While all people with diabetes share some common experiences, there are a series of social and environmental factors that can impact their ability to manage the disease in different ways. These social and environmental factors are known as the social determinants of health (SDOH) and are key for understanding and addressing diabetes health disparities.

A scientific review by endocrinologist and behavioral scientist Felicia Hill Briggs and colleagues describes how physical and food environment, access to healthcare, and socioeconomic context impact outcomes in diabetes. While SDOH impacts all people with diabetes, the scientific review primarily focuses on adults in the US with type 2 diabetes who make up over 95% of diabetes cases in the US.

What are the social determinants of health and how do they relate to diabetes?

The SDOH are the non-medical, social, and environmental factors that are not always in our control. These factors, including but not limited to income, food, and social support, all impact a person’s health in different ways, some more than others, depending on the individual. Because of how complex and varied people’s experiences with the SDOH are, the specific determinants are often defined differently by different researchers, educators, and advocates. 

Briggs focuses on the following five social determinants as having the most impact, in general, on people with diabetes: socioeconomic status, neighborhood and physical environment, food environment, health care, and social context. Look here to learn more about the social determinants of diabetes.

Socioeconomic status and diabetes outcomes

Socioeconomic status (SES) refers to one’s social and economic standing in society, either as an individual or a community, and often accounts for a person’s income, employment, and education. Studies have consistently shown SES to be a strong predictor of diabetes onset and progression largely because it can limit access to the resources needed to prevent and manage the disease. Income, education level, and occupation can determine where a person lives, what they eat, who they spend time with, and how easy it is for them to access and afford high-quality health care – which will have a substantial impact on a person’s physical and mental health. 

• Income is generally used to describe how much money we make as individuals but  can also refer to the income of a household or the average income of an entire community.
• Education is often thought of in terms of years of schooling, but the difference between quality and quantity of education can make a big difference in health outcomes. Literacy is one such measure of quality that is increasingly being accepted as a better measure of education, specifically in Black and lower-income white populations. Literacy is directly related to health literacy, which can be a predictor of diabetes health outcomes.
• Occupation mainly refers to a person’s job type, but it can also encompass their employment status and working conditions (shift work, long hours, safety, etc.). These factors can determine the time and resources a person has to manage their diabetes.

The CDC demonstrated that those in the lowest-income bracket in the US have nearly triple the prevalence of diabetes as those in the highest income bracket. Compared to those with high incomes (>400% of the federal poverty level), diabetes prevalence was over 100% higher for low-income individuals (below the federal poverty level). This stark disparity between income groups has only widened in recent years and is also reflected in community-level data. Neighborhoods with low annual incomes (at or below the federal poverty level), low educational attainment, and greater numbers of SNAP benefit recipients have a much higher chance of adults with prediabetes progressing to type 2 diabetes than those with higher SES. 

How your physical environment affects your A1C

As described above, SES can influence your access to affordable housing and well-resourced neighborhoods. Where people live influences their health due to a host of factors, such as the availability of open public spaces for exercise and leisure, the walkability of the neighborhood, and the proximity to sources of pollutants and toxins. 

• Exercise regulates blood sugar, reduces the risk of cardiovascular disease, and improves overall mood. Safe, well maintained public spaces like parks, playgrounds, and beaches are ideal places to walk, run and play but can be scarce in lower-income neighborhoods. These neighborhoods also tend to be disproportionately inhabited by people of color, which contributes to racial health disparities in diabetes. 
• Walkability is characterized by the presence of sidewalks, street connectivity, and street safety. Several studies, both in and outside of the United States, have demonstrated that more walkable neighborhoods are linked with a lower prevalence of type 2 diabetes among the local population. 
• Toxins in the environment are often invisible and can vary dramatically depending on where people live. These toxins can occur naturally, such as radon gas in basements, or due to human activity, such as with air pollution and pesticides. Toxins have been shown to be associated with diabetes risk and limited studies indicate that toxin exposure can decrease insulin sensitivity and production, though more research is needed. These toxins disproportionately affect low-income neighborhoods due to their proximity to industrial sources and dangerous waste facilities. 

While these three factors can influence a person’s risk for diabetes, the way physical environments influence health is different for everyone. For those experiencing housing instability, their physical environment is constantly changing, making it difficult to manage diabetes. While research on unhoused populations is limited, living without stable housing clearly increases stress and risk for diabetes. Studies have shown that unhoused people with diabetes or those who frequently experience housing instability spend a disproportionate amount of time and resources on finding a safe place to live, rather than on diabetes medications, supplies, and healthy foods.

Food insecurity and diabetes outcomes

Food is crucial in managing diabetes. Unfortunately, an estimated 1 in 5 of people with diabetes do not have reliable access to healthy foods. Food insecurity is defined as not having an adequate quantity and quality of food at all times for household members to have an active, healthy life, and this deprivation is a major risk for diabetes and related complications. A person’s food environment can be described as the number of accessible food stores in their neighborhood as well as the availability and affordability of healthy foods within those stores. 

Studies on food insecurity and its impact on diabetes outcomes have identified three main takeaways: 

• Neighborhood grocery stores with healthy options are not enough to improve eating habits. Living close to fast-food restaurants was linked to a greater prevalence of type 2 diabetes regardless of the number of local grocery stores because individuals can more easily opt for inexpensive, quick meals of low nutritional value.  
• Quality is just as important as quantity. For people with diabetes, it is important to not only ensure adequate food intake to meet the daily calorie requirements but also to ensure a diet of high quality and varied foods to regulate blood sugar levels. 
• About 20% of people with diabetes report household food insecurity. This can adversely impact diabetes health outcomes by limiting their access to foods that help manage the disease or forcing individuals to choose between paying for food or healthcare.

Government programs such as The Supplemental Nutrition Assistance Program (SNAP) support Americans experiencing food insecurity by increasing their access to food, but more can be done to help people with their diabetes management. A pilot program in Texas, California, and Ohio provided healthy food, blood glucose monitors, diabetes management support, and primary care referrals to food pantry clients with diabetes. After two years, researchers found that the clients improved their A1C, ate more fruits and vegetables, and enhanced their diabetes self-management. Food pantries are not traditional sites for diabetes support but could be reimagined as sources of diabetes self-management support given that they serve low-income, food-insecure communities. Learn more about food insecurity and diabetes here.

Seeking health care with diabetes

An individual’s race, socioeconomic status, and geographical location all affect their ability to seek affordable, high-quality healthcare, mainly due to their access to health insurance. In reviewing several population-based studies, Briggs and her colleagues found that having health insurance was the strongest predictor of whether adults will be able to access preventive tools such as A1C screenings and blood pressure checks as well as urgent care when needed. Barriers to preventive medicine lead to higher rates of undiagnosed diabetes, which can increase a person’s risk of avoidable health complications and hospitalizations. For people with diabetes, not having insurance has been correlated with: 

• 60% fewer office visits with a physician
• 52% fewer medication prescriptions 
• 168% more emergency department visits

The health care costs of people with diabetes are nearly 2.3 times those of people without the condition, and not having insurance makes the financial burden even worse. Lower-income and Black populations tend to be disproportionately uninsured, leading these communities to delay life-saving healthcare. This leads to higher A1C levels, decreased ability to perform daily activities, and shorter life spans. Even with insurance, the quality of care that these disadvantaged groups receive is significantly worse than higher-income groups. A study of 21 Veterans Affairs facilities found that Black people with diabetes were more likely to receive care at lower-quality healthcare facilities than their white counterparts. 

Diabetes healthcare and self-management programs need to account for the barriers facing low-income and minority populations and deliver services catered to populations with low literacy, limited access to care/free time, and diabetes-related disabilities. There are three main strategies that address these challenges:

• Community Health Workers (CHWs): CHWs serve as a health resource outside of traditional healthcare spaces. Individual attention given to people with diabetes who otherwise lack medical support can go a long way in ensuring positive health outcomes and engagement in good diabetes care practices. 
• Health information technology: Patient registries in electronic health records, outreach to people with diabetes who are overdue for specific services, and appointment reminders for both providers and patients can all improve the quality of diabetes care.
• Self-management programs: For people on Medicare, programs such as the Diabetes Prevention Program have been shown to improve clinical outcomes, self-care behaviors, and self-management knowledge.

Your social community and diabetes

A person’s community and who they rely on for support is beneficial for emotional wellbeing and a person’s mental and physical health. A study based on the Jackson Heart Study revealed that having a high degree of shared values and trust with neighbors, defined as “neighborhood social cohesion,” was associated with a 22% lower incidence of type 2 diabetes. Other studies have demonstrated a link between emotional support and companionship with managing blood sugar more easily and having a better quality of life. 

These outcomes, however, can also manifest themselves in negative ways. Those surrounded by a community in which they frequently experience racism or other forms of discrimination will be more at risk of developing diabetes and other chronic diseases. The Black Women’s Health Study – a long-term observational study on Black women’s health outcomes conducted by Boston University – found that women who had the highest exposure to everyday racism had a 31% increased risk of diabetes, and women with the highest lifetime exposure to racism had a 16% increased risk. While research on how the social environment affects health outcomes is limited, discrimination can have an impact on a person’s stress levels, in turn affecting the way their body regulates blood sugar levels. 

Briggs calls for systemic change for systemic problems, to alter the systems of oppression that lead to discrimination rather than merely addressing the symptoms of it. Health disparities are rooted in discriminatory policies that date back centuries; and to address these disparities, we need what Briggs calls “next-generation interventions” to target the root cause of problems to make sure they do not persist for decades to come.

How should the SDOH affect the way we think about diabetes?

We all experience diabetes differently, and the worlds we live in shape our lived experience of diabetes in ways that are often beyond our control. Our health is a product of many factors, and it is important to acknowledge that diabetes is not the fault of an individual or an outcome of personal decisions. Understanding the role of SDOH in all this can make it easier to: 

• Identify what is in and what is not in a person’s control. Realize that diabetes is not the fault of an individual, and health outcomes can fall beyond what an individual does or does not do. 
• Recognize how systemic barriers make it harder to access food, healthcare, and information, and that interventions need to be implemented at the systemic level to create long-lasting change.
• Realize the ways in which a person’s environment is affecting them and what changes are within their control. 
• Be aware of the barriers to healthcare and good health for disadvantaged populations so you can better advocate for these communities. 

At diaTribe Change, we are working to highlight the barriers to health so that we can more effectively address them. Diabetes and its complications are not a result of personal choices but a combination of systemic forces that are difficult to address on a population level and often impossible to control at an individual level. Understanding this is a first step toward reducing diabetes stigma and identifying the social, political, and environmental sources of diabetes health disparities.