Green environments and cardiometabolic health: exploring incidence and progression through multi-state analysis

It is unknown how greenness affects the development, progression and prognosis of cardiometabolic multimorbidity (CMM). We aimed to evaluate the role of greenness on trajectories of CMM, particularly the transitions from healthy to first cardiometabolic disease (FCMD), then to CMM and followed by death. We used Normalized difference vegetation index (NDVI) as the exposure indicator. CMM was defined as the presence of more than one cardiometabolic diseases, namely ischemic heart disease, type 2 diabetes, and stroke. As a result, among 454,777 participants, 5889 FCMD cases, 6607 CMM cases, and 25,666 death events were observed after a median follow-up of 12.1 years. We found greenness significantly associated with transitions from baseline to FCMD, baseline to death, FCMD to CMM, as well as FCMD to death. When further specifying FCMDs, the effect varied across disease-specific transitions. In conclusion, residential greenness may have an impact on the occurrence, progression and prognosis of CMM.