All ETDs from UAB

Advisory Committee Chair

April P Carson

Advisory Committee Members

Andrea L Cherrington

Bertha A Hidalgo

Emily B Levitan

Dleann Long

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Public Health


Cardiovascular disease risk is higher among adult with diabetes than those without diabetes. This increase in risk may vary by race, sex, and neighborhood characteristics. Recent US data showed a resurgence in stroke and coronary heart disease (CHD) among adults with diabetes, and an increase in heart failure (HF) mortality. Therefore, this dissertation investigated how cardiovascular disease risk may vary by race, sex, and neighborhood characteristics for adults across the glycemic spectrum.Data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing prospective cohort of 30,239 Black and White adults age 45 years at baseline (2003-07) was used. Race and sex were self-reported and geocoded residential address was linked to national databases to identify neighborhood characteristics. Diabetes status was classified using blood glucose and medication history. Adjudicated incident HF and CHD events occurring through 12/31/2017 were included. In this contemporaneous US cohort, diabetes was associated with increased risk for incident HF. This association did not differ by race, sex, or HF subtype, but the magnitude of the association was stronger among middle-aged (HR=3.66 [95% CI=2.78-4.81]) than older adults (HR=1.82 [1.54-2.15]). Secondly, compared to adults living in the most advantaged neighborhood, those living in the most disadvantaged neighborhood had 1.45 [1.18-1.79] times higher hazard of incident HF, and the magnitude of this association was generally weaker among adults with diabetes than those without diabetes. Thirdly, the association between CHD risk and urban-rural residence varied by diabetes status. Among adults with diabetes, those living in isolated rural areas had an increased CHD risk than those living in urban areas (HR=1.91 [1.14-3.22]). However, living in isolated rural area was not associated with CHD risk among adults without diabetes (HR=0.75 [0.45-1.32]). In conclusion, neighborhood characteristics were associated with CHD and HF risk, although this differed by the neighborhood measure investigated and for those with and without diabetes. Race and sex did not modify any of these associations, while age differences were observed. Addressing neighborhood social, economic, and structural factors and optimal resource allocation for adults in rural areas, especially those with diabetes, is needed for preventing cardiovascular disease.

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