Disparities in Diabetes: The Nexus of Race,Poverty, and Place

Objectives. We sought to determine the role of neighborhood poverty and racial composition on race disparities in diabetes prevalence.Methods. We used data from the 1999–2004 National Health and Nutrition Examination Survey and 2000 US Census to estimate the impact of individual race and poverty and neighborhood racial composition and poverty concentration on the odds of having diabetes.Results. We found a race–poverty–place gradient for diabetes prevalence for Blacks and poor Whites. The odds of having diabetes were higher for Blacks than for Whites. Individual poverty increased the odds of having diabetes for both Whites and Blacks. Living in a poor neighborhood increased the odds of having diabetes for Blacks and poor Whites.Conclusions. To address race disparities in diabetes, policymakers should address problems created by concentrated poverty (e.g., lack of access to reasonably priced fruits and vegetables, recreational facilities, and health care services; high crime rates; and greater exposures to environmental toxins). Housing and development policies in urban areas should avoid creating high-poverty neighborhoods.In the United States, 25.6 million or 11.3% of adults aged 20 years and older had diabetes in 2010.1 Non-Hispanic Blacks had the highest prevalence at 12.6% compared with non-Hispanic Whites at 7.1%.1 Traditional explanations for the observed race disparity in diabetes prevalence include differences in health behaviors, socioeconomic factors, family history of diabetes, biological factors, and environmental factors.2–4 Little work has been conducted to understand how individual and environment-level factors operate together to produce disparities in diabetes prevalence.A relatively new line of research has begun to show that risk of diabetes is associated with neighborhood attributes that are also associated with race. Auchincloss et al. found that higher diabetes rates were related to lack of availability of neighborhood resources that support physical activity and healthy nutrition.5 Schootman et al. found that poor housing conditions were associated with diabetes prevalence.6 Black neighborhoods are more likely to be characterized by these risk factors (i.e., having food deserts, being less likely to have recreational facilities, and tending to have lower-quality housing than White neighborhoods).7–18 As such it stands to reason that failing to adjust national estimates of diabetes prevalence for these social conditions might influence perceptions of diabetes disparities. LaVeist et al. compared disparities in diabetes in an urban, racially integrated, low-income community with a national sample from the National Health Interview Survey.19,20 They found that when urban Whites and Blacks resided in the same low-income community, the race disparity in diabetes prevalence disappeared, largely because the prevalence rate for Whites increased substantially.19 Ludwig et al. used data from the Moving to Opportunity demonstration project and found a lower prevalence of diabetes among low-income adults who moved from high-poverty neighborhoods to low-poverty neighborhoods compared with low-income adults who moved from a high-poverty neighborhood to another high-poverty neighborhood.21 Findings from these studies suggest the need to further explore the role of place in race disparities in diabetes.We explored whether the nexus of race, poverty, and neighborhood racial composition and poverty concentration illuminates the race disparities in diabetes. Specifically, we examined (1) whether diabetes prevalence increases in predominantly Black neighborhoods compared with predominantly White neighborhoods, (2) whether diabetes prevalence is higher in poor neighborhoods than in nonpoor neighborhoods, and (3) whether the impact of neighborhood racial composition and poverty concentration on the risk of diabetes varies by race. We hypothesized that residential segregation and concentrated poverty (1) increase Black individuals’ exposure to environmental risks associated with poor health, (2) reduce their access to community amenities that promote good health and healthy behaviors, and (3) limit their access to social determinants that promote good health such as quality jobs, education, public safety, and social networks.7,22–24