# Housing Instability and Type 2 Diabetes Outcomes

## TL;DR

Housing instability is linked to slightly worse diabetes outcomes, suggesting that addressing housing issues alone may not be enough to significantly improve health.

## Contribution

The study reveals that housing instability is modestly associated with worse diabetes control, but not with cholesterol levels.

## Key findings

- Housing instability was associated with a 0.12% lower mean HbA1c if housing were stable.
- Stable housing was linked to lower systolic and diastolic blood pressure but not LDL cholesterol.
- The effects were small, indicating the need for combined interventions to improve diabetes outcomes.

## Abstract

Is housing instability associated with worse type 2 diabetes outcomes?

This cohort study including 90 233 adults with type 2 diabetes found that housing instability was associated with modestly worse hemoglobin A1c and systolic and diastolic blood pressure values, but not with worse low-density lipoprotein cholesterol.

The association of housing instability with modestly worse diabetes outcomes suggests that interventions to address housing instability may need to be combined with interventions that address other barriers to optimal diabetes care to have large impacts on diabetes outcomes.

This cohort study of US adults with type 2 diabetes examines the association of housing instability with health outcomes, including hemoglobin A1c, blood pressure, and cholesterol levels.

Housing instability may worsen control of type 2 diabetes outcomes.

To estimate the association between stable vs unstable housing and type 2 diabetes outcomes.

This cohort study analyzed electronic health record data of adults with type 2 diabetes from US community-based health centers from June 2016 to April 2023. Targeted minimum loss estimation was used to examine the association between having vs not having housing instability and subsequent type 2 diabetes outcomes, adjusting for age, date of housing instability assessment, sex, race and ethnicity (social constructs that may indicate the experience of racism), language, comorbidities, health insurance, income, and census-tract level social vulnerability index. Analyses were conducted from July 2023 to September 2024.

Report of housing stability or instability.

Mean hemoglobin A1c (HbA1c) level was the primary outcome; secondary outcomes included systolic and diastolic blood pressure (SBP and DBP) and low-density lipoprotein (LDL) cholesterol. The primary time point was 12 months after initial assessment, with secondary time points at 6, 18, 24, 30, and 36 months.

A total of 90 233 individuals were included (mean [SD] age, 55.4 [13.7] years; 50 772 female [56.3%]; 25 602 Black [28.4%], 27 277 Hispanic [31.4%], 51 720 White [57.3%]); 28 784 individuals (31.9%) had a primary language other than English, and 15 713 (17.4%) reported housing instability. Prior to first housing instability assessment, mean (SD) HbA1c was 7.64% (1.94%), mean (SD) SBP was 130.0 (13.5) mm Hg, mean (SD) DBP was 78.2 (7.8) mm Hg, and mean (SD) LDL cholesterol was 101.1 (35.2) mg/dL. We estimated had all individuals experienced stable housing, compared with unstable housing, mean HbA1c would have been 0.12% lower (95% CI, −0.16% to −0.07%; P < .001), SBP would have been 0.77 mm Hg lower (95% CI, −1.14 mm Hg to −0.39 mm Hg; P < .001), and DBP 0.27 mm Hg lower (95% CI, −0.49 mm Hg to −0.06 mm Hg; P = .01), but LDL cholesterol would not have been lower (estimated difference, −1.46 mg/dL, 95% CI, −2.96 mg/dL to 0.03 mg/dL; P = .05) at 12 months, with numerically similar results at other time points.

In this cohort study, housing stability was associated with small differences in type 2 diabetes outcomes; combining housing stability interventions with other diabetes interventions may be needed to improve type 2 diabetes outcomes more substantially.