Neighborhood deprivation and inequities in coronary heart disease among patients with diabetes mellitus: a multilevel study of 334,000 patients

Income variability and incident cardiovascular disease in diabetes: a population-based cohort study

BACKGROUND AND AIMS

Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D).

METHODS

Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders.

RESULTS

High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results.

CONCLUSIONS

Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.

Disparities in cardiovascular disease and treatment in the Nordic countries

The Nordic countries, including Denmark, Finland, Iceland, Norway, and Sweden have seen a steep decline in cardiovascular mortality in recent decades. They are among the most egalitarian countries by several measures, and all have universal, publicly funded welfare systems providing healthcare for all citizens. However, despite these seemingly ideal conditions, disparities in access to cardiovascular care and outcomes persist. To address this challenge, The Lancet Region Health-Europe convened experts from a broad range of countries to summarize the current state of knowledge on cardiovascular disease disparities across Europe. This Series Paper presents the main challenges in Nordic countries based on evidence from high-quality nationwide registries. Focusing on major cardiovascular health determinants, areas in need of improvement were identified. There is a need for addressing structural causes underlying these disparities, such as poverty and discrimination, but also to improve access to healthcare in deprived neighborhoods and to address underlying social determinants of health that may mitigate disparities in cardiovascular outcomes. Overall, while the Nordic countries have made great strides in promoting egalitarianism and providing universal healthcare, there is still much work to be done to ensure equitable access to care and improved cardiovascular outcomes for all members of society.

Social inequalities between neighborhoods and cardiovascular disease: a multilevel analysis in a Latin American city

Studies analyzing relations between cardiovascular diseases (CVDs) and environmental aspects in Latin American cities are relatively recent and limited, since most of them are conducted in high-income countries, analyzing mortality outcomes, and comprising large areas. This research focuses on adults with diabetes and/or hypertension under clinical follow-up who live in deprived areas. At the individual level we evaluated sociodemographic and cardiovascular risk factors from patient's records, and at the neighborhood level, socioeconomic conditions from census data. A multilevel analysis was carried out to study CVD. More women than men were under clinical follow-up, but men had higher frequency, higher odds, and shorter time to CVD diagnosis. Multilevel analysis showed that residing in neighborhoods with worst socioeconomic conditions leads to higher odds of CVDs, even after controlling for individual variables: OR (CI95%) of CVD in quartile 2 (Q2) 3.9 (1.2-12.1); Q3 4.0 (1.3-12.3); Q4 2.3 (0.7-8.0) (vs. highest socioeconomic level quartile). Among individuals living in unequal contexts, we found differences in CVD, which makes visible inequalities within inequalities. Differences between women and men should be considered through a gender perspective.

Comparing Global and Spatial Composite Measures of Neighborhood Socioeconomic Status Across US Counties

Area-level neighborhood socioeconomic status (NSES) is often measured without consideration of spatial autocorrelation and variation. In this paper, we compared a non-spatial NSES measure to a spatial NSES measure for counties in the USA using principal component analysis and geographically weighted principal component analysis (GWPCA), respectively. We assessed spatial variation in the loadings using a Monte Carlo randomization test. The results indicated that there was statistically significant variation (p = 0.004) in the loadings of the spatial index. The variability of the census variables explained by the spatial index ranged from 60 to 90%. We found that the first geographically weighted principal component explained the most variability in the census variables in counties in the Northeast and the West, and the least variability in counties in the Midwest. We also tested the two measures by assessing the associations with county-level diabetes prevalence using data from the CDC's US Diabetes Surveillance System. While associations of the two NSES measures with diabetes did not differ for this application, the descriptive results suggest that it might be important to consider a spatial index over a global index when constructing national county measures of NSES. The spatial approach may be useful in identifying what factors drive the socioeconomic status of a county and how they vary across counties. Furthermore, we offer suggestions on how a GWPCA-based NSES index may be replicated for smaller geographic scopes.

Sleep and neighborhood socioeconomic status: a micro longitudinal study of chronic low-back pain and pain-free individuals

Individuals with chronic low back pain (cLBP) frequently report sleep disturbances. Living in a neighborhood characterized by low-socioeconomic status (SES) is associated with a variety of negative health outcomes, including poor sleep. Whether low-neighborhood SES exacerbates sleep disturbances of people with cLBP, relative to pain-free individuals, has not previously been observed. This study compared associations between neighborhood-level SES, pain-status (cLBP vs. pain-free), and daily sleep metrics in 117 adults (cLBP = 82, pain-free = 35). Neighborhood-level SES was gathered from Neighborhood Atlas, which provides a composite measurement of overall neighborhood deprivation (e.g. area deprivation index). Individuals completed home sleep monitoring for 7-consecutive days/nights. Neighborhood SES and pain-status were tested as predictors of actigraphic sleep variables (e.g., sleep efficiency). Analyses revealed neighborhood-level SES and neighborhood-level SES*pain-status interaction significantly impacted objective sleep quality. These findings provide initial support for the negative impact of low neighborhood-level SES and chronic pain on sleep quality.

Moving Diabetes Upstream: the Social Determinants of Diabetes Management and Control Among Immigrants in the US

PURPOSE OF REVIEW

Relative to the US-born population, immigrants are less likely to successfully manage and control their diabetes, leading to a host of diabetes-related complications. This review draws on the social determinants of health framework (SDoH) to summarize the multilevel factors that shape diabetes care and management among immigrants in the USA.

RECENT FINDINGS

While the diabetes literature is replete with research on individual-level risk factors and health behaviors, empirical literature linking the SDoH to diabetes management among immigrants is limited. However, housing precarity, food insecurity, poverty, uninsurance and underinsurance, and limited support for immigrants in healthcare systems are consistently shown to deter diabetes management and care. Immigrants with diabetes face a multitude of structural constraints to managing their diabetes. More research that theorizes the role of SDoH in diabetes management along with empirical qualitative and quantitative studies are needed. Interventions to address diabetes also require a more upstream approach in order to mitigate the drivers of diabetes disparities among immigrants.

Effect of socioeconomic deprivation on outcomes of diabetes complications in patients with type 2 diabetes mellitus: a nationwide population-based cohort study of South Korea

INTRODUCTION

This study aimed to examine the effect of socioeconomic deprivation on the outcomes of diabetes complications in patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

We conducted a cohort study using claims data and 2005 national census data. We included of 7510 patients newly diagnosed with T2DM from 2004 to 2012 and aged 40 years or above. We excluded participants who had onset of diabetes complications and hospitalization within 1 year after initial onset T2DM, aged less than 40 years and with missing covariates. We used the regional socioeconomic deprivation index and classified study participants into five categories according to the quintile distribution. We calculated the adjusted HR and 95% CI for hospitalization related to diabetes complications and all-cause mortality by applying Cox proportional hazards model and the adjusted subdistribution hazards model.

RESULTS

The percentages of participants in the first quintile (least deprived) to fifth quintile (most deprived) were 27.0%, 27.9%, 19.5%, 14.8%, and 10.8% for socioeconomic deprivation; 25.4%, 28.8%, 32.4%, 34.6%, and 37.6% for hospitalization due to diabetes complications; 1.3%, 2.1%, 2.5%, 2.9%, and 3.6% for deaths from diabetes complications; and 5.7%, 7.2%, 9.7%, 9.7%, and 13.1% for deaths from all causes, respectively. Participants with higher socioeconomic deprivation had a higher HR for hospitalization and mortality from all-cause and diabetes complications. These associations were the strongest among men and participants in their 40s in hospitalization related to diabetes complications, 50s in diabetes complications-specific mortality and 50s and 60s in all-cause mortality.

CONCLUSIONS

Patients with T2DM with high socioeconomic deprivation had higher hospital admission and mortality rates for diabetes complications than those with low deprivation. We cannot fully explain the effect of socioeconomic deprivation on diabetes outcomes. Therefore, further studies are needed in order to find underlying mechanisms for these associations.

Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

Water insecurity and gendered risk for depression in rural Uganda: a hotspot analysis

Background

Water insecurity is linked to depression in low- and middle-income countries (LMICs), though it remains unclear how geospatial clustering of water insecurity in rural regions is associated with risk for depression.

Methods

We conducted a population-based survey of a rural parish in southwestern Uganda (N = 1603) to evaluate the joint geospatial clustering of water insecurity and risk for depression among men and women living in rural Uganda.

Results

Geospatial clustering of self-reported water insecurity and depressive symptoms was found to be present among both men and women. Depression hotspots were more often observed near water insecurity hotspots among women, relative to men. Multivariable regression revealed that residing in a water insecurity hotspot significantly increased risk for depressive symptoms among women, but not among men.

Conclusions

Residing in a water insecurity hotspot is associated with greater risk for probable depression among women, but not among men, pointing to the need for focused depression screening among women residing in water insecure households.

Neighborhood Environments and Diabetes Risk and Control

PURPOSE OF REVIEW

The objective of this review is to highlight the evidence on the association between contextual characteristics of residential environments and type 2 diabetes, to provide an overview of the methodological challenges and to outline potential topics for future research in this field.

RECENT FINDINGS

The link between neighborhood socioeconomic status or deprivation and diabetes prevalence, incidence, and control is robust and has been replicated in numerous settings, including in experimental and quasi-experimental studies. The association between characteristics of the built environment that affect physical activity, other aspects of the built environment, and diabetes risk is robust. There is also evidence for an association between food environments and diabetes risk, but some conflicting results have emerged in this area. While the evidence base on the association of neighborhood socioeconomic status and built and physical environments and diabetes is large and robust, challenges remain related to confounding due to neighborhood selection. Moreover, we also outline five paths forward for future research on the role of neighborhood environments on diabetes.

Outcomes of Secondary Prevention among Coronary Heart Disease Patients in a High-Risk Region in Finland

Despite comprehensive national treatment guidelines, goals for secondary prevention of coronary heart disease (CHD) have not been sufficiently met everywhere in Finland. We investigated the recorded risk factor rates of CHD and their spatial differences in North Karelia Hospital District, which has a very high cardiovascular burden, in order to form a general view of the state of secondary prevention in a high-risk region. Appropriate disease codes of CHD-diagnoses and coding for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) were used to identify from the electronic patient records the patient group eligible for secondary prevention. The cumulative incidence rate of new patients (n = 2556) during 2011–2014 varied from 1.9% to 3.5% between municipalities. The success in secondary prevention of CHD was assessed using achievement of treatment targets as defined in national guidelines. Health centres are administrated by municipalities whereupon the main reporting units were municipalities, together with composed classification of patients by age, gender and dwelling location. Health disparities between municipalities, settlement types and patient groups were found and are interpreted. Moreover, spatial high-risk and low-risk clusters of acute CHD were detected. The proportion of patients achieving the treatment targets of low-density lipoprotein cholesterol (LDL-C) varied from 21% to 38% between municipalities. Variation was also observed in the follow-up of patients; e.g., the rate of follow-up measurements of LDL-C in municipalities varied from 72% to 86%. Spatial variation in patients’ sociodemographic and neighbourhood characteristics and morbidity burden partly explain the differences in outcomes, but there are also very likely differences in the care process between municipalities which requires a study in its own right.

Health inequalities and the impact on the prevalence of cardiovascular risk factors and chronic complications in Argentina: a study on national risk factors surveys

BACKGROUND

In Argentina, there is evidence of health inequalities, measured both at the general level and also using income as a parameter of social status. However, few studies address the issue of health equality in chronic diseases such as cardiovascular risk factors.

OBJECTIVE

To describe health inequalities, using cardiovascular risk factors as a tracer for chronic diseases in different areas of the country and over time. In addition, we aim to identify differences in the quality of care provided to people with cardiovascular risk factors, between 2005 and 2009.

METHODS

This is an observational study, which used descriptive and quantitative methods. Data from the National Risk Factors Survey from 2005 and 2009 in the cohorts who have chronic diseases (hypertension, diabetes, dyslipidemia and overweight/obesity) were analyzed to assess associations between health status and several demographic, epidemiological and socioeconomic variables. Additionally, clinical and metabolic characteristics of people with diabetes and other cardiovascular risks factors were analyzed in 2005 and 2009 using the database Quality of Diabetes Care (QUALIDIAB).

RESULTS

Cardiovascular risk factors are more frequent in people with lower socioeconomic status, regardless of the indicator. The inequalities detected showed the worst indicators in strata with lower education and income, with the same results both nationwide and separated by region. This inequalities were more pronounced in 2009, and their magnitude changed by region and cardiovascular risk factor. From 2005 to 2009, body mass index, blood glucose and HbA1c value increased. In contrast, both systolic blood pressure and triglycerides decreased, with no significant changes in total cholesterol and diastolic blood pressure.

CONCLUSION

Cardiovascular risk factors present inequalities attributed to social status manifesting at both national and regional levels.

Snus use and risk of schizophrenia and non-affective psychosis

BACKGROUND

Recent studies suggest a possible causal role for smoking in schizophrenia and psychosis. Most studies have focused on cigarette smoking, the most common form of tobacco use, but other forms of tobacco exist, including smokeless products such as Swedish snuff (or "snus").

METHODS

We explored whether snus use is associated with schizophrenia and non-affective psychotic illness in a large Swedish registry data set. The majority of participants were aged 18 or 19 at the time of assessment.

RESULTS

We observed a positive association between snus use and odds of schizophrenia in all analyses, but the magnitude of the association was small and the confidence interval wide, consistent with no association (fully adjusted HR 1.03, 95% 0.70-1.54). A similar pattern was observed for non-affective psychosis, but the magnitude of the association was somewhat greater and the confidence intervals narrower, so that these analyses provided stronger statistical evidence for this association (fully adjusted HR 1.22, 95% CI, 1.00-1.48).

CONCLUSIONS

Our results therefore provide modest evidence for an association between snus use and risk for non-affective psychosis. This is consistent with emerging evidence from a range of studies and methodologies that tobacco use may be a risk factor for psychotic illness. However, our results provide some evidence against the hypothesis that it is the burnt products of cigarette smoke that are psychotogenic.

Smoking and schizophrenia in population cohorts of Swedish women and men: a prospective co-relative control study

OBJECTIVE

The purpose of this study was to clarify the causes of the smoking-schizophrenia association.

METHOD

Using Cox proportional hazard and co-relative control models, the authors predicted future risk for a diagnosis of schizophrenia or nonaffective psychosis from the smoking status of 1,413,849 women and 233,879 men from, respectively, the Swedish birth and conscript registries.

RESULTS

Smoking was assessed in women at a mean age of 27 and in men at a mean age of 18. The mean age at end of follow-up was 46 for women and 26 for men. Hazard ratios for first-onset schizophrenia were elevated both for light smoking (2.21 [95% CI=1.90-2.56] for women and 2.15 [95% CI=1.25-3.44] for men) and heavy smoking (3.45 [95% CI=2.95-4.03] for women and 3.80 [95% CI=1.19-6.60] for men). These associations did not decline when schizophrenia onsets 3-5 years after smoking assessment were censored. When age, socioeconomic status, and drug abuse were controlled for, hazard ratios declined only modestly in both samples. Women who smoked into late pregnancy had a much higher risk for schizophrenia than those who quit early. Hazard ratios predicting nonaffective psychosis in the general population, in cousins, in half siblings, and in full siblings discordant for heavy smoking were, respectively, 2.67, 2.71, 2.54, and 2.18. A model utilizing all relative pairs predicted a hazard ratio of 1.69 (95% CI=1.17-2.44) for nonaffective psychosis in the heavy-smoking member of discordant monozygotic twin pairs.

CONCLUSIONS

Smoking prospectively predicts risk for schizophrenia. This association does not arise from smoking onset during a schizophrenic prodrome and demonstrates a clear dose-response relationship. While little of this association is explained by epidemiological confounders, a portion arises from common familial/genetic risk factors. However, in full siblings and especially monozygotic twins discordant for smoking, risk for nonaffective psychosis is appreciably higher in the smoking member. These results can help in evaluating the plausibility of various etiological hypotheses for the smoking-schizophrenia association.

The causal nature of the association between neighborhood deprivation and drug abuse: a prospective national Swedish co-relative control study

BACKGROUND

Risk for drug abuse (DA) is strongly associated with neighborhood social deprivation (SD). However, the causal nature of this relationship is unclear.

METHOD

Three Swedish population-based cohorts were followed up over 5 years for incident registration of DA in medical, legal or pharmacy records. In each cohort, we examined the SD-DA association, controlling carefully for individual socio-economic status (SES) with multiple measures, in the entire sample and among pairs of first cousins, paternal and maternal half-siblings, full siblings and monozygotic (MZ) twins discordant for SD exposure. The number of informative relative pairs ranged from 6366 to 166,208.

RESULTS

In all cohorts, SD was prospectively related to risk for incident DA. In relative pairs discordant for SD exposure, the SD-DA association was similar to that seen in the entire population in cousins, half-siblings, full siblings and MZ twins. Eliminating subjects who were residentially unstable or had DA in the first two follow-up years did not alter this pattern. When divided by age, in the youngest groups, the SD-DA association was weaker in siblings than in the entire population.

CONCLUSIONS

Across three cohorts, controlling for individual SES and confounding familial factors, SD prospectively predicted risk for incident DA registration. These results support the hypothesis that the SD-DA association is in part causal and unlikely to result entirely from personal attributes, which both increase risk for DA and cause selection into high SD environments. At least part of the SD-DA association arises because exposure to SD causes an increased risk of DA.

Association between socioeconomic status, type 2 diabetes and its chronic complications in Argentina

AIM

To compare the socioeconomic status (SES) of people with type 2 diabetes (T2DM) in Argentina (Córdoba) with and without major chronic complications of diabetes, with that recorded in persons without diabetes matched by age and gender.

METHODS

For this descriptive and analytic case-control study, potential candidates were identified from the electronic records of one institution of the Social Security System of the city of Córdoba. We identified and recruited 387 persons each with T2DM with or without chronic complications and 774 gender- and age-matched persons without T2DM (recruitment rate, 83%). Data were obtained by telephone interviews and supplemented with data from the institution's records. Group comparisons were performed with parametric or non-parametric tests as appropriate. We used ordinary least squares to regress household income and the difference between income and household expenses on diabetes status, age, sex, education and body mass index.

RESULTS

Persons with T2DM, particularly those with complications, reported fewer years of general education (13.6±4.2 years vs. 12.2±4.4 years), a lower percentage of full time jobs (43.0% vs. 26.9%), lower salaries and monthly household income among those with full-time jobs (> 5000 ARG$: 52.6% vs. 24.5%), and a higher propensity to spend more money than they earned (expenditure/income ratio≥1: 10.2% vs. 16.0%). The percentage of unmarried people was also higher among people with type 2 diabetes (7.0% vs. 10.9%).

CONCLUSION

T2DM and the development of its complications are each positively associated with lower SES and greater economic distress in Argentina.

Cardiovascular disease in relation to diabetes status in immigrants from the Middle East compared to native Swedes: a cross-sectional study

BACKGROUND

Type 2 diabetes is highly prevalent in immigrants to Sweden from Iraq, but the prevalence of cardiovascular disease (CVD) and its risk factors are not known. In this survey we aimed to compare the prevalence of CVD and CVD-associated risk factors between a population born in Iraq and individuals born in Sweden.

METHODS

This population-based, cross-sectional study comprised 1,365 Iraqi immigrants and 739 Swedes (age 30-75 years) residing in the same socioeconomic area in Malmö, Sweden. Blood tests were performed and socio-demography and lifestyles were characterized. To investigate potential differences in CVD, odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by multivariate logistic regression analysis with adjustment for metabolic, lifestyle and psychosocial risk factors for CVD. Outcome measures were odds of CVD.

RESULTS

There were no differences in self-reported prevalence of CVD between Iraqi- and Swedish-born individuals (4.0 vs. 5.5%, OR 0.9, 95% CI 0.4-1.8). However, the prevalence of type 2 diabetes was higher in Iraqi compared to Swedish participants (8.4 vs. 3.3%, OR = 4.2, 95% CI 2.6-6.7). Moreover, among individuals with type 2 diabetes, Iraqis had a higher prevalence of CVD (22.8 vs. 8.0%, OR = 4.2, 95% CI 0.9-20.0), after adjustment for age and sex. By contrast, among those without diabetes, immigrants from Iraq had a lower prevalence of CVD than Swedes (2.2 vs. 5.5%, OR = 0.6, 95% CI 0.3-0.9).Type 2 diabetes was an independent risk factor for CVD in Iraqis only (OR = 6.8, 95% CI 2.8-16.2). This was confirmed by an interaction between country of birth and diabetes (p = 0.010). In addition, in Iraqis, type 2 diabetes contributed to CVD risk to a higher extent than history of hypertension (standardized OR 1.5 vs. 1.4).

CONCLUSIONS

This survey indicates that the odds of CVD in immigrants from Iraq are highly dependent on the presence or absence of type 2 diabetes and that type 2 diabetes contributes with higher odds of CVD in Iraqi immigrants compared to native Swedes. Our study suggests that CVD prevention in immigrants from the Middle East would benefit from prevention of type 2 diabetes.

Diabetes distress and neighborhood characteristics in people with type 2 diabetes

OBJECTIVE

Diabetes-specific distress is an important psychological issue in people with diabetes. The neighborhood environment has the potential to be an important factor for diabetes distress. This study investigates the associations between neighborhood characteristics and diabetes distress in adults with type 2 diabetes.

METHODS

We used cross-sectional data from a community-based sample of 578 adults with type 2 diabetes from Quebec, Canada. Information on perceived neighborhood characteristics and diabetes distress was collected from phone interviews. We used factor analysis to combine questionnaire items into neighborhood factors. Information on neighborhood deprivation was derived from census data. We performed linear regressions for diabetes distress and specific domains of diabetes distress (emotional, regimen-related, physician-related and interpersonal distress), adjusting for individual-level variables.

RESULTS

Factorial analysis uncovered 3 important neighborhood constructs: perceived order (social and physical order), culture (social and cultural environment) and access (access to services and facilities). After adjusting for individual-level confounders, neighborhood order was significantly associated with diabetes distress and all specific domains of distress; neighborhood culture was specifically associated with regimen-related distress; and neighborhood access was specifically associated with physician-related distress. The objective measure of neighborhood material deprivation was associated with regimen-related distress.

CONCLUSIONS

Neighborhood characteristics are associated with diabetes distress in people with type 2 diabetes. Clinicians should consider the neighborhood environment reported by their patients with diabetes when assessing and addressing diabetes-specific distress.