How much the burden of diabetes and hypertension is attributable to social inequalities? An intersectional analysis in Brazil

Objective This study aimed to analyze the association between the intersectionality of sex, race/skin color, educational attainment, and the occurrence of hypertension and/or diabetes mellitus among adults, using data from the 2023 Brazilian Vigitel National Survey. Methods A cross-sectional study was conducted using data from Vigitel 2023, which included 21,690 individuals aged ≥ 18 years. The outcomes were self-reported diabetes mellitus, hypertension, and the co-occurrence of both conditions. The exposures of interest were sex, race/skin color, and educational attainment. Analyses were guided by the “multiple jeopardy” framework (Jeopardy Index) to assess the intersectionality of these social markers. Results Black, Brown (mixed-race), Asian, and Indigenous women with low educational attainment had a four-fold higher risk of presenting with both conditions, a three-fold higher risk of diabetes, and a 2.3-fold higher risk of hypertension than that of white men with high educational attainment. Individuals with low educational attainment exhibited a higher prevalence of all assessed morbidities, regardless of sex, race, or skin color. It was estimated that 34.6%, 21.6%, and 44.2% of cases of diabetes, hypertension, and co-occurring diabetes/hypertension, respectively, were attributable to low educational attainment. Conclusions Social and racial markers of inequality are associated with the coexistence of diabetes and hypertension in Brazil. Low educational attainment emerged as a key social determinant of these conditions. Therefore, prevention and control strategies should incorporate actions aimed at addressing these structural vulnerabilities into public health policies.