Structural Racism Linked to Increased Prevalence of Kidney Disease, Diabetes, & Cardiovascular Disease

Dinushika Mohottige, MD, MPH
Credit: Duke University

Results of a new study are shining a spotlight on the effect of structural racism on the prevalence of chronic health conditions in the US.

A collaborative effort from investigators at Duke, the University of North Carolina, and Icahn School of Medicine at Mount Sinai, results of the study provide evidence of associations between multiple indicators of structural racism with increased prevalence of chronic kidney disease (CKD), diabetes, and hypertension in residential neighborhoods.

“This study fills an important evidence gap and helps us identify factors which might be targeted to address community health inequities,” said study investigator Dinushika Mohottige, MD, MPH, assistant professor at the Institute of Health Equity Research at the Icahn School of Medicine at Mount Sinai.²

To improve equity in healthcare, evaluating the effects of structural racism has become a focal point of many research efforts, especially in light of the disproportionate impact of the COVID-19 pandemic on racially and ethnically minoritized. With this in mind, investigators designed their research endeavor as a cross-sectional study of public health data and deidentified electronic health records to quantify associations of structural racism indicators with neighborhood prevalence of CKD, diabetes, and hypertension in 150 residential neighborhoods in Durham County, North Carolina, from US census block groups. Neighborhoods selected for inclusion in the study were identified through use of the Durham Neighborhood Compass.^1,2,3

Global indicators of structural racism used as exposure included neighborhood percentage of White residents, economic-racial segregation, and area deprivation. Discrete indicators of structural racism included the amount of neighborhood childcare centers, bus stops, tree cover, reported violent crime, impervious areas, evictions, election participation, income, poverty, education, unemployment, health insurance coverage, and police shootings.¹

Among the 150 neighborhoods included in the study, the median number of residents was 1708 (Interquartile range [IQR], 1109-2489) and the median residential income was $54,531 (IQR, 37,729.27-$78,895.25). The median proportion of Asian, Black, Hispanic or Latino, Indigenous, and White residents were 2% (IQR, 0-6%), 30% (IQR, 16-56%), 10% (IQR, 4-20%), 0% (IQR, 0-1%), and 44% (IQR, 18-70%), respectively.¹

Initial analysis found the prevalence of CKD (0.6-8.2%), diabetes (3.3-24.4%), and hypertension (3.6-48.9%) varied across neighborhoods, with distinct clusters of neighborhoods with greater condition prevalence. Investigators highlighted neighborhoods with lesser prevalence of CKD, diabetes, and hypertension had greater median proportions of White residents, greater concentrations of White households with income $100,000 or greater, and lesser area deprivation. Additionally, reduced prevalence of CKD, diabetes, and hypertension were observed in neighborhoods with lesser median rates of poverty and the greatest median rates of college education.¹

When assessing the impact of global indicators, an increased burden of chronic health conditions was observed for each 1-SD increase in percentage of White population ( prevalence ratio [PR], 1.27; 95% highest density interval [HDI], 1.18-1.35; diabetes PR, 1.43; 95% HDI, 1.37-1.52; hypertension PR, 1.19; 95% HDI, 1.14-1.25), with similar associations observed for economic-racial segregation and area deprivation index.¹

Select results from the analysis of discrete indicators are highlighted below.¹

Violent Crimes


• CKD PR, 1.15; 95% HDI, 1.07-1.23
• Diabetes PR, 1.20; 95% HDI, 1.13-1.28
• Hypertension PR, 1.08; 9% HDI, 1.02-1.14

Median Household Income (per 1-SD decrease)

• CKD PR, 1.19; 95% HDI, 1.12-1.28
• Diabetes PR, 1.25; 95% HDI, 1.18-1.33
• Hypertension PR, 1.06; 95% HDI, 1.03-1.14

Primary Election Participation (per 1-SD decrease)

• CKD PR, 1.15; 95% HDI, 1.06-1.23
• Diabetes PR, 1.32; 95% HDI, 1.23-1.41
• Hypertension PR, 1.06; 95 HDI, 1.01-1.14

Investigators called attention to multiple limitations to consider when interpreting the results of their study. These included the inability to make causal inferences with this data, the use of structural racism indicators not originally developed to describe structural racism, and the use of prevalence data that was only representative of those who used health care.¹

“This cross-sectional study found numerous indicators of structural racism associated with inequities in residential neighborhood health. Although caution should be used when interpreting findings from this cross-sectional ecological analysis, these structural racism constructs could be considered in future efforts to mitigate neighborhood health inequities,” wrote investigators.¹

References:

1. Mohottige D, Davenport CA, Bhavsar N, et al. Residential Structural Racism and Prevalence of Chronic Health Conditions. JAMA Netw Open. 2023;6(12):e2348914. doi:10.1001/jamanetworkopen.2023.48914
2. Mount Sinai Health System. Where you live matters: A first-of-its-kind study illustrates how racism is interrelated with poor health. Newswise. December 21, 2023. Accessed December 21, 2023. https://www.newswise.com/articles/where-you-live-matters-a-first-of-its-kind-study-illustrates-how-racism-is-interrelated-with-poor-health.
3. Adhikari S, Pantaleo NP, Feldman JM, Ogedegbe O, Thorpe L, Troxel AB. Assessment of community-level disparities in coronavirus disease 2019 (COVID-19) infections and deaths in large US metropolitan areas. JAMA Netw Open. 2020;3(7):e2016938. doi:10.1001/jamanetworkopen.2020.16938