Poverty is a significant, independent risk factor for death in patients with diabetes, even when these patients have equal access to healthcare resources, a population-based Swedish registry study indicated.
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Diabetes patients with low socioeconomic status had almost twice the risk for all-cause-, cardiovascular-, and diabetes-related death as high-income patients, even after controlling for other risk factors associated with mortality, reported Araz Rawshani, MD, PhD, of Sahlgrenska University Hospital in Gothenburg, Sweden, and colleagues in JAMA Internal Medicine.
Comparison of hazard ratios for the lowest versus highest income quintiles revealed that:
  • The hazard ratios for all-cause-, cardiovascular-, diabetes-, and cancer-related mortality were 1.71 (95% CI 1.60-1.83), 1.87 (95% CI 1.72-2.05), and 1.80 (95% CI 1.61-2.01), and 1.28 (95% CI 1.14-1.44), respectively.
  • Compared with native Swedes, hazard ratios for all-cause, cardiovascular, diabetes-, and cancer-related mortality for non-Western immigrants were 0.55 (95% CI 0.48-0.63), 0.46 (95% CI 0.38-0.56), 0.38 (95% CI 0.29-0.49), and 0.72 (95% CI 0.58-0.88), respectively.
  • Hazard ratios for patients with a college/university degree compared with 9 years or less of education were 0.85 (95% CI 0.80-0.90), 0.84 (95% CI 0.78-0.91), and 0.84 (95% CI 0.76-0.93) for all-cause, cardiovascular, and cancer mortality, respectively.
The study setting is important because, compared with the U.S., socioeconomic status should have less impact in Sweden on access to health services and their utilization, where the healthcare system is largely taxpayer-funded and open to all.
"In general, low compared with high income was associated with almost twice the risk of all-cause-, cardiovascular- and diabetes-related mortality and a 30% elevated risk of overall cancer mortality," the researchers wrote.
The study included 217,364 diabetic patients in Sweden who were younger than age 70 (mean age 58.3±9.3) when enrolled in the Sweden National Diabetes Register from 2003 through 2010. The patients (60.2% male) were monitored through Dec. 31, 2012. Cox proportional hazards regression modelling with up to 17 covariates was used for analysis.
A total of 17,589 of the patients included in the analysis were non-Western immigrants, including 1,699 (9.7%) from Latin America and the Caribbean, 2,902 (16.5%) from East or South Asia, and 10,506 (59.7%) from sub-Saharan Africa. These patients tended to be younger than native Swedes (mean age 52.1±9.8).
"Non-Western immigrants were approximately six years younger at diagnosis of diabetes and had lower income, higher education levels, and a higher prevalence of albuminuria," the researchers wrote.
During the follow-up there were a total of 19,105 all-cause deaths, including 11,423 (59.8%) associated with cardiovascular causes, 6,984 (36.6%) associated with diabetes, and 6,438 (33.7%) associated with cancer.
Marital status was also linked to mortality, with married patients having a lower risk for death than single patients in fully adjusted models (hazard ratio for all-cause mortality 0.73, 95 CI 0.70-0.77; for cardiovascular death 0.67, 95% CI 0.63-0.71; and for diabetes death 0.62, 95% CI 0.57-0.67). Marital status was not associated with overall cancer mortality, but married men had a 33% lower risk of prostate cancer mortality compared with single men.
The observational design of the study and limited information on alcohol use and smoking status were cited by the researchers as study limitations.
In an editorial published with the study, Victor Montori, MD, and colleagues from the Mayo Clinic, Rochester, Minn., wrote that the disproportionate burden of type 2 diabetes among people living in poverty "shines light on the problematic way in which we have chosen to respond."
"This approach -- to prevent diabetes one person at a time -- has hampered our response as a society to the diabetes epidemic," they wrote.
In 2013 the American Diabetes Association issued a scientific statement on socioeconomic determinants of prediabetes and type 2 diabetes, which encouraged addressing social context as a strategy to curb the diabetes epidemic.
Montori and colleagues argue that this advice has been largely ignored, with efforts to reduce diabetes incidence and morbidity still focused on getting the individual patient to change.
"The current paradigm, then, endorses improving each individual patient and clinician's behavior as the solution yet obviates the social, environmental, and economic factors that drive the epidemic," they wrote -- adding, "Prospects for change are not encouraging."
Funding for this research was provided by the Swedish National Diabetes Register, the Swedish Heart and Lung Foundation, the Swedish Research Council, and others.The researchers declared no relevant relationships with industry related to this study.Montori and colleagues reported no relevant relationships with industry.