ABSTRACT
BACKGROUND
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.
OBJECTIVES
To evaluate the association between community-level neighborhood walkability and glycemic
control as measured by hemoglobin A1c (A1c) among pregnant individuals with pregestational
diabetes.
STUDY DESIGN
This was a retrospective analysis of pregnant individuals with pregestational diabetes
enrolled in an integrated prenatal and diabetes care program from 2012-2016. Participant
addresses were geocoded and linked at the census tract level. The exposure was community
walkability, defined by the U.S. Environmental Protection Agency (EPA) 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) defined
per national EPA 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.
RESULTS
Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes), 10% were living
in the most walkable communities. All 417 individuals underwent A1c assessment in
early pregnancy (median gestational age: 9.7 weeks; IQR: 7.4, 14.1), and 376 underwent
repeat A1c in late pregnancy (median gestational age: 30.4 weeks, IQR: 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%; aRR: 1.46; 95% CI: 1.00-2.16), as well
as an A1c <6.5% in late pregnancy compared to those living in less walkable communities
(13% vs. 9%; aRR: 1.33; 95% CI: 1.08-1.63). For individuals living in the most walkable
communities, the median A1c was 7.5 (IQR 6.0, 9.4) in early pregnancy and 5.9 (IQR
5.4, 6.4) in late pregnancy. For those living in less walkable communities, the median
A1c was 7.3 (IQR 6.2, 9.2) in early pregnancy and 6.2 (IQR 5.6, 7.1) in late pregnancy.
Change in A1c across pregnancy was not associated with walkability.
CONCLUSIONS
Pregnant individuals with pregestational diabetes 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.
KEY WORDS
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Article info
Publication history
Accepted:
January 31,
2023
Received:
January 30,
2023
Publication stage
In Press Accepted ManuscriptIdentification
Copyright
© 2023 Elsevier Inc. All rights reserved.
