Abstract
IMPORTANCE: Place-based Climate Vulnerability Index (CVI) may shape metabolic risk through environmental and socioeconomic stressors, but its association with incident type 2 diabetes (T2D) is not well characterized. OBJECTIVE: To determine whether residence in communities with higher CVI is associated with risk of incident T2D. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from the Houston Methodist Learning Health System Registry, a large integrated health system that primarily serves Greater Houston, Texas. Participants included adults aged 18 years or older without T2D at baseline and with at least 1 outpatient encounter and at least 1 subsequent health care encounter from June 2016 to August 2023. Data analysis was conducted September 2025. EXPOSURES: US census tract-level CVI categorized into quartiles (Q1-Q4). MAIN OUTCOMES AND MEASURES: The primary outcome was incident T2D identified by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes, antihyperglycemic prescriptions, or hemoglobin A1c 6.5% or higher. Primary measures were incidence rates (cases per 100 person-years) and adjusted hazard ratios (HRs) with 95% CIs comparing Q4 vs Q1 from Cox models adjusted for demographics, insurance, cardiometabolic risk factors, and baseline hemoglobin A1c. RESULTS: Among 1 003 526 participants (mean [SD] age, 50.9 [18.4] years; 605 829 women [60.4%]; 132 451 African American or Black [13.2%]; 71 408 Asian [7.1%]; 156 989 Hispanic or Latinx [15.6%]; 566 632 White [56.5%]; 35 565 other [3.5%]; 42 942 unknown or not reported [4.3%]), 40 152 developed T2D over 2.1 million person-years (overall incidence, 1.88 cases per 100 person-years). Diabetes incidence was higher among participants residing in Q4 vs Q1 CVI areas (2.66 vs 1.48 cases per 100 person-years), and the 7-year risk was 14.1% for Q4 participants vs 8.6% for Q1 participants. Residence in Q4 vs Q1 CVI was associated with higher T2D risk (HR, 1.23; 95% CI, 1.11-1.36), a statistically significant difference. CONCLUSIONS AND RELEVANCE: In this cohort study of 1 003 526 adults, higher community CVI was associated with greater risk of incident T2D independently of traditional risk factors. Linking geocoded CVI to electronic health records may support targeted prevention, risk stratification, and population health planning.