Citizenship and health insurance status predict glycemic management: NHANES data 2007-2016

The prevalence of diabetes in United States (US) immigrants is higher than the general population. Non-citizenship and lack of health insurance have been associated with increased health risks including diabetes, but previous US studies were done in non-representative samples and did not examine the effect on glycemic management. The purpose of this study was to compare demographic, metabolic, and behavioral risk factors for increased blood glucose including citizenship and health insurance status, and determine predictors of poor glycemic management (A1C >= 8.0%). Logistic regression was used to analyze data from the 2007-2016 National Health and Nutrition Examination Surveys (NHANES) of persons with diabetes and available citizenship data ages 30 to 70 years (N = 2702), excluding persons with A1C < 5% and pregnant women. Results represent the weighted sample. Among participants, 92% indicated citizenship by birth (81%) or naturalization (11%). Insured rates increased from 83% to 91% between 2007 and 2008 and 2015-2016 (p < .001). Citizenship was positively associated with insurance status, higher income and education, better diet, increased smoking, and more sedentary hours (ps < .05). Noncitizens (OR: 1.74, 95% CI: 1.20-2.51) and uninsured persons (OR: 1.99, 95% CI: 1.53-2.59) were nearly twice as likely to have poor glycemic management than US citizens by naturalization and insured individuals respectively. We conclude that citizenship and absence of health insurance negatively impacts diabetes management. Policy decisions are needed that address primary and secondary prevention strategies for individuals without citizenship and health insurance to reduce diabetes burden in the US.