardiovascular and lower-
respiratory-tract illness.
Certain areas of the United States are susceptible to
extreme heat events. Research have found that measures to
reduce excess urban heat (known as ‘‘ urban heat islands’’ )
can have a positive impact on health during extreme heat
events. One study found that a 10% increase in urban
surface reflectivity (from vegetation) could reduce the
number of deaths during heat events by an average of 6%
(Kalkstein et al. 2013). An even larger reduction would be
expected in hospital admissions from heat-related illness,
although this was not a specific finding in the analysis
(Kalkstein et al. 2013).
Another study examined the prospective association
between residential greenness and mortality in women. In
models adjusted for mortality risk factors (age, race/
ethnicity, smoking, and individual- and area-level socio-
economic status), women living in the highest quintile of
cumulative average greenness (accounting for changes in
residence during follow-up) in a 250-m area around their
home had a 12% lower rate of all-cause non-accidental
mortality than those in the lowest quintile (Beyer et al.
2014). These associations were strongest for respiratory-
and cancer-related mortality. Policies and/or programs to
increase vegetation may provide opportunities for physical
activity, reduce harmful exposures, increase social engage-
ment, improve mental health, as well as mitigate the effects
of climate change.
Another study examined the association of several health
outcomes with ‘‘green’’ housing (with various environmen-
tal amenities, including plants) and conventional low-
income housing (where the prevalence of morbidities and
environmental pollutants is elevated) by comparing sick
building syndrome (SBS) symptoms and asthma-related
morbidity among residents in multifamily units (Colton et
al. 2015). Adults living in green units reported 1.35 fewer
SBS symptoms annually than those living in conventional
(control) homes. Furthermore, asthmatic children living in
green homes experienced substantially lower incidence of
asthma symptoms, asthma attacks, hospital visits, and
asthma-related school absences than children living in
conventional public housing (Colton et al., 2015). Other
studies also validate that respiratory disease and related
mortality are less prevalent in greener residential sur-
roundings (Donovan et al. 2013, Maas et al. 2009,
Richardson et al. 2010, Villeneuve et al. 2012).
Improved Pain Control
Distraction therapy with sights and sounds from natural
landscapes significantly reduces pain in patients undergo-
ing acute, painful, invasive procedures (Diette et al. 2003,
Lechtzin et al. 2010). Distraction therapy can be used in
addition to standard analgesic medications, especially with
procedures that require only local anesthesia. Patients with
chronic musculoskeletal pain who participated in horticul-
ture therapy programs experienced better physical and
mental health (Verra et al. 2012), relied less on pain
medications, and also scored better on coping behavior
assessments related to anxiety and pain management
(Verra et al. 2012).
Obesity Reduction
Studies have found evidence tying greener residential
areas with lower rates of obesity (Dadvand et al. 2014b,
James et al. 2015, Lovasi et al. 2011, Michimi and
Wimberly 2012, Pereira et al. 2012, Sanders et al. 2015,
Wolch et al. 2011). People who live in close proximity to
green spaces are three times more likely to engage in
physical activity and 40% less likely to be overweight
(Watson and Moore 2011). Having clean parks and nearby
park access has been associated with healthier weights and
greater life satisfaction amongst users. A 2014 study
showed greater availability of neighborhood parks (either
large or small) and greater park cleanliness to be associated
with healthier weights among adults after adjusting for
neighborhood features that could influence park use, such
as walkability and violent crime (Stark et al. 2014).
In one study, green space was associated with a reduced
likelihood of obesity among women. Another study found
that street tree density was associated with lower obesity
prevalence (Lovasi et al. 2013b). Individuals further from
green spaces were less likely to partake in physical activity
and had higher odds of obesity than those living closer
(Toftager et al. 2011, Lachowycz and Jones 2011).
Residential greenness has also been tied to lower rates of
obesity across the lifespan, in rural and urban environ-
ments, for multiple measures of greenness (park access,
street trees, green cover, etc.) and for multiple measures of
weight status [Body Mass Index (BMI), change in weight
status, skin fold thickness] (Lovasi et al. 2013b, Pereira et
al. 2012). Since obesity entails higher risks of other health
problems including cancer, coronary heart disease, type II
diabetes, and stroke (NIH 2012), regular exposure to green
spaces could also potentially protect against hypertension
and coronary heart disease.
Dadvand et al. (2014b) aimed to simultaneously evaluate
health benefits and risks associated with different levels of
greenness in children. Sedentary behavior (represented by
excessive screen time) resulted in obesity, asthma, and
allergic rhinoconjunctivitis (Dadvand et al. 2014b). An
interquartile increase in residential surrounding greenness
was associated with 11–19% lower relative prevalence of
being overweight or obese (residential proximity to green
spaces was defined as living within 300 m of a forest or a
park). Similarly, residential proximity to green spaces was
associated with a 39% decrease in excessive screen time
and 25% lower incidence of obesity (Dadvand et al.
2014b).
In a study assessing community gardeners, both women
and men community gardeners had significantly lower
BMIs than did their neighbors who were not in the
community gardening program. Significantly lower BMIs
for women community gardeners compared with their
sisters and men community gardeners compared with their
brothers were also observed (Zick et al. 2013). Community
gardeners also had lower odds of being overweight or
obese than did their otherwise similar non-gardening
neighbors.
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Decreased Atopy (Allergies)
Growing up and living in areas with high amounts of
green spaces can lead to lesser symptoms of atopy
(allergies) (Dadvand et al. 2014b, Fuertes et al. 2016,
Fuertes et al. 2014, Grazuleviciene et al. 2016, Kuo 2015,
Lovasi et al. 2013a, Lovasi et al. 2008, Ruokolainen et al.
2015). Contact with nature, or more specifically, biodiver-
sity, has been proposed to help the immune system learn to
tolerate allergens rather than attack non-threats (Rook
2013). However, the findings on this question are
extremely mixed, perhaps because vegetation has multiple
effects, capturing pollutants and training the immune
system on the positive side, but emitting pollen on the
negative side. Multiple studies have reported that allergies,
asthma, and eczema (which all reflect hypersensitivity of
the immune system) are less prevalent among persons with
greener residential surroundings (Fuertes et al. 2014,
Hanski et al. 2012, Lovasi et al. 2008, Maas et al. 2009,
Ruokolainen et al. 2015).
A few studies considered green spaces in relation to
developmental outcomes and allergies in children. While
beneficial effects may be mediated by physical activity,
social engagement, reduced stress, and noise, heat, and air
pollution reductions (Dadvand et al. 2014b), distance to the
nearest green space from a child’s residence was positively
associated with odds of hyperactivity and inattention
(Markevych et al. 2014).
Physical Activity
There is available evidence to show that there can be
direct health benefits by increasing the level of physical
activity on individuals of all ages (Barton et al. 2016,
Broekhuizen et al. 2013, Cohen-Cline et al. 2015, Elliott
2016, Fan et al. 2011, Feda et al. 2015, Hartig and Kahn
2016, Mitchell 2013, Nielsen and Hansen 2007, Sharma-
Brymer et al. 2015, Thompson Coon et al. 2011, Thompson
et al. 2016, Wolf and Wohlfart 2014). A number of studies
have assessed the association between green space and
physical activity typically in cross-sectional analyses
where neighborhood ‘‘greenness’’ is derived from land-
use files and physical activity is ascertained by survey. In
general, this evidence supports a positive association
between green space and physical activity in adults (Chaix
et al. 2014, Gong et al. 2014, Karusisi et al. 2012, Mytton
et al. 2012, Richardson et al. 2013).
Other reviews have shown a relationship between green
spaces and several determinants of health, such as physical
activity and stress (CDC 2011, Bowler et al. 2010,
Croucher et al. 2008, Di Nardo et al. 2012, Health Council
of the Netherlands 2004, Lachowycz and Jones 2011, Lee
and Maheswaran 2011, Shafer et al. 2000). Of studies that
included measures of perceived greenness, one found that
both subjective and objective green space were associated
with walking and other forms of exercise (Sugiyama et al.
2013).
Natural surroundings such as vegetated streetscapes,
parks, and schoolyards are generally associated with higher
levels of physical activity in both children and adults, a
plausible mechanism for many of the observed health
benefits of nature contact (Bancroft et al. 2015, Bingham et
al. 2016, Calogiuri and Chroni 2014, Fraser and Lock
2011, Gray et al. 2015, Hunter and Askarinejad 2015,
Kaczynski and Henderson 2007, Koohsari et al. 2015, Lee
et al. 2015, Shanahan et al. 2016, Stigsdotter et al. 2010,
Sugiyama et al. 2014). While the mechanisms by which
green surroundings might facilitate physical activity are not
well understood, aesthetic preferences for green spaces
may play a role (Shanahan et al. 2016). There is also a high
association with green space usage and physical activity
among dog owners (White et al. 2018).
For children, greenness has been associated with
increased playtime outdoors (Grigsby-Toussaint et al.
2011), and in a study by Almanza et al. (2012), with
higher odds of extemporaneous physical activity when in
greener areas. Similar studies in children found that about
half of weekend moderate–to-vigorous physical activity
took place in green spaces (Lachowycz and Jones 2011),
and periods of moderate–to-vigorous physical activity were
significantly more likely to occur in green spaces for boys,
but the relationship was positive, but not statistically
significant for girls (Wheeler et al. 2010). Children and
adolescents with better access to parks are less likely to
have higher BMI levels (Wolch et al. 2011) and the level of
children’s physical activity seems to be influenced by
access to parks and vegetation (Ding et al. 2011). Evidence
also suggests that play in natural environments is
associated with the development of fine motor skills such
as balance and coordination, which in turn enable and
predict physical activity (Fjørtoft 2001, Fjørtoft, 2004).
The dynamic and irregular characteristics of natural play
spaces may explain this observation.
Gardening has been shown to encourage people to
undertake physical exercise, which in turn would contrib-
ute to improving both the physical and psychological
health of gardeners (Soga et al. 2017). For older
individuals, participants who spent 1 hour or more
gardening per week exhibited better balance performance,
fewer functional limitations, and fewer chronic conditions.
Significantly fewer gardeners than non-gardeners reported
a fall in a measured 2-year period (Chen and Janke 2012).
Given the concerns about low rates of physical activity
among low-income minority youth, many community-
based organizations are investing in the creation or
renovation of public parks in order to encourage youth to
become more physically active. Park improvements can
have a significant impact on increasing park use and local
physical activity of youth (Cohen et al. 2015). In a study
assessing 11-to-13-year-old children’s activity levels, the
proportion of neighborhood land covered by trees and other
green spaces was independently associated with the
physical activity outcome, and for each additional 5%
increase in the proportion of neighborhood land covered by
green spaces, there was a corresponding 5% increase in the
relative odds of increasing free-time physical activity
outside of school hours (Janssen and Rosu 2015).
Positive Cognitive Development
Cognitive development in students (assessed as a 12-
month change in the developmental trajectory of working
68 J. Environ. Hort. 37(2):63–73. June 2019
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memory and in-attentiveness) was found to be influenced
by the level of greenness within and surrounding school
boundaries. A high total-surrounding greenness index
(including greenness surrounding student homes, commut-
ing route, and school) was correlated with higher levels of
working memory and attentiveness (Dadvand et al. 2015).
Being outdoors in natural settings also contributes to a
sense of vitality or energy available for purposive action by
adults (Ryan et al. 2010). Although vitality has been
investigated independently of attention restoration, it is
likely that vitality and attention restoration are simply
different facets of a single process. The descriptions of
vitality (Ryan et al. 2010) sound very much like the
descriptions of ‘‘rejuvenation’’ and ‘‘ recovery from mental
fatigue’’ associated with attention restoration (Kuo 2015)
that is enhanced by green spaces. Multiple authors have
found that attention restoration, state changes in cognitive
functioning, and recovery from ego-depletion are influ-
enced by the same underlying green space mechanisms
(Hofmann et al. 2012, Kaplan and Kaplan 1989, Kaplan
and Berman 2010, Ryan et al. 2010).
Summary
Consumers have historically shown an inclination to
purchase products that enhance their quality of life (Hall
and Dickson 2011), meaning they will purchase items that
positively influence their physical, psychological, cogni-
tive, environmental, social, and spiritual well-being. Plants
in natural and improved landscapes (and interiorscapes)
have been documented to influence each of these quality of
life constructs. This paper focused on providing evidence
from the literature regarding the physiological health
benefits associated with plants, thereby influencing the
physiological, psychological, and cognitive well-being
constructs affecting quality of life. This research should
be strategically incorporated into both industry-wide and
firm-specific marketing messages that highlight the quality
of life value proposition in order to maintain the industry’s
sense of value and relevance to residential landscape
consumers of the future. These findings also present
evidence that municipal leaders and policymakers can
use in justifying green infrastructure-related funding
decisions, as well as grounds for the construction industry
using biophilic design principles in ensuring the built
environment offers opportunities for green space interac-
tions. The green industry can play a pivotal role not only in
providing plants of high quality for these applications but
educating stakeholders regarding the benefits discussed
herein.
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