Long-term effects of neighbourhood deprivation on diabetes risk: quasi-experimental evidence from a refugee dispersal policy in Sweden

Abstract

SUMMARY Background While numerous studies have shown associations between neighborhood quality and chronic disease outcomes, such correlations are potentially confounded by selection of different types of people into different neighborhood environments. We sought to identify the causal effects of neighborhood deprivation on type 2 diabetes risk, by comparing refugees to Sweden who were actively dispersed by government policy to low-, moderate-, or high-deprivation neighborhoods. Methods We studied national register data on N=61,386 refugees who arrived in Sweden at age 25–50 during 1987–1991, a period of quasi-random dispersal of refugees to Swedish neighborhoods varying in poverty, unemployment levels, schooling, and social welfare participation. Individuals in our sample were assigned to one of 4,833 neighborhoods, categorized as high-deprivation” (≥1 SD above the mean), “moderate deprivation” (within 1 SD of the mean), or “low-deprivation” (≥1 SD below the mean). The primary outcome was diagnosis with type 2 diabetes measured through 2010. We used multivariate logistic and linear regressions to assess the effects of neighborhood deprivation on diabetes risk, controlling for potential confounders affecting neighborhood assignment and assessing effects of cumulative exposure to different neighborhood conditions. Findings Being assigned to an area deemed high-deprivation versus low-deprivation was associated with an increased risk of diabetes among refugees (OR 1·22, 95% CI: 1·07, 1·38; p=0·001). In analyses that included fixed effects for assigned municipality, the increased diabetes risk was estimated to be 0·85 percentage points (−0·030, 1·728; p=0·058). Neighborhood effects grew over time, such that 5 years of additional exposure to high-deprivation versus low-deprivation neighborhoods was associated with a 9% increase in diabetes risk. Interpretation This study leverages a natural experiment to show that neighborhood deprivation increased the risk of diabetes among refugees to Sweden. This finding has heightened significance in the context of the current refugee crisis in Europe. Funding U.S. National Heart, Lung, and Blood Institute, U.S. National Center for Advancing Translational Sciences, U.S. National Institute on Minority Health and Health Disparities, Swedish Research Council.

Regional deprivation is associated with the distribution of vulnerable asylum seekers: a nationwide small area analysis in Germany

“…Another study from Sweden created a historical cohort to test the hypothesis that neighbourhood deprivation affects the development of type 2 diabetes among refugees quasi-randomly assigned to neighbourhoods throughout the country 26. The study provides evidence that exposure to high neighbourhood deprivation (compared with low deprivation) increases the risk for diabetes26 an association that has also been found in Germany among the general population 14 27…”

“…One of these has assessed the association between neighbourhood income inequality (based on the Gini coefficient) and the risk of being admitted to hospitals among refugees in Sweden and found no statistically significant effect of the exposure on the outcome 25. Another study from Sweden created a historical cohort to test the hypothesis that neighbourhood deprivation affects the development of type 2 diabetes among refugees quasi-randomly assigned to neighbourhoods throughout the country 26. The study provides evidence that exposure to high neighbourhood deprivation (compared with low deprivation) increases the risk for diabetes26 an association that has also been found in Germany among the general population 14 27…”

Type 2 diabetes in young adults in Central Auckland: demography and complications

“…Studies from many parts of the world have since shown that the prevalence of diabetes is high in migrants . Migration involves losses, disruption to usual life habits, exposure to new experiences and challenges that can impact adiposity and T2D through nutrition transition to high‐caloric diets, physical inactivity, stress and neighbourhood deprivation . Pacific people (40%), Māori (27%) and Asian (20%) people are more likely to reside in the poorest areas (NZ Dep 13 Quintile 5 areas) than people of European descent .…”

“…Pacific people (40%), Māori (27%) and Asian (20%) people are more likely to reside in the poorest areas (NZ Dep 13 Quintile 5 areas) than people of European descent . Several studies have shown a strong association between disadvantaged neighbourhood environments and the increased risk of developing T2D . The potential mediating factors include reduced employment and income opportunities, the purchase of calorie‐dense food, limited psychosocial resources, language barriers and poor coping strategies resulting in chronic high stress …”

“…[17][18][19][20] Migration involves losses, disruption to usual life habits, exposure to new experiences and challenges that can impact adiposity and T2D through nutrition transition to high-caloric diets, physical inactivity, stress and neighbourhood deprivation. 21,22 Pacific people (40%), M aori (27%) and Asian (20%) people are more likely to reside in the poorest areas (NZ Dep 13 Quintile 5 areas) than people of European descent. 3,23 Several studies have shown a strong association between disadvantaged neighbourhood environments and the increased risk of developing T2D.…”