Social Factors Shape Diabetes, Dementia Risk Across Populations

There is a well-established link between diabetes and cognitive decline,^1-3 but 2 oral presentations at the American Diabetes Association 2026 Scientific Sessions suggest that social context may be just as consequential as blood sugar levels in determining who develops cognitive impairment.

Taken together, the studies point to a more nuanced picture: social risk factors do not simply add to cognitive vulnerability. They may fundamentally alter the nature of the relationship between metabolic disease and brain health. For clinicians and policymakers alike, the implications are significant, suggesting that cognitive risk stratification in diabetes care cannot be divorced from patients’ social circumstances.

Researchers from the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, drew on a decade of longitudinal data from the Health and Retirement Study to examine whether economic stability, education, and other social risk factors modify the association between prediabetes and cognitive impairment.⁴ Separately, a Tulanw University team investigated how a composite measure of adverse social determinants compounds dementia and mild cognitive impairment risk among adults living with type 2 diabetes.⁵

The Social Side of Cognitive Risk in Prediabetes⁴

Approximately 8 in 10 US adults do not know they have prediabetes of the 115.2 million adults,⁶ or 38%, overall with the condition. Cognitive decline/dementia in this setting is has been documented, but less understood is whether social risk factors that include economic hardship, limited education, and neighborhood disadvantage modify the relationship or co-exist alongside it. The research team from Buffalo set out to answer that question using a robust longitudinal dataset, with findings that could carry significant implications for how clinicians screen and stratify cognitive risk in at-risk populations.

The study drew on data for 2006 to 2016 from the Health and Retirement Study, a nationally representative survey of US adults aged 50 and older. The analytic sample included 11,943 participants; their mean (SD) age was 64.7 (11.0) years and most were female patients (60%). Prediabetes was defined using hemoglobin A_1C values between 5.7% and 6.4%. Participants with a prior diagnosis of diabetes or stroke were excluded to isolate the effect of prediabetes on cognitive trajectory. Cognitive status was assessed using the Langa-Weir algorithm, and cognitive impairment status incorporated scores from 4 domains: immediate word recall (0-10 points), delayed word recall (0-10 points), serial 7s (0-5 points), and backwards counting from 20 (0-2 points). A total score of 0 to 11 indicated cognitive impairment.

Social risk factors were operationalized across Healthy People 2030 domains, which encompassed economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. Specific indicators included difficulty paying bills, medication cost-related nonadherence, low income, employment adversity, food insecurity, neighborhood physical disorder, and lack of health insurance. The team tracked associations between prediabetes and cognitive impairment/dementia over time, then tested interaction terms between prediabetes and each social risk factor in adjusted models.

Economic stability, specifically difficulty paying bills and employment adversity, and education level below high school were significant modifiers. Stratified analyses showed an association between prediabetes and meaningfully higher chances of cognitive impairment among individuals who did not have a hard time paying bills (adjusted OR [aOR], 1.76; 95% CI, 1.33-2.34), who did not have employment adversity (aOR, 1.43; 95% CI, 1.13-1.89), and who had at least a high school education (aOR, 1.46; 95% CI, 1.13-1.89). Among individuals already experiencing economic hardship or educational disadvantage, or who had less than a high school education, the association between prediabetes and cognitive impairment/dementia was not statistically significant.

The results challenge a one-size-fits-all approach to cognitive risk screening. For patients navigating both metabolic vulnerability and social adversity, the clinical picture is considerably more complicated than hemoglobin A_1C alone can capture, and interventions targeting blood sugar in isolation may miss the broader determinants driving cognitive decline in the most vulnerable patients.

The Dementia Burden of Adverse Social Conditions in Type 2 Diabetes⁵

Emerging research suggests that social circumstances may amplify the risk of developing dementia or mild cognitive impairment for people living with type 2 diabetes compared with the contribution from blood sugar alone. In this population, this risk is already elevated. But now, a new study from Tulane University that drew on data from the UK Biobank and the All of Us Research Program shows that where a person lives, their economic stability, and their access to education and health care may yet show how adverse social determinants compound cognitive decline in this population.

The All of Us analysis focused on 13,429 dementia-free adults with type 2 diabetes, and the UK Biobank arm provided a euglycemic, or normal blood glucose level, comparator group. Outcomes of interest were incident mild cognitive impairment and dementia, tracked over a median follow-up of 3 years in All of Us participants. The 5 social domains evaluated were economic stability, education access and quality, health and health care, neighborhood and build environment, and social and community context.

The investigators constructed a composite social determinants of health (SDOH) score drawing on race and 21 indicators across the 5 domains. Cox proportional hazards regression assessed associations with mild cognitive impairment and dementia, adjusting for age, diabetes duration, sex, race, antidiabetes and antihypertensive medications, lipid-lowering agents, and Alzheimer disease polygenic risk score.

Overall, 488 individuals developed mild cognitive impairment and 131, dementia. Each 1 standard deviation increase in the SDOH score was associated with a 24% higher risk of mild cognitive impairment (HR, 1.24; 95% CI, 1.12-1.37) and a 73% higher risk of dementia (HR, 1.73; 95% CI, 1.48-2.02). In addition, compared with those in the lowest SDOH tertile, participants in the highest and moderate SDOH tertiles faced significantly increased risks of MCI (highest, HR, 1.17; 95% CI, 0.91-1.50; moderate, HR, 1.61; 95% CI, 1.27-2.03) and dementia (HR, 1.67; 95% CI, 0.95-2.95; and HR, 4.90; 95% CI, 2.92-8.22, respectively). Male participants carried a significantly lower risk of incident MCI compared with female participants (HR: 0.68; 95% CI, 0.56-0.82).

The authors explain that their findings make a compelling case for SDOH-informed risk stratification in diabetes care. Identifying patients with both high metabolic and high social risk could enable earlier cognitive monitoring and more targeted intervention. A composite SDOH score may meaningfully enhance cognitive risk stratification among people living with T2D.

References

1. Diabetes and cognitive decline. Alzheimer’s Association. Updated January 2025. Accessed June 6, 2026. https://www.alz.org/getmedia/84b5cf98-5b5f-402d-bd4d-9f8b8f497d52/alzheimers-dementia-diabetes-cognitive-decline-ts.pdf
2. Your brain and diabetes. CDC. July 16, 2024. Accessed June 6, 2026. https://www.cdc.gov/diabetes/diabetes-complications/effects-of-diabetes-brain.html
3. Zilliox LA, Chadrasekaran K, Kwan JY, Russell JW. Diabetes and cognitive impairment. Curr Diab Rep. 2016;16(9):87. doi:10.1007/s11892-016-0775-x
4. Ekwunife O, Xu Y, Barthelus H, et al. Prediabetes and cognitive impairment: the influence of social risk factors, HRS 2006-2016. Presented at: American Diabetes Association 2026 Scientific Sessions; June 5-8, 2026; New Orleans, LA. Poster 2362-P.
5. Lu Y, Yoshida Y. Social determinants of health and risk of dementia in people with and without type 2 diabetes-findings from two large national-scale cohorts. Presented at: American Diabetes Association 2026 Scientific Sessions; June 5-8, 2026; New Orleans, LA. Poster 2263-P.
6. Prediabetes: could it be you? CDC. Updated February 17, 2026. Accessed June 6, 2026. https://www.cdc.gov/diabetes/communication-resources/prediabetes-statistics.html