Association of Socioeconomic Status with Mortality in Type 1 Diabetes: The Pittsburgh Epidemiology of Diabetes Complications Study
Introduction
Mortality is inversely associated with socioeconomic gradients in the general population 1, 2, 3, 4. Disadvantaged individuals have higher rates of mortality, and data suggest this inequality is becoming more apparent over time (5). However, only a few studies have examined the relationship between socioeconomic status (SES) and mortality in diabetes, specifically type 1 diabetes, and study designs and definitions of SES measures have varied widely.
Some studies report a clear SES gradient in mortality for those with diabetes 6, 7, 8, whereas others have reported that SES plays less of a role or no role in mortality in those with diabetes compared to the general population 9, 10, 11. The SES differences in mortality seen for individuals with diabetes seems to be largely the result of cardiovascular-related deaths. A disproportionate number of these cardiovascular deaths have occurred among individuals with type 1 diabetes 7, 10. Noted associations between SES and mortality in the literature differ by SES measures, and studies separating diabetes by type report a stronger association of SES with type 1 diabetes 7, 8.
Given these diverse data in the literature, we examined the relationship between SES and all-cause mortality using a large prospective cohort of childhood-onset type 1 diabetes. Three different SES measures were captured at or near age 28, including household income, education, and occupation, and were used to evaluate this relationship. We also sought to identify which SES measures were most strongly associated with all-cause mortality in type 1 diabetes.
Section snippets
Study Population
Participants in the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study, an ongoing prospective investigation of patients with childhood-onset (age = <17 years) type 1 diabetes were included in this analysis. EDC participants (n = 658) were either diagnosed or seen within 1 year of diagnosis at Children’s Hospital of Pittsburgh between 1950 and 1980 and were on insulin therapy at initial discharge. Participants have been followed biennially by survey since the baseline examination in
Results
Over a median follow-up time of 16.3 years (range: 2.0–21.7 years), there were 34 (10.7%) deaths in our Age 28 cohort of childhood-onset type 1 diabetes as of January 1, 2008. No differences by sex, age, race, or diabetes duration were seen at the Age 28 baseline examination (Table 1). Of the SES measures, income and education level were associated with mortality in type 1 diabetes; occupation was not. The highest income group comprised 20.1% of the surviving cohort, but only 5.9% of deaths (p
Discussion
These data indicate that all-cause mortality rates in type 1 diabetes are significantly associated with education and income levels attained by early adulthood. Low income and low education groups had significantly higher rates of all-cause mortality compared to the local general population, whereas high income and education groups did not significantly differ from the general population in their mortality rates. Cox proportional hazards modelling revealed that education and income were
Acknowledgments
This work was supported by the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health (R01-DK034818 and F30-DK082137 to A.M.S.).
References (29)
- et al.
Mortality decline and widening social inequalities
Lancet
(1986) - et al.
Coronary heart disease among diabetic and nondiabetic people—socioeconomic differences in incidence, prognosis and mortality
J Diabetes Complications
(2008) - et al.
Choice of urine sample predictive of microalbuminuria in patients with insulin-dependent diabetes mellitus
Am J Kidney Dis
(1989) - et al.
Sociodemographic determinants of glycemic control in young diabetic patients in peninsular Malaysia
Diabetes Res Clin Pract
(2000) - et al.
The role of socioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus
J Pediatr
(2006) - et al.
The size of mortality differences associated with educational level in nine industrialized countries
Am J Public Health
(1994) - et al.
Lifetime socioeconomic position and mortality: prospective observational study
BMJ
(1997) - et al.
Cumulative social class and mortality from various causes of adult men
J Epidemiol Community Health
(2003) - et al.
National trends in educational differentials in mortality
Am J Epidemiol
(1989) - et al.
Socioeconomic and behavioral risk factors for mortality of individuals with IDDM in Japan: population-based case-control study. Diabetes Epidemiology Research International (DERI) US-Japan Mortality Study Group
Diabetologia
(1996)
Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study
BMJ
Socioeconomic differences in mortality among diabetic people in Finland
Scand J Public Health
Mortality and educational level among diabetic and non-diabetic population in the Turin Longitudinal Study: a 9-year follow-up
Int J Epidemiol
Socioeconomic differences in mortality among diabetic people in Finland: five year follow up
BMJ
Cited by (39)
A novel telemedicine protocol improved outcomes for high-risk patients with type 1 diabetes: A 3-month quality improvement project during the COVID-19 pandemic
2021, Journal of Clinical and Translational Endocrinology: Case ReportsCitation Excerpt :supplementary table S1). Our patient population from suburban Chicago is similarly above-average in household income, which tends to correlate with better blood sugar management [6]. Yet a potential confound is our patients may have been drawn from even higher socioeconomic groups, be less racially diverse, and more likely to use CGM, insulin pumps and software than the T1D Exchange patients.
Impact of Anxiety Disorders on Mortality for Persons With Diabetes: A National Population-Based Cohort Study
2017, PsychosomaticsCitation Excerpt :Like many studies, older age increased that risk.7,18,34,35 Being a dependent or having a lower income status also increased that risk, as has been found by studies of Western populations.34,37,38 Our study found that people with diabetes who lived in rural areas had a higher risk for mortality.
Prediabetes prevalence and awareness by race, ethnicity, and educational attainment among U.S. adults
2023, Frontiers in Public Health