Association between residential greenness and risks of diabetic complications among individuals with type 2 diabetes and the roles of healthy lifestyle behaviors

Prospective evidence on the associations between residential greenness and risks of major diabetic complications remains limited. We explored the associations of residential greenness with incident diabetic macrovascular and microvascular complications among individuals with type 2 diabetes (T2D), and further assessed the roles of lifestyle factors in these associations. Our study included 13,848 patients with T2D. The Normalised Difference Vegetation Index (NDVI) within a 300-m buffer was used as the indicator of residential greenness. Eight lifestyle factors were included to construct a weighted healthy lifestyle score. Cox proportional hazard models were performed to assess the links between residential greenness and diabetic complication risks. We found that each interquartile range increase of NDVI within 300-m buffer was significantly associated with decreased diabetic complication risks, with hazard ratios (95% confidence intervals) of 0.921 (0.881, 0.964) for composite macrovascular complications, 0.886 (0.805, 0.975) for stroke, 0.901 (0.825, 0.985) for heart failure, 0.914 (0.866, 0.965) for coronary artery disease, 0.909 (0.865, 0.956) for composite microvascular complications, 0.842 (0.757, 0.937) for diabetic neuropathy, and 0.899 (0.841, 0.961) for diabetic nephropathy. Air pollutants and physical activity partly mediated these associations. Lifestyle factors modified some residential greenness-complications associations, and no significant associations between residential greenness and diabetic complications were observed among participants with poor lifestyles. Higher residential greenness levels were linked with lower risks of diabetic complications, and lifestyle factors might modify these associations.