Abstract Body (Do not enter title and authors here): Background: Given the importance of access to healthy food for adults at risk of cardiometabolic diseases, this study focused on investigating food access as a possible pathway between structural racism and prevalence of disease.

Methods: Census tract level data were combined to create a final analytic dataset of 11,457 census tracts across 201 counties, within 38 states. Structural racism was defined as historic residential redlining using Home Owners’ Loan Corporation (HOLC) residential security maps from the Mapping Inequality project (score between 1=best to 4=redlined). Food access was defined using the modified retail food environment index (mRFEI) calculated as the number of healthy food retailers divided by the number of healthy and less healthy food retailers per census tract. Prevalence of disease in each census tract was based on CDC PLACES data and included prevalence of diabetes (DM), high blood pressure (HBP), coronary heart disease (CHD), and obesity. Direct and indirect relationships between redlining and each cardiometabolic disease via food access was investigated using structural equation modeling run in Stata v17, controlling for population of each census tract.

Results: Mean prevalence of DM was 11.8%, HBP 31.9%, CHD 6.0%, and obesity 31.8%. Redlining (0.22, p<0.001) and lower food access (-0.11, p<0.001) were directly associated with higher prevalence of DM. Redlining (0.10, p<0.001) and lower food access (-0.10, p<0.001) were directly associated with higher prevalence of HBP. Redlining (0.12, p<0.001) and lower food access (-0.04, p<0.001) were directly associated with higher prevalence of CHD. Redlining (0.18, p<0.001) and lower food access (-0.12, p<0.001) were directly associated with higher prevalence of obesity. Redlining was also significantly indirectly associated with DM, HBP, CHD, and obesity via food access (-0.10, p<0.001).

Conclusions: Structural racism measured using historical redlining is associated with higher diabetes, high blood pressure, coronary heart disease, and obesity prevalence via decreased food access. Based on these results, interventions to improve access to healthy food options at the community level may help address the impact of structural racism on the health of individuals, particularly those at risk for cardiometabolic diseases living in historically redlined neighborhoods.