Connecting SDOH and HRSN to Prediabetes and Type 2 Diabetes

Many studies show a clear association between diabetes prevalence and complications and economic stability. Individuals with lower SES are more likely to have type 2 diabetes, experience complications, and die sooner than those with a higher SES.^7,8

Individuals with prediabetes who live in areas associated with lower income, lower educational attainment, and high reliance on Supplemental Nutrition Assistance Program (SNAP) benefits also show a higher risk for developing type 2 diabetes.⁹ Adults with type 2 diabetes living below the federal poverty level have a risk of diabetes-related mortality that is twice as high as those with the highest family income levels.¹⁰ An inverse association between income and HbA1C levels has also been observed among adults with type 2 diabetes.¹¹

Occupational factors have also been linked with prediabetes and/or type 2 diabetes including:

• High job insecurity¹²
• Unemployment¹³
• Exposure to shift work (vs. normal day time schedules)¹⁴
• Long work hours¹⁵

A U.S. population-based survey on diabetes and occupation found the highest prevalence of diabetes among transportation workers and the lowest prevalence of diabetes among physicians.^16,17

Food security is associated with economic stability and has been shown to impact type 2 diabetes prevalence. About 20% of patients with diabetes report food insecurity in their households. Food security improves diabetes management and type 2 diabetes outcomes.^{18,19,20,21,22} Studies have shown that higher access to food (particularly grocery stores and full-service restaurants) is associated with lower type 2 diabetes rates in both metro and non-metro U.S. counties.²³

Educational attainment has been associated with type 2 diabetes prevalence.²⁴ Adults with a college education have the lowest odds of developing type 2 diabetes.²⁵ The risk of diabetes-related mortality is also associated with educational attainment. Individuals with less than a high school education are associated with a diabetes-related mortality rate two times higher than those with a college degree.²⁶ Lower educational attainment is also associated with higher HbA1c levels.²⁷ Additionally, health literacy has been shown to be significantly associated with lower HbA1c levels and increased diabetes knowledge.²⁸

Access, affordability, and quality of health care are associated with diabetes prevalence and outcomes. These metrics are also highly associated with race/ethnicity, SES, and geography in the United States.²⁹ The average health care costs of individuals with diabetes are 2.3 times greater than individuals without diabetes.³⁰ Approximately 14-20% of adults with diabetes report reducing or delaying medication due to cost.^31,32,33 Adults with lower household incomes (less than $50,000) and uninsured adults are also more likely to engage in health care cost-related nonadherence (CRN).³⁴ Individuals with lower incomes, persons of color, and women have been shown to experience disparities in quality of diabetes care.^35,36

Health insurance coverage has been shown to be the strongest predictor of whether adults with diabetes have access to diabetes care.³⁷ Adults without insurance are more likely to have undiagnosed diabetes than those who are insured.³⁸ Geographic availability of health care providers varies substantially in the United States with lower access in areas associated with high diabetes rates and socioeconomic disadvantage.^39,40 Individuals who are uninsured and without a usual source of care have 3‒5 times lower odds of receiving HbA1c screenings, blood pressure tests, or access to needed urgent care.⁴¹

The precise prevalence of diabetes among U.S. adults experiencing housing insecurity is not known; however, one study of individuals receiving care from community health centers found that about 37% of individuals with diabetes reported housing insecurity. These individuals were also more likely to report having an emergency department visit or being hospitalized for diabetes.⁴²

Additional research has also connected housing insecurity to worse health outcomes and less access to care.^{43,44,45,46,47,48} Qualitative research has shown that unstable housing makes it more difficult to engage in self-care, follow self-management routines, afford needed medications and supplies, and eat healthy foods.^49,50 Unstable housing has been identified as a key barrier to diabetes care among low-income individuals.

Results from several studies show that living in a neighborhood with better walkability and access to greenspace is consistently associated with lower risk of type 2 diabetes.^51,52,53,54 Populations more exposed to air pollution are disproportionately at risk for developing type 2 diabetes and evidence from several studies show an increased diabetes risk in populations exposed to environmental chemicals.^{55,56,57,58,59,60,61} Environmental exposures also increase susceptibility to cardiovascular disease (CVD) in people with diabetes.^62.63 Air pollution exposure is related to increased risk of stroke mortality, increased vascular reactivity, and inflammation in those with diabetes compared to those without.^64,65,66

High levels of social cohesion (measured through trust, shared values, and willingness to help neighbors) was associated with a 22% lower incidence of type 2 diabetes.⁶⁷ Additional studies show higher social support is associated with better glycemic control and improved quality of life.^{68,69,70,71,72} Moreover, lack of social support has been associated with diabetes-related mortality complications.⁷³

Some research suggests that social capital, cohesion, and support may influence (or be influenced by) structural racism. One study showed that women with the most exposure to everyday racism had a 31% higher risk of diabetes than those with the lowest exposure; though this association was mediated by BMI.⁷⁴ That said, additional research is needed to understand the intersection between social environment and inequities in diabetes outcomes.⁷⁵