Neighborhoods that are more conducive to walking are associated with increased levels of physical activity and lower levels of obesity and diabetes, but the effect of neighborhood walkability on the clinical course of patients with diabetes is not known. We conducted a retrospective cohort study in 439,392 adults using population-based administrative health databases to evaluate the effect of neighborhood walkability on the incidence of diabetes related complications. Adults (≥30 years) with diabetes living in Southern Ontario cities were followed from April 1 2007 to March 31 2017. Neighborhood walkability was derived from a validated index and classified into quintiles from lowest (Q1) to highest (Q5). Cox proportional hazards models were used to estimate the hazard of neighborhood walkability on retinopathy (laser photocoagulation/vitrectomy/VEGF therapy), nephropathy (dialysis or kidney transplantation), foot complications (infection/amputation), and avoidable hospitalizations (hyper/hypoglycemia), adjusting for age, sex, ethnicity, income, and comorbid conditions, as well as significant interactions between these and walkability. Overall, baseline characteristics were similar across neighborhoods, however, low walkability areas tended to be wealthier than high walkability areas. The cohort sustained 30457 retinopathy events, 4883 nephropathy events, 40989 foot complications, and 24272 avoidable hospitalizations. There was an increased risk of retinopathy (Q1:Q5 adjusted HR 1.13, 95% CI 1.07-1.19, p<0.001), nephropathy (Q1:Q5 aHR 1.33, 95% CI 1.16-1.52, p<0.001), foot complications (Q1:Q5 aHR 1.27, 95% CI 1.18-1.37, p<0.001), and avoidable hospitalizations (Q1:Q5 aHR 1.49, 95% CI 1.36-1.64, p<0.001) in lower walkability compared to higher walkability neighborhoods. Neighborhood design may have beneficial effects on diabetes complications. This has important implications for policies to promote healthy environments to better manage the burden of chronic metabolic diseases.


R. Shah: None. J. Luo: None. H.C. Gerstein: Research Support; Self; Eli Lilly and Company. Advisory Panel; Self; Eli Lilly and Company. Research Support; Self; Sanofi. Advisory Panel; Self; Sanofi. Other Relationship; Self; Sanofi. Advisory Panel; Self; Merck & Co., Inc.. Research Support; Self; Merck & Co., Inc.. Other Relationship; Self; Merck & Co., Inc.. Advisory Panel; Self; AstraZeneca. Research Support; Self; AstraZeneca. Other Relationship; Self; AstraZeneca. Advisory Panel; Self; Novo Nordisk Inc.. Other Relationship; Self; Novo Nordisk Inc.. Advisory Panel; Self; Abbott, Boehringer Ingelheim Pharmaceuticals, Inc.. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Advisory Panel; Self; Janssen Pharmaceuticals, Inc.. G. Booth: None.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at