Structural Racism and Prevalence of Diabetes in a Nationally Representative Sample of US Adults

Background: Prior research has established that historic redlining is a reliable indicator of structural racism. The goal of this study was to investigate the direct and indirect relationships between historic redlining and prevalence of diabetes in a national sample. Methods: Using a previously validated conceptual model, we hypothesized pathways between structural racism and prevalence of diabetes via discrimination, incarceration, poverty, substance use, housing instability, education, and unemployment. We combined census tract level data including diabetes prevalence from the CDC PLACES 2019 database, redlining using historic Home Owners’ Loan Corporation (HOLC) maps from the Mapping Inequality project, and census tract data from the Opportunity Insights database. HOLC grade (a score between 1=best and 4=redlined) for each census tract was based on overlap with historically HOLC graded areas. The final analytic sample consisted of 9,590 US census tracts. Structural equation modeling was used to investigate direct and indirect relationships adjusting for 2010 population. Results: Higher prevalence of diabetes was directly associated with increased redlining (B=0.28, p<0.001). Redlining was directly associated with incarceration (B=0.25, p<0.001); poverty (B=-0.28, p<0.001); housing instability (B=-0.09, p<0.001)); education (B=-0.32, p<0.001); and unemployment (B=-0.34, p<0.001). Redlining was indirectly associated with prevalence of diabetes via discrimination, incarceration, poverty, substance use, housing instability, education, and unemployment with strongest associations for discrimination (B=0.32, p<0.001); binge drinking (B=-0.62, p<0.001) and smoking (B=0.39, p<0.001). Conclusions: Redlining has significant direct and indirect relationships with diabetes prevalence. Discrimination and substance use may be important targets for interventions aiming to mitigate the impact of structural racism on diabetes. Disclosure L.E.Egede: None. R.J.Walker: None. J.A.Campbell: None. S.Linde: None. Funding National Institutes of Health (R01DK118038, R01DK120861, R01MD013826, K01DK131319)