Original Research|Articles in Press, 100898

Association of Community Walkability and Glycemic Control Among Pregnant Individuals with Pregestational Diabetes

Published:February 11, 2023DOI:



      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.


      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 2012-2016. 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.


      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.


      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.


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