Characterizing the association of neighborhood built-environment and type 2 diabetes-related clinical health outcomes: insights from the All of Us Research Program

To characterize the association between neighborhood built-environment attributes supportive of active-lifestyles and diabetes-related clinical health outcomes among adults with type 2 diabetes mellitus (T2DM) and examine effect modification by racial group and co-morbid psychological distress. We conducted a cross-sectional study of US adults (≥ 18 years) with electronic health record (EHR)-confirmed T2DM using the All of Us Registered Tier Dataset v7 (2017–2023). Participants self-identified as non-Hispanic Black or non-Hispanic White. T2DM-related clinical health outcome were defined using linked EHR data including high hemoglobin A1c (HbA1c; primary outcome), estimated glomerular filtration rate (eGFR), low-density lipoprotein (LDL cholesterol), and EHR-documented T2DM-related conditions. Neighborhood built-environment attributes were assessed using the Physical Activity Neighborhood Environment Scale (PANES; scores range from 0 to 8). PANES scores were categorized as ‘least’ (0–2), ‘moderately’ (3–5), and ‘most’ (6–8) favorable built attributes. Psychological distress was defined by Patient Health Questionnaire-9 (PHQ-9) ≥ 5 or EHR-diagnosis of depression. Modified Poisson regression with generalized estimating equations estimated the relative prevalence between PANES score groups and health outcomes, adjusting for sociodemographic factors. Interaction terms assessed effect modification by race and psychological distress. Overall, 89% of the study population had at least one T2DM-related adverse clinical health outcome. Crude and adjusted association between PANES and health outcomes were not statistically significant. Black individuals living in neighborhoods with the least favorable built attributes had 43% greater prevalence of high LDL cholesterol’(adjusted prevalence ratio (aPR):1.43; 95% CI: 1.03–1.98; interaction term p-value = 0.01) compared to White individuals living in neighborhoods with the most favorable built attributes. Our findings highlight the role of neighborhood contextual factors in shaping cardiometabolic risk. This suggests that built environment inequities may exacerbate racial health disparities. Urban planning efforts that prioritize walkability, access to recreation, and safe public spaces, especially in underserved communities, are needed to support more equitable chronic disease health outcomes.