Overview of Social Determinants of Health in the Development of Diabetes

The American Diabetes Association (ADA) systematic review on social determinants of health (SDOH) and diabetes served to increase awareness and understanding of the impact of SDOH on inequities in diabetes development and outcomes (1). Defined by the World Health Organization (WHO) Commission on the Social Determinants of Health as “the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life” (2), SDOH are shaped by the distribution of money, power, and resources locally, nationally, and internationally (3). Between 30% and 55% of health outcomes are attributable to SDOH, and they are deemed to be the primary drivers of avoidable health inequities (2).

Since the ADA review, there have been numerous scientific publications, statements, and public health and health system initiatives that targeted amelioration of SDOH. Although initiatives for SDOH intervention are notable, effective planning and decision-making regarding strategies to address adverse SDOH in the development of diabetes necessitates an understanding of upstream drivers, which entails getting at the source or root causes. Mitigating root causes has population-wide and enduring effects. There are key upstream SDOH that the WHO SDOH framework includes but commonly cited U.S. governmental SDOH frameworks do not yet incorporate. These upstream drivers are socioeconomic and political contexts and racism. This review 1) gives an overview of the socioeconomic status SDOH and racism in the development of diabetes; 2) discusses racism and socioeconomic and political systems as key additional upstream drivers of SDOH that need attention within U.S. governmental SDOH frameworks; 3) demonstrates the role of these drivers in the cyclical, intergenerational, and population-based nature of SDOH; and 4) concludes by examining current and emerging actions within and reaching beyond the health care sector to mitigate adverse SDOH.

Patterns of associations of socioeconomic status (SES) and race and ethnicity with diabetes prevalence and incidence are longstanding and striking. These patterns demonstrate that diabetes is a disease highly influenced by SDOH factors.

As discussed in the previous review (1), SES includes the dimensions of education, income, and occupation. There is a graded association between each dimension of SES and diabetes prevalence and incidence. In high-income countries, people with lower SES are more likely to develop diabetes and to experience excess diabetes morbidity and early mortality than their counterparts with higher SES (4).

Several studies in the U.S. have established that diabetes prevalence and incidence are associated with level of education in a stepwise pattern (1). Figure 1 shows current diagnosed diabetes prevalence and incidence rates among U.S. adults. Diabetes prevalence and incidence are highest among adults with less than a high school education, followed by those with a high school education and then those with more than a high school education (5). In a recent global cohort study using data from 139 countries, including the U.S., from 1990 to 2017, age-standardized level of educational attainment was negatively associated with type 2 diabetes prevalence and trends (P < 0.0001) (6). Recent studies conducted in other high-income countries have found similar results. For example, in a cross-sectional study using survey data collected annually from 2005 to 2017 in Switzerland, participants with only a primary/lower secondary education (9.2% [95% CI 7.4%, 11.1%]) had a significantly higher prevalence of diabetes than those with a higher secondary/apprenticeship education (7.0% [5.3%, 8.8%]) and tertiary education (5.3% [4.2%, 6.4%]) (7). In a cohort study conducted in the Netherlands, a low level of educational attainment was associated with 24% increased odds of developing type 2 diabetes (8).

Previous studies have established that in the U.S., diabetes prevalence increases on a gradient from high to low income (1). Figure 2 shows current diabetes prevalence rates by family income-to-poverty ratio. Diabetes prevalence and incidence increase with progression farther below the federal poverty line (5). These patterns have been observed in other high-income countries. In a study conducted in Sweden using population data from 2000 to 2010, the prevalence of type 2 diabetes increased as income (equivalized annual household income) decreased (9). In fact, in this study, the income gradient became more prominent as age increased, suggesting that the adverse health effects of a lower income accumulate over time. Studies conducted in Switzerland (7) and the Netherlands (8) both found a significant, negative association between monthly household income and incidence of diabetes. Interestingly, in the study conducted in the Netherlands, participants with a combination of a high level of educational attainment and low income had the highest incidence of type 2 diabetes, followed by those with low level of education and low income (8).

Several systematic reviews and meta-analyses have found a significant relationship between different aspects of occupation (e.g., job insecurity, employment status, and work hours) and greater risk for diabetes. For example, previous reviews and meta-analyses indicate a significant association between increased diabetes incidence or prevalence and high job insecurity, unemployment, or shift work compared with working regular daytime schedules and working more than 55 h per week compared with 35–40 h per week (1). In a recent study conducted with older adults in central Spain, type 2 diabetes incidence was lower among professionals, semiskilled professionals, and administrators compared with farmers and unskilled workers (10).

In summary, the associations of lower SES with higher diabetes prevalence and incidence in the U.S. and among other high-income countries reinforce the need for global policy changes that support economic opportunities and quality education for all to address these socioeconomic disparities.

In addition to the SDOH of SES, race and ethnicity have demonstrated longstanding diabetes disparities in the U.S. among populations that are minoritized, meaning they are relegated to a position of subordinate or inferior status. The American Indian/Alaska Native population, non-Hispanic Black population, Hispanic population, and Asian population have higher diabetes prevalence than the White population, and people with diabetes within these minoritized and marginalized populations suffer disproportionate burdens of morbidity and mortality compared with their White counterparts with diabetes (11). These patterns have endured despite advances in medical care and therapeutics, innovations in diabetes technologies and devices, and research initiatives targeting diabetes disparities. Current diabetes prevalence and incidence rates by race and ethnicity are shown in Fig. 3.

In a 2019 report, the Centers for Disease Control and Prevention (CDC) observed that a 20-year period of increasing national incidence and prevalence of diagnosed diabetes was followed by an 8-year period (2008–2012) during which prevalence remained stable and diabetes incidence decreased (12). These improvements, however, were not observed population-wide. During the 8-year period, the improvement was seen for the White population and Asian population, but incidence rates continued to increase among the non-Hispanic Black population, the Hispanic population, and the population with less than a high school education (12). Braveman et al. (13) examined income disparities in diabetes prevalence within racial and ethnic groups to address the confounding of race and ethnicity with SES. Figure 4 demonstrates that the association of lower income with higher diabetes prevalence is observed for the total population as well as within each racial and ethnic group. Diabetes is a disease of both racial inequality and socioeconomic inequality.

The WHO SDOH framework includes race and ethnicity and concomitant racism among the “socioeconomic position” SDOH factors. Socioeconomic position as an SDOH includes social class, gender, ethnicity (race), education, occupation, and income (3). Governmental SDOH frameworks in the U.S. include neither race and ethnicity nor racism among SDOH. Globally, structural racism has been the subject of research on health inequities, and it is both widely documented and widely accepted that racism is an SDOH (14). In the U.S., although racism is not widely acknowledged as an SDOH, Ogunwole and Golden (15) posited a model that describes pathways through which racism is the upstream determinant that causes the socioeconomic SDOH and other downstream SDOH that result in observed diabetes inequities among minoritized and marginalized populations. Egede et al. (16) recently published a review of structural racism as a driver of diabetes outcomes and concluded that although there is a need for more research that examines structural racism and its impact on diabetes, the small number of studies to date provide evidence that racism has a significant impact on clinical outcomes in diabetes.

As another point of deviation from the WHO framework, frequently cited U.S. SDOH frameworks begin with economic stability factors, which represent conditions at the individual or neighborhood level (1,17,18). In contrast, the WHO SDOH framework starts with “socioeconomic and political context” as an upstream SDOH (3). This determinant includes governance, economic policies, social policies (labor, housing, and land), public policies (education, health, and social protection), and culture and societal values. These governance factors and policies lead to the more downstream individual-level and community-level SDOH of socioeconomic position (e.g., social class, education, income, and occupation), social cohesion and social capital (e.g., inclusion vs. marginalization), material circumstances (e.g., housing, neighborhood quality, and food environment), and health care access (3).

The WHO framing of governance and policies as drivers of SDOH versus the U.S. frameworks’ focus on individual or neighborhood circumstances is noteworthy and has important implications for decision-making regarding priority approaches to intervention. In addition, racism and socioeconomic and political systems serve both as upstream drivers of SDOH conditions and as root causes of SDOH conditions that are enduring and embedded within the fabric of the culture and society.

SDOH are cyclical and intergenerational. They are also systemic and population based. As a result, they are entrenched and difficult to mitigate. Children from low-SES households have lower educational achievement and, as adults, have lower occupational classifications and income than their peers from higher-SES households (19). Similarly, parents’ higher educational attainment, higher occupational classifications, and higher income positively influence the educational, occupational, and financial status of future generations (20–22). Parents with higher SES have children who have higher SES as adults. Factors that contribute to the positive influence of parental SES on child SES include availability of financial and other necessary resources to promote achievement, parental role modeling and expectation setting, and more parental involvement with their children than is seen with lower-SES parents due to greater time availability and freedom from socioecological and environmental stressors experienced by lower-SES parents (22).

This pattern occurs at the population level with adverse SDOH. Figure 5 illustrates the systemic, population-based, cyclical, and intergenerational nature of SDOH. The dimensions of SES are interrelated. A person’s educational opportunities and achievement determine their occupational and employment opportunities and status, and their occupational classification and status determine income. Income, in turn, determines other SDOH conditions: what neighborhoods and housing options one has access to; the quality of the built environment; whether or not one has access to food, a healthy physical environment, and care; and the quality of that food, physical environment, and care. Thus, it is generally the case that people experience more than one adverse SDOH concurrently rather than experiencing one adverse SDOH condition in isolation. Where a person lives and the quality of neighborhood and physical environment influence quality of education and educational attainment, and the cycle continues. Hence, SDOH cannot be ameliorated at the level of an individual or independently of other SDOH conditions. The cycle of adverse SDOH contributes to longstanding patterns of diabetes disparities experienced by marginalized populations (1).

SES and the cycle of conditions resulting from one’s SES differ systematically between population subgroups in the U.S. Compared with the White population, racial and ethnic minoritized and marginalized populations have lower educational attainment, lower job classifications, higher unemployment rates, and lower earnings and income (23–25). Cumulatively, this has led to gross patterns of wealth inequality that maintain and reinforce the cyclical and intergenerational pattern of adverse SDOH for affected population subgroups (26,27).

As is the case globally, within the U.S., policies and societal norms have contributed to the patterns of adverse SDOH that affect population subgroups. This can be demonstrated using Black/African Americans as an example. A more comprehensive examination of SDOH and their effects on the Black/African American population is available (28). Here, by way of illustration, factors in Fig. 5 and brief examples of historical policies that affect each factor in the figure are discussed.

The Black/African American population has lower educational attainment and literacy than the White population. Historical policies that contributed to this disparity include U.S. state anti-literacy laws, which made it illegal for enslaved and free Black individuals to learn to read or write or to gather for the purposes of learning to read or write under penalty of death, and U.S. segregation laws, which legally prohibited Black/African Americans from attending public schools attended by White Americans even long after the Brown v Board of Education ruling (29,30). Enduring inequities, including continued disproportionate funding between White and non-White school districts, maintain educational disparities.

In 2019, Black/African Americans had approximately double the unemployment rate of White Americans (31). Among the employed, a persistent pattern over time is that Black/African Americans are more likely to hold service jobs (e.g., food service workers, janitors, building cleaners, and baggage porters) and less likely to be employed in management or professional jobs than White Americans (32). Historical policies that have influenced employment and occupational classification include Jim Crow laws and U.S. segregation laws that restricted types of employment and job classifications allowable for Black/African Americans and prohibited or limited access to White establishments of employment (33).

Gender and racial pay inequalities in the U.S. lead to lower pay for equal work. In 2020, Black/African American women were paid 58% of what White men were paid for the same occupation (34). A 2019 U.S. Federal Reserve survey reported that White families have the highest level of both median ($188,200) and mean ($983,400) family wealth of all racial and ethnic groups. In sharp contrast, Black families' median and mean wealth are less than 15% of those of White families, with Black families having a median wealth of $24,100 and a mean wealth of $142,500 (27). In 2021, 41.4% of Black/African Americans were below 200% of the poverty line, compared with 25.3% of White Americans (35). Factors that contribute to income and wealth inequalities include the centuries of unpaid labor during U.S. slavery that ensured no accumulation of earnings or opportunity to build wealth, Jim Crow laws that resulted in minimal pay for jobs after emancipation, and persisting racial pay inequalities.

Lower SES among Black/African Americans has, in turn, led to other adverse SDOH conditions. For example, Black/African Americans have disproportionately high rates of homelessness, residence within high-poverty and extreme-poverty neighborhoods, and residence within food deserts (28). Systemic contributors to these adverse SDOH conditions include housing racial segregation and redlining policies, zoning laws, and the inequitable impact of U.S. highway policies on Black/African American neighborhoods (33,36,37). Understanding upstream socioeconomic and political contexts and historical drivers of SDOH is essential for informed planning and design of approaches to mitigate adverse SDOH.

The original ADA review (1) reports associations of diabetes risk and outcomes with the SDOH of SES, neighborhood, and physical environment (housing, built environment, and toxic environmental exposures), food environment (food security, food access, and food availability), health care (access, affordability, and quality), and social context (social cohesion, social capital, and social support). There is evidence of the detrimental impact of each of these adverse SDOH in diabetes. As a population, Black/African Americans are overrepresented in each adverse SDOH domain (28). In the setting of these adverse SDOH, Black/African Americans as a population have inequities in diabetes incidence, prevalence, complications, care quality, utilization, and mortality that are longstanding, well-documented, and beyond the scope of this article (28). Without systematic SDOH intervention, these diabetes disparities will remain unmitigated. Although associations of adverse SDOH with disparities in specific diseases can be highlighted, the impact of SDOH is not disease specific; it is ubiquitous (Supplementary Fig. 1).

Because SDOH are systemic, population-based, cyclical, and intergenerational, actions to mitigate adverse SDOH require structural change and policy interventions to affect both health care and the sectors outside of health care that have responsibility for SDOH conditions. Key sectors include housing, food and agriculture, transportation, education, labor, and justice. Recent developments focused on policy are a promising step toward structural change that targets SDOH and health equity in diabetes. Ultimately, legislation that dismantles existing structural inequities is required.

Health in All Policies (HiAP) is “a collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas” (38). A core of both the CDC and the American Public Health Association (APHA) approaches to health equity, HiAP recognizes that health is influenced by social determinants, and HiAP is a comprehensive approach specifically to address SDOH in the planning and policy-making of all sectors (38,39).

An example of HiAP in action is the 2021 National Clinical Care Commission Report to Congress on Leveraging Federal Programs to Prevent and Control Diabetes and Its Complications (40,41). Established by Congress, the purpose of the National Clinical Care Commission (NCCC) was to make recommendations to leverage federal policies and programs to prevent and treat diabetes more effectively. Recommendations are far-reaching and outline what federal agencies (e.g., Department of Agriculture, Department of Housing and Urban Development, CDC, Centers for Medicare & Medicaid Services, and Food and Drug Administration) and programs (e.g., Supplemental Nutrition Assistance Program for children, Department of Agriculture programs to support farmers, product nutrition labeling, and breastfeeding programs) to make specified changes to ensure operations support health for all and do not represent impediments to health for all. Foundational recommendations address health equity, access to health care, and establishment of an Office of National Diabetes Policy (ONDP) “to develop and implement a national diabetes strategy that leverages and coordinates work across federal agencies and departments to positively change the social and environmental conditions that are promoting the type 2 diabetes epidemic” (41). An ONDP would be inclusive of a broad range of departments and agencies and would represent the multiple sectors outlined by the NCCC as essential to an all-of-government approach, including the Departments of Agriculture, Housing and Urban Development, Transportation, Education, Justice, Defense, Labor, Treasury, Veterans Affairs, and Health and Human Services; the Federal Trade Commission and Federal Communications Commission; the Federal Bureau of Prisons; the Environmental Protection Agency; and the Bureau of Indian Education and Bureau of Indian Affairs. The NCCC report represents a major step forward in advocacy for an HiAP approach that can result in significant structural change to improve outcomes and equity in diabetes prevention and management.

In the context of socioeconomic and political systems as drivers of SDOH, and the magnitude and breadth of SDOH impact, the role of the health care sector in addressing SDOH can be daunting and unclear. Over the last decade, there have been increasing efforts in the U.S. health care system to identify and address adverse SDOH conditions. These efforts have ranged from demonstration projects, such as the Centers for Medicare & Medicaid Services Accountable Health Communities (42), to the recent policy changes by the Joint Commission and the National Committee for Quality Assurance to accredit hospitals and health systems based on their efforts to provide equitable care, treatment, and services. Progression from a sole focus on social needs to the inclusion of advocacy and partnerships in multisector actions for permanent, structural change is needed.

Most efforts by health systems as well as policy changes that affect hospitals and health systems have been focused on addressing patients’ social needs in the setting of health care delivery. According to the National Academy of Sciences 2019 report (43) entitled Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health, five health care sector activities are needed to integrate social care effectively: awareness, adjustment, assistance, alignment, and advocacy. Health systems are focused on refining workflows to identify patients’ social risks via screening (awareness) and connecting patients to social services and community resources to address social needs (assistance). Although screening and referral programs are imperative to help address immediate needs experienced by patients, they only address adverse conditions at the individual patient and family levels. Moreover, referrals generally provide temporary solutions or relief (e.g., food for today or a housing solution for 1 week); thus, they are compensatory in the setting of enduring SDOH conditions (44). Screening and referrals to address social risks, therefore, only scratch the surface of mitigating the SDOH condition or root causes of inequities. These efforts have limited effect on mitigating the SDOH condition or root cause of inequalities unless they are combined with investments in more structural changes.

Alignment and advocacy activities by the health care sector involve understanding the needs of the community they serve, financial and other resource investment, and advocating for policies that promote increasing assets in the community to address health inequities (43). There are a growing number of examples of this type of work happening in large and small health care systems across the U.S. that are increasing economic and educational opportunities as well as addressing other SDOH domains (e.g., food access and housing) that have implications for diabetes prevalence and complications. For instance, Eskenazi Health Center Pecar, a federally qualified health center (FQHC) in Indianapolis, IN, partnered with a coalition of community organizations to develop a clinic-integrated food pantry to increase access to healthy food, to provide nutrition education, and to address food insecurity in the community (45). To address the lack of public transportation in the low-income communities they served, the Henry Ford Health System partnered with a scheduling platform startup, Ford Motor Company, Uber, and Lyft to provide transportation services to their patients (43). Anchor institutions, such as the University of Pennsylvania, Rutgers University, Henry Ford Health System, and Rush University Medical Center, all have made financial or resource investments in their surrounding, primarily low-income communities to support the following initiatives: building affordable housing; training students to teach and to provide other services to low-resourced public schools, thus increasing access to quality education; hiring low-SES-neighborhood residents to work in their facilities; and integrating local businesses that are owned by women or people of color in supply chain initiatives to spur economic growth and opportunities (43). Further research is needed to evaluate these programs fully to determine their effects on health outcomes. However, it has been well established that these alignment and advocacy activities do not happen in a vacuum. Partnership with public-sector agencies and organizations is essential, as is the willingness of health system leadership to invest funds back into the community.

Hospitals operating as nonprofits in the U.S. have a “community benefit” standard requirement to meet for tax exemption. In 1969, the Internal Revenue Code instituted the community benefit standard to compel hospitals to enact programs and activities that benefit the communities they serve through spending that promotes community health and charity care (46). In a recent national study using data from 2015 to 2019, hospital community benefit spending was not associated with any improvements in the rate of food insecurity or diabetes medication adherence at the county level (47). According to the data in this study, 45% of the hospital community benefit spending per capita in the U.S. has been used to cover financial losses from Medicaid reimbursement, whereas only 4% and 1% of community benefit dollars have gone toward community health improvement services and community building, respectively (47). Thus, efforts to improve the health of people with low SES are woefully underfunded by the health care sector. Community benefit spending should be informed by the community health need assessments that hospitals are required to conduct every 3 years to ensure that they make financial investments that actually meet the needs of the communities they serve rather than balance their budget. Through increased health care and community-based partnerships as well as health care sector financial and resource investments, the health care sector can move the needle in addressing disparities in diabetes prevalence and complications and advance health equity.

Momentum is gaining for acknowledgment of racism as a key SDOH that drives observed patterns of U.S. health inequities. The National Institutes of Health, CDC, APHA, American Medical Association, American Psychological Association (APA), and U.S. Preventive Services Task Force (USPSTF) are among organizations that have affirmed racism as a public health issue, a social justice issue, and a root cause of health inequities. Actions taken by a few of these organizations are highlighted below. The CDC provides the following definition of racism: “Racism is a system—consisting of structures, policies, practices, and norms—that assigns value and determines opportunity based on the way people look or the color of their skin. This results in conditions that unfairly advantage some and disadvantage others throughout society” (48). APA verifies race is a social construct that has no underlying genetic or biological basis, and it debunks the practice and idea that different human groups or populations can be ranked hierarchically on the basis of physical appearance (49). In 2021, the APA passed three resolutions (49) acknowledging the historical and present role of racism against people of color in the U.S. The resolution Apology to People of Color for APA’s Role in Promoting, Perpetuating, and Failing to Challenge Racism, Racial Discrimination, and Human Hierarchy in U.S. addresses harm caused by the organization’s complicity in U.S. racism. It also enumerates the promulgation of racism in psychological science and testing and affirms the organization’s commitment to disarming racism, because racism is a violation of inalienable human rights that impedes fulfillment of the organization’s mission of benefiting society and improving lives. Role of Psychology and APA in Dismantling Systemic Racism Against People of Color in U.S. describes psychology’s role in exposing, understanding, and dismantling racism that operates in U.S. society in areas including education, science, health care, work and economic opportunities, criminal justice, early childhood development, and government and public policy. The third APA resolution, Advancing Health Equity in Psychology, posits comprehensive actions to undo discriminatory practices and advance equity in the areas of psychological science and research, education and training, professional practice, and advocacy.

The APHA declared racism a public health crisis and began an initiative across the nation for the adoption by policymakers of declarations that racism is a public health crisis (50). Declarations are formally adopted by city councils, county boards, school boards, and public health departments and are found in governor or mayoral statements. As of August 2021, 37 states had passed 207 declarations (51). Although the declarations may not be enforceable by law, they are an important step in bringing attention to racism and shifting the narrative to drive changes to laws and allocation of resources. Strategic actions associated with the declarations vary and include suggestions for creating an office or task force to collect and disaggregate data on racial inequities and ensure accountability on equity goals, engaging communities more effectively, instituting new policies and programs, building organizational capacity and training, and proposing funding needs and recommendations (50).

Finally, the USPSTF made a commitment to transforming its recommendation-making process with the intention of mitigating the influence of systemic racism in the recommendations it puts forth (28). Strategic actions include science-based steps, such as considering race as a social, not a biological, construct; commissioning a report to understand how systemic racism undermines the benefits of evidence-based clinical preventive services; iteratively updating its recommendation methods to overcome health inequities experienced by populations affected by systemic racism; and communicating what gaps are created by systemic racism in all dissemination efforts. Strategic actions also include steps specific to the USPSTF committee and partnerships, including promoting racial and ethnic diversity in USPSTF membership and leadership and fostering a culture of inclusivity, and collaborating with USPSTF partners and experts to reduce the influence of systemic racism on health. Additional actions include an audit of framework, policy, and position statements that address racism and a systematic review of interventions that reduce health inequities or prevent racism (28). Movement by these organizations and committees is promising and will enable a broadening of the scope of SDOH mitigation actions to tackle the eradication of the deleterious effects of racism on diabetes risks, outcomes, and beyond.

Socioeconomic and racial and ethnic disparities in diabetes are longstanding and widely recognized. While SES is deemed an upstream SDOH in the WHO framework and across all U.S. SDOH frameworks, racism is included as an SDOH in the WHO framework but not in U.S. governmental frameworks. Similarly, socioeconomic and political systems, and their role in policies and societal norms that drive SDOH, are important upstream factors not currently included in U.S. governmental SDOH frameworks. The systemic, cyclical, intergenerational, and population-based nature of SDOH, illustrated with Black/African Americans as an example of a population affected by SDOH, demonstrates the effects of racism and socioeconomic and political contexts as root causes of adverse SDOH conditions in the U.S. Understanding SDOH drivers, including racism and political context, is critical to solving the health inequities caused by SDOH; a problem that is not acknowledged cannot be solved. Institutions, agencies, and individuals seeking to mitigate SDOH must educate themselves on the historical roots of SDOH conditions that affect population subgroups in the U.S. Importantly, because policies played a large historical role in adverse SDOH conditions that persist today, policy will be an essential path forward to mitigate SDOH. Promising advances are Health in All Policies, health system movement from individual-level social needs assessment and referral interventions to leveraging multisector partnerships that can bring structural changes, and emerging actions toward acknowledgment of racism as both a root cause and as an SDOH in the U.S.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

Prior Presentation. Parts of this work were presented at the 83rd Scientific Sessions of the American Diabetes Association, San Diego, CA, 23–26 June 2023. A video of the presentation can found in the full version of the article online at https://doi.org/10.2337/dci23-0001.