The built environment can influence human health, but the available evidence is modest and almost entirely from urban communities in high-income countries. Here we aimed to analyse built environment characteristics and their associations with obesity in urban and rural communities in 21 countries at different development levels participating in the Prospective Urban and Rural Epidemiology (PURE) Study.

Photographs were acquired with a standardised approach. We used the previously validated Environmental Profile of a Community's Health photo instrument to evaluate photos for safety, walkability, neighbourhood beautification, and community disorder. An integrated built environment score (ie, a minimum of 0 and a maximum of 20) was used to summarise this evaluation across built environment domains. Associations between built environment characteristics, separately and combined in the integrated built environment score, and obesity (ie, a BMI >30kg/m2) were assessed using multilevel regression models, adjusting for individual, household, and community confounding factors. Attenuation in the associations due to walking was examined.

Analyses include 143 338 participants from 530 communities. The mean integrated built environment score was higher in high-income countries (13·3, SD 2·8) compared with other regions (10·1, 2·5) and urban communities (11·2, 3·0). More than 60% of high-income country communities had pedestrian safety features (eg, crosswalks, sidewalks, and traffic signals). Urban communities outside high-income countries had higher rates of sidewalks (176 [84%] of 209) than rural communities (59 [28%] of 209). 15 (5%) of 290 urban communities had bike lanes. Litter and graffiti were present in 372 (70%) of 530 communities, and poorly maintained buildings were present in 103 (19%) of 530. The integrated built environment score was significantly associated with reduced obesity overall (relative risk [RR] 0·58, 95% CI 0·35-0·93; p=0·025) for high compared with low scores and for increasing trend (0·85, 0·78-0·91; p<0·0001). The trends were statistically significant in urban (0·85, 0·77-0·93; p=0·0007) and rural (0·87, 0·78-0·97; p=0·015) communities. Some built environment features were associated with a lower prevalence of obesity: community beautification RR 0·75 (95% CI 0·61-0·92; p=0·0066); bike lanes RR 0·58 (0·45-0·73; p<0·0001); pedestrian safety RR 0·75 (0·62-0·90; p=0·0018); and traffic signals RR 0·68 (0·52-0·89; p=0·0055). Community disorder was associated with a higher prevalence of obesity (RR 1·48, 95% CI 1·17-1·86; p=0·0010).

Community built environment features recorded in photographs, including bike lanes, pedestrian safety measures, beautification, traffic density, and disorder, were related to obesity after adjusting for confounders, and stronger associations were found in urban than rural communities. The method presents a novel way of assessing the built environment's potential effect on health.

Population Health Research Institute, Hamilton Health Sciences Research Institute, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research's Strategy for Patient Oriented Research, Ontario Support Unit, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline.

Cardiovascular diseases (CVDs) are a major cause of death globally, and minority communities are at higher risk of chronic health outcomes. A combination of lifestyle, including physical activity (PA), good nutrition, and reduced stress, can improve life expectancy. This study aimed to analyze the association between CVDs and PA among the adult population (N = 3,956) based on the World Health Organization (WHO) STEPwise Approach to Surveillance (STEPS) survey in Afghanistan. Descriptive statistics, logistic regression, and spatial analytical techniques were used to analyze the data. Based on the WHO STEPS data, the computed prevalence of CVDs, obesity, hypertension, diabetes, and high cholesterol were 7.41%, 45.57%, 34.06%, 9.51%, and 12.16%, respectively. Multivariate logistic analysis indicated that moderate work-related PA was associated with higher odds of CVDs and high cholesterol while inversely associated with obesity. Moderate leisure-related PA was positively associated with obesity. Vigorous leisure-related PA was associated with lower risks of CVDs, obesity, and high cholesterol but had a positive association with hypertension. Spatial analysis revealed a CVD hotspot in the southern region and the risk factors clustered in the northern region. These findings offer valuable insights for community and public health practitioners to design targeted interventions for reducing the burden of CVDs and risk factors in communities in developing countries.

Black, Indigenous, and People of Color (BIPOC) are disproportionately impacted by the diabetes epidemic. This health inequity, aggravated by environmental, lifestyle, and genetic factors, has been further exacerbated by the COVID-19 pandemic. The increased risk of severe complications due to COVID-19 in BIPOC communities speaks to the importance of understanding the impacts of social and structural factors on health. This report aims to outline the connection between diabetes and vulnerability to COVID-19 through the lens of racism.

Review of original report and subsequent modeling and interpretations.

We reviewed and analyzed original data in relation to health inequity, diabetes, COVID-19, and BIPOC.

This holistic approach framed the disproportionate prevalence of diabetes and vulnerability to COVID-19 not just as a health disparity, but as a health inequity.

Defining the relationship between diabetes, vulnerability to COVID-19, and systems of advantage, such as racism, can further support the design of health interventions and policies that reduce the disproportionate impact of these diseases on the health of BIPOC communities.

Immigration policies shape the composition, socioeconomic characteristics, and health of migrant populations. The health of migrants is also influenced by a confluence of social, economic, environmental, and political factors. Immigrants and refugees often face various barriers to accessing health care because of factors such as lack of familiarity with navigating the health care system, language barriers, systemic racism, and gaps in health insurance. Social determinants of health and access to primary care health services likely influence the burden of cardiovascular risk factors among immigrants. The relatively low burden of many cardiovascular risk factors in many immigrant populations likely contributes to the generally lower incidence rates of acute myocardial infarction, heart failure, and stroke in immigrants compared with nonimmigrants, although cardiovascular disease incidence rates vary substantially by country of origin. The "healthy immigrant effect" is the hypothesis that immigrants to high-income countries, such as Canada, are healthier than nonimmigrants in the host population. However, this effect may not apply universally across all immigrants, including recent refugees, immigrants without formal education, and unmarried immigrants. As unfolding sociopolitical events generate new waves of global migration, policymakers and health care providers need to focus on addressing social and structural determinants of health to better manage cardiovascular risk factors and prevent cardiovascular disease, especially among the most marginalized immigrants and refugees.

Urban environmental factors such as air quality, heat islands, and access to greenspaces and community amenities impact public health. Some vulnerable populations such as low-income groups, children, older adults, new immigrants, and visible minorities live in areas with fewer beneficial conditions, and therefore, face greater health risks. Planning and advocating for equitable healthy urban environments requires systematic analysis of reliable spatial data to identify where vulnerable populations intersect with positive or negative urban/environmental characteristics. To facilitate this effort in Canada, we developed HealthyPlan.City ( https://healthyplan.city/ ), a freely available web mapping platform for users to visualize the spatial patterns of built environment indicators, vulnerable populations, and environmental inequity within over 125 Canadian cities. This tool helps users identify areas within Canadian cities where relatively higher proportions of vulnerable populations experience lower than average levels of beneficial environmental conditions, which we refer to as Equity priority areas. Using nationally standardized environmental data from satellite imagery and other large geospatial databases and demographic data from the Canadian Census, HealthyPlan.City provides a block-by-block snapshot of environmental inequities in Canadian cities. The tool aims to support urban planners, public health professionals, policy makers, and community organizers to identify neighborhoods where targeted investments and improvements to the local environment would simultaneously help communities address environmental inequities, promote public health, and adapt to climate change. In this paper, we report on the key considerations that informed our approach to developing this tool and describe the current web-based application.

Serious mental illness (SMI) may compromise diabetes self-management. This study assessed the association between SMI and glycemic control, and explored sociodemographic predictors and geographic clustering of this outcome among patients with and without SMI.

We used electronic health record data for adult primary care patients with diabetes from 2 San Francisco health care delivery systems. The primary outcome was poor glycemic control (hemoglobin A1c >9.0%), which was modeled on SMI diagnosis status and sociodemographics. Geospatial analyses examined hotspots of poor glycemic control and neighborhood characteristics.

The study included 11 694 participants with diabetes, 21% with comorbid SMI, of whom 22% had a schizophrenia spectrum or bipolar disorder. Median age was 62 years; 52% were female and 79% were Asian, Black, or Hispanic. In adjusted models, having schizophrenia spectrum disorder or bipolar disorder was associated with greater risk for poor glycemic control (vs participants without SMI, adjusted relative risk [aRR] = 1.24; 95% confidence interval, 1.02, 1.49), but having broadly defined SMI was not. People with and without SMI had similar sociodemographic correlates of poor glycemic control including younger versus older age, Hispanic versus non-Hispanic White race/ethnicity, and English versus Chinese language preference. Hotspots for poor glycemic control were found in neighborhoods with more lower-income, Hispanic, and Black residents.

Poor diabetes control was significantly related to having a schizophrenia spectrum or bipolar disorder, and to sociodemographic factors and neighborhood. Community-based mental health clinics in hotspots could be targets for implementation of diabetes management services.

Diabetes poses a substantial disease burden, prompting preventive interventions. Physical inactivity, a major risk factor for type 2 diabetes, can potentially be mitigated by enhancing area-level walkability. Despite this, limited population-based studies have investigated the link between walkability and objective diabetes measures. Our study aims to estimate the association between area-level walkability and individual glycated haemoglobin levels in the Portuguese adult population without the diagnosis of diabetes. Data from the 2011 census and an updated street map were obtained to construct a walkability index based on residential density, land-use mix, and street connectivity. Individual health data were sourced from The National Health Examination Survey (INSEF) 2015, a representative survey of the Portuguese adult population. Gamma regression was employed for estimation of the main associations, revealing that residing in moderately walkable areas significantly reduced average glycated haemoglobin levels (Exp(β) = 0.906; 95% CI: 0.821, 0.999) compared to the least walkable areas. The association was less pronounced and not statistically significant for the third tertile of walkability (Exp(β) = 0.919; 95% CI: 0.822, 1.028). Our findings highlight a nonlinear protective association between walkability and glycated haemoglobin, emphasizing the potential policy implications for urban planning, diabetes prevention, and health promotion.

Housing is a major social determinant of health that affects health status and outcomes across the lifespan.

An interagency portfolio analysis assessed the level of funding invested in "health and housing research" from fiscal years (FY) 2016-2020 across the National Institutes of Health (NIH), the United States Department of Housing and Urban Development (HUD), and the Centers for Disease Control and Prevention (CDC) to characterize the existing health and housing portfolio and identify potential areas for additional research and collaboration.

We identified NIH, HUD, and CDC research projects that were relevant to both health and housing and characterized them by housing theme, health topic, population, and study design. We organized the assessment of the individual housing themes by four overarching housing-to-health pathways. From FY 2016-2020, NIH, HUD, and CDC funded 565 health and housing projects combined. The Neighborhood pathway was most common, followed by studies of the Safety and Quality pathway. Studies of the Affordability and Stability pathways were least common. Health topics such as substance use, mental health, and cardiovascular disease were most often studied. Most studies were observational (66%); only a little over one fourth (27%) were intervention studies.

This review of the research grant portfolios of three major federal funders of health and housing research in the United States describes the diversity and substantial investment in research at the intersection between housing and health. Analysis of the combined portfolio points to gaps in studies on causal pathways linking housing to health outcomes. The findings highlight the need for research to better understand the causal pathways from housing to health and prevention intervention research, including rigorous evaluation of housing interventions and policies to improve health and well-being.

Neighborhood environments significantly influence the development of diabetes risk factors, morbidity, and mortality throughout an individual's life. The social, economic, and physical environments of a neighborhood all affect the health risks of individuals and communities and also affect population health inequities. Factors such as access to healthy food, green spaces, safe housing, and transportation options can impact the health outcomes of residents. Social factors, including social cohesion and neighborhood safety, also play an important role in shaping neighborhood environments and can influence the development of diabetes. Therefore, understanding the complex relationships between neighborhood environments and diabetes is crucial for developing effective strategies to address health disparities and promote health equity. This review presents landmark findings from studies that examined associations between neighborhood socioeconomic, built and physical, and social environmental factors and diabetes-related risk and outcomes. Our framework emphasizes the historical context and structural and institutional racism as the key drivers of neighborhood environments that ultimately shape diabetes risk and outcomes. To address health inequities in diabetes, we propose future research areas that incorporate health equity principles and place-based interventions.

Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined.

This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes.

This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type.

Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability.

Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.

Older immigrants are at higher risks for inactivity due to cultural, environmental, and social barriers in the postmigration context. Community-based physical activity (PA) programs increase PA in older adults, yet little is known about approaches that specifically target older immigrants. This scoping review explores the literature on community-based programs that increase PA and physical fitness in immigrant older adults and identifies barriers and facilitators to PA program participation in this population. A systematic search of electronic databases and gray literature was conducted, and a total of 11 articles met the inclusion criteria after full-text screening. A range of populations and PA program characteristics are described, yet there is a lack of studies on older immigrant men, Black older immigrants, and immigrants from Arab and African countries. There is a need for further research to develop evidence-informed PA programs for this diverse population.

The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.

Since the first Federal Commission on Diabetes issued its report in 1975, the diabetes epidemic in the U.S. has accelerated, and efforts to translate advances in diabetes treatment into routine clinical practice have stalled. In 2021, the National Clinical Care Commission (NCCC) delivered a report to Congress that provided recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. In the five articles in this series, we present the NCCC's evidence-based recommendations to 1) reduce diabetes-related risks, prevent type 2 diabetes, and avert diabetes complications through changes in federal policies and programs affecting the general population; 2) prevent type 2 diabetes in at-risk individuals through targeted lifestyle and medication interventions; and 3) improve the treatment of diabetes and its complications to improve the health outcomes of people with diabetes. In this first article, we review the successes and limitations of previous federal efforts to combat diabetes. We then describe the establishment of and charge to the NCCC. We discuss the development of a hybrid conceptual model that guided the NCCC's novel all-of-government approach to address diabetes as both a societal and medical problem. We then review the procedures used by the NCCC to gather information from federal agencies, stakeholders, key informants, and the public and to conduct literature reviews. Finally, we review the NCCC's three foundational recommendations: 1) improve the coordination of non-health-related and health-related federal agencies to address the social and environmental conditions that are accelerating the diabetes epidemic; 2) ensure that all Americans at risk for and with diabetes have health insurance and access to health care; and 3) ensure that all federal policies and programs promote health equity in diabetes.

lifestyle and cardiometabolic risk factors information is scarce regarding youth and adults of Latin-American ethnics.

the primary aim was to describe the lifestyle and cardiometabolic risk factors for arterial hypertension (HTN) and diabetes in ethnic Latin-American groups (Mapuche and Aymara) and other non-ethnics > 15 years of age in the Chilean population. A secondary aim was to determine the association between physical activity 'intensity' with HTN and diabetes markers.

a representative sample from the National Chilean Health Survey 2016-2017, included Mapuche (EG-Map; women n = 166, men n = 300; total n = 466), Aymara (EG-Aym; women n = 96, men n = 55; total n = 151), and a non-ethnic population group (No-EG; women n = 2057, men n = 3445; total n = 5502). The main outcomes were; systolic blood pressure (SBP), diastolic blood pressure (DBP), and fasting plasma glucose (GL), and secondary outcomes were other anthropometric, lipid profile, and lifestyle parameters.

the GL was significantly associated with nutrition (0.9 %, p < 0.0001), and tobacco and alcohol habits (0.6 %, p < 0.0001). SBP was significantly associated with nutrition (whole-grains 0.04, p = 0.001; water consumption 0.07, p < 0.0001), sleep hygiene (week 0.04, p = 0.030; on weekends -0.04, p = 0.026), and alcohol consumption (-0.06, p < 0.0001).

in conclusion, lifestyle differences among Mapuche and Aymara ethnic groups in comparison with non-ethnic Chilean peers > 15 years are significantly associated with blood pressure and glycemia.

Epidemiological studies have reported an association between traffic-related pollution with risk of metabolic syndrome (MetS). However, evidence from prospective studies on the association of walkability and nitrogen dioxide (NO2) with MetS is still scarce. We, therefore, aimed to evaluate the association of long-term exposure to NO2 and walkability with hazards of incident MetS.

A total of 17,965 participants without MetS diagnosed within one year at baseline were included in our study from a population-based prospective cohort in Yinzhou District, Ningbo, Zhejiang Province, China. Participants were followed up by the regional Health Information System (HIS) until December 15, 2021. MetS was defined based on the criteria of Chinese Diabetes Society (CDS2004). We used walkscore tools, calculating with amenity categories and decay functions, and spatial-temporal land-use regression (LUR) models to estimate walkability and NO2 concentrations. We used Cox proportional hazards regression models to examine the association of walkability and NO2 with hazards of MetS incidence reporting with hazard ratios (HRs) and 95% confidence intervals (CIs).

Overall, we followed up 77,303 person-years and identified 4040 incident cases of MetS in the entire cohort. Higher walkability was inversely associated with incident MetS (HR = 0.94, 95 % CI: 0.91-0.99), whereas NO2 was positively associated with MetS incidence (HR = 1.07, 95 %CI: 1.00-1.15) per interquartile range increment in two-exposure models. Furthermore, we found a significant multiplicative interaction between walkability and NO2. Stronger associations were observed for NO2 and incident MetS among men, smokers, drinkers and participants who aged < 60 years and had higher levels of income.

In summary, we found living in areas with lower walkability and higher concentrations of NO2 were associated with increased incidence of MetS. The beneficial effect of higher walkability may be attenuated by exposure to NO2.

In recent decades, the prevalence of obesity and diabetes has risen substantially in North America and worldwide. To address these dual epidemics, researchers and policymakers alike have been searching for effective means to promote healthy lifestyles at a population level. As a consequence, there has been a proliferation of research examining how the "built" environment in which we live influences physical activity levels, by promoting active forms of transportation, such as walking and cycling, over passive ones, such as car use. Shifting the transportation choices of local residents may mean that more members of the population can participate in physical activity during their daily routine without structured exercise programs. Increasingly, this line of research has considered the downstream metabolic consequences of the environment in which we live, raising the possibility that "healthier" community designs could help mitigate the rise in obesity and diabetes prevalence. This review discusses the evidence examining the relationship between the built environment, physical activity, and obesity-related diseases. We also consider how other environmental factors may interact with the built environment to influence metabolic health, highlighting challenges in understanding causal relationships in this area of research.

Large-scale longitudinal studies evaluating influences of the built environment on risk for type 2 diabetes (T2D) are scarce, and findings have been inconsistent.

To evaluate whether land use environment (LUE), a proxy of neighborhood walkability, is associated with T2D risk across different US community types, and to assess whether the association is modified by food environment.

The Veteran's Administration Diabetes Risk (VADR) study is a retrospective cohort of diabetes-free US veteran patients enrolled in VA primary care facilities nationwide from January 1, 2008, to December 31, 2016, and followed longitudinally through December 31, 2018. A total of 4,096,629 patients had baseline addresses available in electronic health records that were geocoded and assigned a census tract-level LUE score. LUE scores were divided into quartiles, where a higher score indicated higher neighborhood walkability levels. New diagnoses for T2D were identified using a published computable phenotype. Adjusted time-to-event analyses using piecewise exponential models were fit within four strata of community types (higher-density urban, lower-density urban, suburban/small town, and rural). We also evaluated effect modification by tract-level food environment measures within each stratum.

In adjusted analyses, higher LUE had a protective effect on T2D risk in rural and suburban/small town communities (linear quartile trend test p-value <0.001). However, in lower density urban communities, higher LUE increased T2D risk (linear quartile trend test p-value <0.001) and no association was found in higher density urban communities (linear quartile trend test p-value = 0.317). Particularly strong protective effects were observed for veterans living in suburban/small towns with more supermarkets and more walkable spaces (p-interaction = 0.001).

Among veterans, LUE may influence T2D risk, particularly in rural and suburban communities. Food environment may modify the association between LUE and T2D.

Reducing sedentary behaviour (SB) and increasing physical activity (PA) by sitting less and standing/walking more is advised to prevent chronic diseases. However, the mechanisms underlying this recommendation are not well established, especially in individuals with obesity living in low-income regions. The present study evaluated whether there are associations between PA indicators (PAI - standing time, walking time and the number of steps/d) and SB indicators (SBI - sitting/lying down time) with the hormonal profile and resting energy expenditure (REE) of adult women living in a low-income region. This is a cross-sectional study. We collected data on hormones (insulin resistance, leptin and thyroid axis), body composition (tetrapolar bioimpedance), REE (indirect calorimetry), and PAI and SBI (triaxial accelerometers, ActivPAL). Multivariable linear models adjusting for age and fat-free mass were performed. Fifty-eight women (mean age of 31 years and BMI of 33 kg/m²) were included. The mean sitting/lying down time and standing time were 16·08 and 5·52 h/d, respectively. Sitting/lying down time showed a direct association with free thyroxine (FT₄) (β = 0·56 ng/dl; 95 % CI = -1·10, -0·02). Standing time showed a direct association with FT₄ (β = 0·75 ng/dl; 95 % CI = 0·01; 1·48) and inverse association with free triiodothyronine (β = -2·83 pg/ml 95 % CI = -5·56, -0·10). There were no associations between PAI and SBI with the REE, insulin resistance, leptin and thyroid-stimulating hormone. Thus, decreased SB is associated with thyroid hormones levels but not with REE, insulin resistance or leptin in women with obesity living in low-income regions.

This study aimed to describe how strong is the relationship between TEE and PAL in women living in an impoverished Brazilian urban area.

Anthropometric, hormonal (insulin, TSH, FT₄ , and FT₃ ), body composition (deuterium), TEE (doubly labeled water) and PAL (metabolic equivalent task [MET]-7-day triaxial accelerometer, ActivPAL®) data were collected from 55 women (mean age: 31y, mean BMI: 27.4 kg/m² ). Adjusted-TEE models were calculated incorporating the residuals of anthropometric, hormonal, and body composition variables in the TEE, to assess the relation between MET and adjusted-TEE, through three different analyzes: linear regression, nonlinear regression and change-point regression.

Most participants (89.1%, n = 49) were classified as low-active. There was no association between crude TEE and MET.h/d (R²  = 0.05; p = 0.09). There was a positive, although weak, linear relationship between adjusted-TEE and MET.h/d (β = 2705.26 kcal; 95% CI: 436.25; 4974.27; adj-R²  = 0.08). A change point of this relationship was identified in the MET.h/d value of 1.53 (SD = 0.02; adj-R² = 0.13). The association between adjusted-TEE and MET.h/d before the change point (β = 5101.46 kcal; 95%CI: 978.84; 9224.08; adj-R²  = 0.11) was stronger than the association in the full linear model, nevertheless, it was still weak. This association stop existing when it is assessed in individuals after the change point (β = -6609.92 kcal; 95%CI: -16773.24; 3553.40; adj-R²  = 0.08).

These results suggest that the relationship between TEE and PAL is weak and it is not completely linear in women living in an impoverished Brazilian urban area.

One hundred years have passed since the discovery of insulin-an achievement that transformed diabetes from a fatal illness into a manageable chronic condition. The decades since that momentous achievement have brought ever more rapid innovation and advancement in diabetes research and clinical care. To celebrate the important work of the past century and help to chart a course for its continuation into the next, the Canadian Institutes of Health Research's Institute of Nutrition, Metabolism and Diabetes and the U.S. National Institutes of Health's National Institute of Diabetes and Digestive and Kidney Diseases recently held a joint international symposium, bringing together a cohort of researchers with diverse interests and backgrounds from both countries and beyond to discuss their collective quest to better understand the heterogeneity of diabetes and thus gain insights to inform new directions in diabetes treatment and prevention. This article summarizes the proceedings of that symposium, which spanned cutting-edge research into various aspects of islet biology, the heterogeneity of diabetic phenotypes, and the current state of and future prospects for precision medicine in diabetes.

We aim to evaluate whether the current literature supports (i) a causal relationship between neighbourhood walkability and risk of diabetes or instead (ii) a strictly epidemiologic association.

Both cross-sectional and longitudinal studies have reported that neighbourhoods that are scored as having higher levels of walkability have lower rates of prevalent and incident diabetes, respectively. However, other studies have been inconclusive, with more nuanced findings suggesting that this association may be limited to particular demographic groups defined by age and socio-economics. Key factors limiting this literature include disparities in the measurement of walkability, the necessary reliance on observational study designs (recognizing the infeasibility of randomized controlled trials for addressing this question), and the difficulty of disentangling the potential concomitant effects of other components of the built environment. At this time, causality cannot be ascertained in the relationship between neighbourhood walkability and risk of diabetes.

One hundred years have passed since the discovery of insulin-an achievement that transformed diabetes from a fatal illness into a manageable chronic condition. The decades since that momentous achievement have brought ever more rapid innovation and advancement in diabetes research and clinical care. To celebrate the important work of the past century and help to chart a course for its continuation into the next, the Canadian Institutes of Health Research's Institute of Nutrition, Metabolism and Diabetes and the U.S. National Institutes of Health's National Institute of Diabetes and Digestive and Kidney Diseases recently held a joint international symposium, bringing together a cohort of researchers with diverse interests and backgrounds from both countries and beyond to discuss their collective quest to better understand the heterogeneity of diabetes and thus gain insights to inform new directions in diabetes treatment and prevention. This article summarizes the proceedings of that symposium, which spanned cutting-edge research into various aspects of islet biology, the heterogeneity of diabetic phenotypes, and the current state of and future prospects for precision medicine in diabetes.

One hundred years have passed since the discovery of insulin-an achievement that transformed diabetes from a fatal illness into a manageable chronic condition. The decades since that momentous achievement have brought ever more rapid innovation and advancement in diabetes research and clinical care. To celebrate the important work of the past century and help to chart a course for its continuation into the next, the Canadian Institutes of Health Research's Institute of Nutrition, Metabolism and Diabetes and the U.S. National Institutes of Health's National Institute of Diabetes and Digestive and Kidney Diseases recently held a joint international symposium, bringing together a cohort of researchers with diverse interests and backgrounds from both countries and beyond to discuss their collective quest to better understand the heterogeneity of diabetes and thus gain insights to inform new directions in diabetes treatment and prevention. This article summarizes the proceedings of that symposium, which spanned cutting-edge research into various aspects of islet biology, the heterogeneity of diabetic phenotypes, and the current state of and future prospects for precision medicine in diabetes.

Multimorbidity has become highly prevalent around the globe and been associated with adverse health outcomes and cost of care. The built environment has become an important dimension in response to obesity and associated chronic diseases by addressing population sedentariness and low physical activity.

The aim of the following study was to examine whether there was an increased risk for multimorbidity for those living in less walkable neighbourhoods. It was hypothesised that participants residing in less walkable neighbourhoods would have a higher risk for multimorbidity.

City of Toronto and 14 neighbouring regions/municipalities within Ontario, Canada.

Study participants who had completed the Canadian Community Health Survey between the year 2000 and 2012, between 20 and 64 and 65 and 95 years of age, residing within a neighbourhood captured in the Walkability Index, and who were not multimorbid at the time of interview, were selected.

The Walkability Index was the key exposure in the study, which is divided into quintiles (1-least, 5-most walkable neighbourhoods). Participants were retrospectively allocated to one of five quintiles based on their area of residency (at the time of interview) and followed for a maximum of 16 years.

Becoming multimorbid with two chronic conditions.

Becoming multimorbid with three chronic conditions.

Risk for multimorbidity (two chronic conditions) was highest in least compared with most walkable neighbourhoods with an HR of 1.14 (95% CI: 1.02 to 1.28, p=0.0230). While results showed an overall gradient response between decreased walkability and increased risk for multimorbidity, they were not statistically significant across all quintiles or in the older-adult cohort (65-95 years of age).

Study results seem to suggest that low neighbourhood walkability may be a risk factor for multimorbidity over time. More studies are needed to examine whether neighbourhood walkability is a potential solution for multimorbidity prevention at the population level.

The prevalence of Type 2 Diabetes Mellitus among adolescents in the United States continues to rise, following the trajectory of the obesity epidemic which posits not only a substantial health burden to our society, but also a significant threat to the wellbeing of America's youth. While a number of studies have explored the perception of the risk for developing diabetes in the adult population in the United States, this data is minimal for the adolescent population. In this study, we examined the self-perceived risk of diabetes among adolescents with overweight/obesity.

Cross-sectional study of 808 non-diabetic U.S. adolescents overweight or obese, ages 12-19, who completed a physical exam and in-home interview during the 2011-2014 National Heath and Nutritional Examination Survey (NHANES).

Of adolescents with obesity, African Americans (aOR 0.27, 95% CI: 0.15, 0.51) and Hispanic Americans (aOR 0.50, 95% CI: 0.28, 0.90) were significantly less likely to perceive themselves as being at risk for developing diabetes/prediabetes compared to Non-Hispanic Whites. Additionally, individuals with overweight (aOR 13.1, 95% CI: 4.54, 37.5) and obesity (aOR 3.40, 95% CI: 1.71, 6.74) who had been informed by their physician that they were at risk for diabetes, were significantly more likely to perceive themselves to be at risk for diabetes.

Significant racial differences exist in the self-perceived risk for diabetes among U.S. adolescents with overweight and obesity. Further investigation focused on preventing the development of diabetes among at-risk adolescents who do not comprehend their risk, i.e. through more effective healthcare communication, is warranted.

Immigrants may have variable access to chronic disease screening and treatment in their countries of origin and host country, often limited by their immigration status. Immigrants face barriers to chronic disease management and preventive care, including health insurance access, linguistic challenges, lack of culturally sensitive care, limited records, and acculturation. Health care providers should prioritize chronic disease screening and follow up regularly to encourage preventive care and self-management of chronic disease.

Various aspects of the urban environment and neighbourhood socio-economic status interact with each other to affect health. Few studies to date have quantitatively assessed intersections of multiple urban environmental factors and their distribution across levels of deprivation.

To explore the spatial patterns of urban environmental exposures within three large Canadian cities, assess how exposures are distributed across socio-economic deprivation gradients, and identify clusters of favourable or unfavourable environmental characteristics.

We indexed nationally standardized estimates of active living friendliness (i.e. "walkability"), NO₂ air pollution, and greenness to 6-digit postal codes within the cities of Toronto, Montreal and Vancouver. We compared the distribution of within-city exposure tertiles across quintiles of material deprivation. Tertiles of each exposure were then overlaid with each other in order to identify potentially favorable (high walkability, low NO₂, high greenness) and unfavorable (low walkability, high NO₂, and low greenness) environments.

In all three cities, high walkability was more common in least deprived areas and less prevalent in highly deprived areas. We also generally saw a greater prevalence of postal codes with high vegetation indices and low NO₂ in areas with low deprivation, and a lower greenness prevalence and higher NO₂ concentrations in highly deprived areas, suggesting environmental inequity is occurring. Our study showed that relatively few postal codes were simultaneously characterized by desirable or undesirable walkability, NO₂and greenness tertiles.

Spatial analyses of multiple standardized urban environmental factors such as the ones presented in this manuscript can help refine municipal investments and policy priorities. This study illustrates a methodology to prioritize areas for interventions that increase active living and exposure to urban vegetation, as well as lower air pollution. Our results also highlight the importance of considering the intersections between the built environment and socio-economic status in city planning and urban public health decision-making.

We examined to what extent perceived neighbourhood crime moderates, associations between type 2 diabetes mellitus (T2DM) and perceived local amenities, recreational facilities, footpaths and public transit, and potential mediation of environmental characteristics-T2DM association by physical activity, social contact, sleep and body mass index (BMI).

The 45 and Up Study data of 36, 224 individuals collected from 2010 to 2015 were analysed in 2019 using multilevel logistic regression to examine the association between T2DM and clustering of unfavourable built environment, and any difference in the association with increasing unfavourable environment and area disadvantage. We performed causal mediation analyses stratified by crime to examine whether crime moderated the strength of identified local amenities-T2DM pathways.

The results showed that irrespective of crime, perceived lack of local amenities was associated with increased odds of developing T2DM, and BMI mediated 40% and 30.3% of this association among those who reported unsafe and safe daytime crime, respectively. The proportion mediated by BMI among those who reported unsafe and safe night-time crime was 27.3% and 35.1%, respectively. Walking mediated 5.7% of the local amenities-T2DM association among those who reported safe daytime crime. The odds of T2DM increased with rising unfavourable environment and area disadvantage.

The results suggest that the availability of neighbourhood amenities may lower T2DM risk by increasing walking and reducing BMI regardless of area crime. Policies to enhance access to local amenities and prevent crime, especially in disadvantaged areas, may support healthy behaviour and physical health that can potentially reduce T2DM risk.

Low individual socioeconomic status (SES) is known to be associated with a higher risk of type 2 diabetes mellitus (T2DM), but the extent to which the local context in which people live may influence T2DM rates remains unclear. This study examines whether living in a low property value neighbourhood is associated with higher rates of T2DM independently of individual SES.

Using cross-sectional data from the Maastricht Study (2010-2013) and geographical data from Statistics Netherlands, multilevel logistic regression was used to assess the association between neighbourhood property value and T2DM. Individual SES was based on education, occupation and income. Of the 2,056 participants (aged 40-75 years), 494 (24%) were diagnosed with T2DM.

Individual SES was strongly associated with T2DM, but a significant proportion of the variance in T2DM was found at the neighbourhood level (VPC = 9.2%; 95% CI = 5.0%-16%). Participants living in the poorest neighbourhoods had a 2.38 times higher odds ratio of T2DM compared to those living in the richest areas (95% CI = 1.58-3.58), independently of individual SES.

Neighbourhood property value showed a significant association with T2DM, suggesting the usefulness of area-based programmes aimed at improving neighbourhood characteristics in order to tackle inequalities in T2DM.

We examined whether adults living in highly walkable areas are less likely to develop pre-diabetes and if so, whether this association is consistent according to immigration status and ethnicity.

Population-level health, immigration, and administrative databases were used to identify adults aged 20-64 (n=1 128 181) who had normoglycemia between January 2011 and December 2011 and lived in one of 15 cities in Southern Ontario, Canada. Individuals were assigned to one of ten deciles (D) of neighborhood walkability (from lowest (D1) to highest (D10)) and followed until December 2013 for the development of pre-diabetes.

Overall, 220 225 individuals in our sample developed pre-diabetes during a median follow-up of 8.4 years. Pre-diabetes incidence was 20% higher among immigrants living in the least (D1) (adjusted HR 1.20, 95% CI 1.15 to 1.25, p<0.0001) versus most (D10, referent) walkable neighborhoods after accounting for age, sex, and area income. Findings were similar among long-term residents and across sexes. However, susceptibility to walkability varied by ethnicity where D1 versus D10 adjusted HRs ranged from 1.17 (95% CI 1.02 to 1.35, p=0.03) among West Asian and Arab immigrants to 1.32 (95% CI 1.19 to 1.47, p<0.0001) in Southeast Asians. Ethnic variation in pre-diabetes incidence was more marked in low walkability settings. Relative to Western Europeans, the adjusted HR for pre-diabetes incidence was 2.11 (95% CI 1.81 to 2.46, p<0.0001) and 1.50 (95% CI 1.27 to 1.77, p<0.0001) among Sub-Saharan African and the Carribean and Latin American immigrants, respectively, living in the least walkable (D1) neighborhoods, but only 1.24 (95% CI 1.08 to 1.42, p=0.002) and 1.00 (95% CI 0.87 to 1.15, p=0.99) for these same groups living in the most walkable (D10) neighborhoods.

Pre-diabetes incidence was reduced in highly walkable areas for most groups living in Southern Ontario cities. These findings suggest a potential role for walkable urban design in diabetes prevention.

Diabetes is one of the most widespread global epidemics and has become the main component of the global disease burden. Based on data regarding the prevalence of diabetes in 203 countries and territories from 2013 to 2017, we employed the Bayesian space-time model to investigate the spatiotemporal trends in the global diabetes prevalence. The factors influencing the diabetes prevalence were assessed by the Bayesian LASSO regression model. We identified 77 (37.9%) hotspots with a higher diabetes prevalence than the global average, 10 (0.4%) warm spots with global average level and 116 (57.1%) cold spots with lower level than global average. Of the 203 countries and territories, 68 (33.5%), including 31 hotspots, 5 warm spots and 32 cold spots, exhibited an increasing trend. Of these, 60 experienced an annual increase of more than 0.25%, and 8 showed an increasing trend. Three populous countries, namely China, the USA and Mexico, exhibited a high prevalence and an increasing trend simultaneously. Three socioeconomic factors, body mass index (BMI), urbanization rate (UR) and gross domestic product per capita (GDP-PC), and PM_2.5 pollution were found to significantly influence the prevalence of diabetes. BMI was the strongest factor; for every 1% increase in BMI, the prevalence of diabetes increased by 2.371% (95% confidence interval (95% CI): 0.957%, 3.890%) in 2013 and by 3.045% (95% CI: 1.803%, 4.397%) in 2015 and 2017. PM_2.5 pollution could be a risk factor, and its influencing magnitude gradually increased as well. With an annual PM_2.5 concentrations increase of 1.0% in a country, the prevalence of diabetes increased by 0.196% (95% CI: 0.020%, 0.356%). The UR, on the other hand, was found to be inversely associated with the prevalence of diabetes; with each UR increase of 1%, the prevalence of diabetes decreased by 0.006% (95% CI: 0.001%, 0.011%).

Using data from the United States Behavioral Risk Factor Surveillance System (2003-2012; N = 3,397,124 adults), we estimated associations between prevalent diabetes and four county-level exposures (fast food restaurant density, convenience store density, unemployment, active commuting). All associations confirmed our a priori hypotheses in conventional multilevel analyses that pooled across years. In contrast, using a random-effects within-between model, we found weak, ambiguous evidence that within-county changes in exposures were associated with within-county change in odds of diabetes. Decomposition revealed that the pooled associations were largely driven by time-invariant, between-county factors that may be more susceptible to confounding versus within-county associations.

Higher neighborhood walkability has been associated with a lower risk of type 2 diabetes mellitus (T2DM) by promoting greater physical activity (thereby reducing weight and lowering insulin resistance). However, it is not known if walkability may similarly reduce maternal risk of gestational diabetes mellitus (GDM), which arises in the setting of the severe physiologic insulin resistance of pregnancy. Indeed, the insulin resistance of pregnancy is primarily driven by placental hormones and not maternal weight gain. Thus, we sought to evaluate the impact of neighborhood walkability on maternal risk of GDM and the pathophysiologic determinants thereof (insulin sensitivity and pancreatic beta-cell function).

In this study, 1318 women reported their pregravid physical activity (Baecke questionnaire) while undergoing an oral glucose tolerance test (OGTT) at mean 29.3 weeks' gestation. The OGTT identified 290 women with GDM and enabled assessment of insulin sensitivity and beta-cell function. Based on their residential Walk Score, the women were stratified into the following four established categories of neighborhood walkability: car dependent (n=328), somewhat walkable (n=315), very walkable (n=406), and walker's paradise (n=269).

There was a progressive increase in pregravid total physical activity (p=0.002), non-sport leisure-time activity (p=0.009) and sport activity (p=0.01) across the walkability groups (from car dependent to somewhat walkable to very walkable to walker's paradise), coupled with a concomitant decline in pre-pregnancy body mass index (p=0.007). However, in pregnancy, the groups did not differ in gestational weight gain (p=0.80). Moreover, the walkability groups also did not differ in mean adjusted insulin sensitivity, beta-cell function, or glycemia on the antepartum OGTT. On logistic regression analysis, Walk Score did not predict GDM (OR=1.001, 95% CI 0.995 to 1.007).

Neighborhood walkability is not a significant determinant of maternal risk of GDM. Thus, in contrast to T2DM, the effect of neighborhood design on incidence of GDM will be comparatively modest.

The aim of this study was to compare absolute and relative rates of conversion from prediabetes to diabetes among non-European immigrants to Europeans and Canadian-born residents, overall, and by age and level of glycemia.

We conducted a retrospective cohort population-based study using administrative health databases from Ontario, Canada, to identify immigrants (n=23 465) and Canadian born (n=1 11 085) aged ≥20 years with prediabetes based on laboratory tests conducted between 2002 and 2011. Individuals were followed until 31 December 2013 for the development of diabetes using a validated algorithm. Immigration data was used to assign ethnicity based on country of origin, mother tongue, and surname. Fine and Gray's survival models were used to compare diabetes incidence across ethnic groups overall and by age and glucose category.

Over a median follow-up of 5.2 years, 8186 immigrants and 39 722 Canadian-born residents developed diabetes (7.1 vs 6.1 per 100 person-years, respectively). High-risk immigrant populations such as South Asians (HR: 1.72, 95% CI 1.55 to 1.99) and Southeast Asians (HR: 1.65, 95% CI 1.46 to 1.86) had highest risk of converting to diabetes compared with Western Europeans (referent). Among immigrants aged 20-34 years, the adjusted cumulative incidence ranged from 18.4% among Eastern Europeans to 52.3% among Southeast Asians. Conversion rates increased with age in all groups but were consistently high among South Asians, Southeast Asians and Sub-Saharan African/Caribbeans after the age of 35 years. On average, South Asians converted to diabetes 3.1-4.6 years earlier than Western Europeans and at an equivalent rate of conversion to Western Europeans who had a 0.5 mmol/L higher baseline fasting glucose value.

High-risk ethnic groups converted to diabetes more rapidly, at younger ages, and at lower fasting glucose values than European populations, leading to a shorter window for diabetes prevention.

Highly walkable neighbourhoods may increase transport-related and leisure-time physical activity and thus decrease the risk for obesity and obesity-related diseases, such as type 2 diabetes (T2D).

We investigated the association between walkability and prevalent/incident T2D in a pooled sample from five German cohorts. Three walkability measures were assigned to participant's addresses: number of transit stations, points of interest, and impedance (restrictions to walking due to absence of intersections and physical barriers) within 640 m. We estimated associations between walkability and prevalent/incident T2D with modified Poisson regressions and adjusted for education, sex, age at baseline, and cohort.

Of the baseline 16,008 participants, 1256 participants had prevalent T2D. Participants free from T2D at baseline were followed over a mean of 9.2 years (SD: 3.5, minimum: 1.6, maximum: 14.8 years). Of these, 1032 participants developed T2D. The three walkability measures were not associated with T2D. The estimates pointed toward a zero effect or were within 7% relative risk increase per 1 standard deviation with 95% confidence intervals including 1.

In the studied German settings, walkability differences might not explain differences in T2D.

Background Individuals living in unwalkable neighborhoods appear to be less physically active and more likely to develop obesity, diabetes mellitus, and hypertension. It is unclear whether neighborhood walkability is a risk factor for future cardiovascular disease. Methods and Results We studied residents living in major urban centers in Ontario, Canada on January 1, 2008, using linked electronic medical record and administrative health data from the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort. Walkability was assessed using a validated index based on population and residential density, street connectivity, and the number of walkable destinations in each neighborhood, divided into quintiles (Q). The primary outcome was a predicted 10-year cardiovascular disease risk of ≥7.5% (recommended threshold for statin use) assessed by the American College of Cardiology/American Heart Association Pooled Cohort Equation. Adjusted associations were estimated using logistic regression models. Secondary outcomes included measured systolic blood pressure, total and high-density lipoprotein cholesterol levels, prior diabetes mellitus diagnosis, and current smoking status. In total, 44 448 individuals were included in our analyses. Fully adjusted analyses found a nonlinear relationship between walkability and predicted 10-year cardiovascular disease risk (least [Q1] versus most [Q5] walkable neighborhood: odds ratio =1.09, 95% CI: 0.98, 1.22), with the greatest difference between Q3 and Q5 (odds ratio=1.33, 95% CI: 1.23, 1.45). Dose-response associations were observed for systolic blood pressure, high-density lipoprotein cholesterol, and diabetes mellitus risk, while an inverse association was observed with smoking status. Conclusions In our setting, adults living in less walkable neighborhoods had a higher predicted 10-year cardiovascular disease risk than those living in highly walkable areas.

Living in unwalkable neighborhoods has been associated with heightened risk for diabetes and hypertension. However, highly walkable environments may have higher concentrations of traffic-related air pollution, which may contribute to increased cardiovascular disease risk. We therefore aimed to assess how walkability and traffic-related air pollution jointly affect risk for hypertension and diabetes.

We used a cross-sectional, population-based sample of individuals aged 40-74 years residing in selected large urban centres in Ontario, Canada on January 1, 2008, assembled from administrative databases. Walkability and traffic-related air pollution (NO₂) were assessed using validated tools and linked to individuals based on neighborhood of residence. Logistic regression was used to estimate adjusted associations between exposures and diagnoses of hypertension or diabetes accounting for potential confounders.

Overall, 2,496,458 individuals were included in our analyses. Low walkability was associated with higher odds of hypertension (lowest vs. highest quintile OR = 1.34, 95% CI: 1.32, 1.37) and diabetes (lowest vs. highest quintile OR = 1.25, 95% CI: 1.22, 1.29), while NO₂ exhibited similar trends (hypertension: OR = 1.09 per 10 p.p.b., 95% CI: 1.08, 1.10; diabetes: OR = 1.16, 95% CI: 1.14, 1.17). Significant interactions were identified between walkability and NO₂ on risk for hypertension (p < 0.0001 and diabetes (p < 0.0001). At higher levels of pollution (40 p.p.b.), differences in the probability of hypertension (lowest vs. highest walkability quintile: 0.26 vs. 0.25) or diabetes (lowest vs. highest walkability quintile: 0.15 vs. 0.15) between highly walkable and unwalkable neighborhoods were diminished, compared to differences observed at lower levels of pollution (5 p.p.b.) (hypertension, lowest vs. highest walkability quintile: 0.21 vs. 0.13; diabetes, lowest vs. highest walkability quintile: 0.09 vs. 0.06).

Walkability and traffic-related air pollution interact to jointly predict risk for hypertension and diabetes. Although walkable neighborhoods appear to have beneficial effects, they may accentuate the harmful effects of air pollution on cardiovascular risk factors.

Childhood asthma has shown variable associations with children's physical activity. Neighborhood walkability captures community features that promote walking and is protective against some chronic conditions, such as obesity and diabetes.

We evaluated associations between home neighborhood walkability and incident and ongoing childhood asthma.

In this population-based cohort study, we used prospectively collected administrative healthcare data for the Province of Ontario housed at the Institute for Clinical Evaluative Sciences. We followed an administrative data cohort of 326,383 Toronto children born between 1997 and 2003, inclusive, until ages 8-15 years. Home neighborhood walkability quintile was measured using a validated walkability index with four dimensions: population density, dwelling density, access to retail and services, and street connectivity. Incident asthma was defined by time of entry into the validated Ontario Asthma Surveillance Information System database, which requires two outpatient visits for asthma within two consecutive years or any hospitalization for asthma and follows children with asthma longitudinally starting at any age. Associations between walkability and incident asthma were examined using Cox proportional hazards models. Associations between ongoing asthma and walkability in each year of life were examined using generalized linear mixed models.

Twenty-one percent of children (n = 69,628) developed incident asthma and were followed longitudinally in the Ontario Asthma Surveillance Information System database. Low birth home neighborhood walkability was associated with an increased incidence of asthma (hazard ratio, 1.11; 95% confidence interval, 1.08-1.14). Among children with asthma, low walkability in a given year of a child`s life was associated with greater odds of ongoing asthma in the same year (odds ratio, 1.12; 95% confidence interval, 1.09-1.14).

Children living in neighborhoods with low walkability were at increased risk of incident and ongoing asthma. Neighborhood walkability improvement, such as by adding pedestrian paths to improve street connectivity, offers potential strategies to contribute to primary asthma prevention.