Racial Disparities in School Belonging and Prospective Associations With Diabetes and Metabolic Syndrome

Importance: School belonging has important implications for academic, psychological, and health outcomes, but the associations between racial disparities in school belonging and health have not been explored to date. Objective: To examine associations between school-level racial disparities in belonging and cardiometabolic health into adulthood in a national sample of Black and White children, adolescents, and young adults. Design, Setting, and Participants: Prospective cohort study of a US national sample of 4830 Black and White students (National Longitudinal Study of Adolescent Health) followed up for 13 years. The study was conducted from 1994 to 1995 for wave 1 and in 2008 for wave 4. Data were analyzed from June 14 to August 13, 2021. Main Outcomes and Measures: School-level racial disparities in belonging at baseline were calculated as the mean level of school belonging for Black students minus the mean level of school belonging for White students at the school that they attended when they were aged 12 to 20 years. Diabetes and metabolic syndrome were measured as outcomes for these same participants at 24 to 32 years of age. Results: The study included 4830 students. For wave 1, mean (SD) age was 16.1 (1.7) years, and for wave 4, 29.0 (1.7) years. A total of 2614 (54.1%) were female, 2219 were non-Hispanic Black (45.9%), and 2611 were non-Hispanic White (54.1%). Among Black students, attending a school with a greater Black-White disparity in school belonging (more negative scores) was associated with an increased risk for diabetes (odds ratio, 0.66 [95% CI, 0.46-0.95]) and more risk factors for metabolic syndrome (rate ratio, 0.95 [95% CI, 0.90-1.00]) in adulthood 13 years later. These associations persisted above individual-level controls (age, sex, and body mass index) and school-level controls (school size, percentage of Black students, and percentage of Black teachers) and were not explained by either an individual's own perception of school belonging or the mean level of belonging across the whole school. Conclusions and Relevance: In this prospective cohort study of US students, racial disparities in school belonging were associated with risks for diabetes and metabolic syndrome in Black students. Among students, fostering a more equal sense of school belonging across racial groups may have implications for health disparities in the cardiometabolic domain into adulthood.