Even With Level Access, Diabetes Death Risk Higher for Poor

Marcia Frellick

June 28, 2016

Even in Sweden, a country where healthcare is equally accessible and affordable to all, low socioeconomic status was linked with an increased risk of death for patients with type 2 diabetes.

The higher risk among this population was evident from all-cause mortality, cardiovascular disease, and diabetes-related mortality, according to an article published online June 27 in JAMA Internal Medicine.

Results showed a less pronounced, but still increased, risk of cancer death.

A related viewpoint in the same issue suggests strategies that target individual behavior for preventing type 2 diabetes may miss the wider societal roots of the problem.

Unusual Advantage of Equitable, Accessible Healthcare System

Many previous studies have made the connection that socioeconomic status is linked with higher death risk for those with type 2 diabetes. But factors such as access to healthcare, education level, and neighborhood often are important confounders.

Sweden is one of the most equitable health systems in the world, Araz Rawshani, MD, PhD, from the Institute of Medicine, at Sahlgrenska University Hospital, in Gothenburg, Sweden, and colleagues note in their paper, so they were able to look at the results independently of disparities in access to and use of healthcare.

"All citizens have equal access to all aspects of the healthcare system, and individual costs represent a fraction of actual costs; being hospitalized costs approximately $10 per day regardless of level of care or the type and number of interventions and examinations carried out," explained Dr Rawshani.

But even with a level field for access and use, low income was independently associated with almost a doubling of risk for three causes of death.

Comparison of hazard ratios (HRs) for the lowest- vs highest-income groups for all-cause, cardiovascular, and diabetes-related mortality were 1.71, 1.87, and 1.8, respectively.

HRs for diabetes death also increased gradually with declining income, the researchers found.

The study included all 217,364 people younger than 70 years old with type 2 diabetes in the Swedish National Diabetes Register. The researchers also analyzed whether marital status, educational level, and birth country were associated with causes of death.

Among their most significant finding was a strong relationship with education level. As opposed to those who had 9 years of education or less, HRs for those with 10 to 12 years and those with a college degree were 0.90 and 0.85, respectively.

Also, "being married was linked with a 30% to 40% reduced risk of all-cause, CV, and diabetes-related mortality," they write.

Targeting Individual Behavior Underestimates Problem

In the related viewpoint, Gabriela Spencer Bonilla, of the Knowledge and Evaluation Research Unit of the Department of Medicine at Mayo Clinic in Rochester, Minnesota, and colleagues say almost all approaches to type 2 diabetes target lifestyle, but trying to reduce the risk on an individual basis underestimates the pervasiveness of the problem.

Both the Centers for Disease Control and Prevention and the American Medical Association have promoted such an individual approach.

Ms Bonilla told Medscape Medical News that lifestyle interventions in diet and exercise benefit people overall and have been shown to delay progression to diabetes.

"But the issue we're pointing out is that there's a huge portion of the population that may not be able to access these initiatives," she said, and they take a substantial effort from the healthcare system, clinicians, and patients.

Other approaches that address socioeconomic disadvantage — the effects of poverty, income gaps, and loneliness — need attention, she said.

Opportunities for education for all and job training are interventions that could better get at the underlying problem, she suggested.

But research has centered on the clinical, because that's what healthcare researchers know, that's the arena where the people with diabetes are seen, and that's where the research money is, she points out.

She and her coauthors say they are aware of only one study that has tested a socioeconomic intervention in preventing diabetes (N Engl J Med. 2011;365:1509-1519).

In that 2011 study, researchers studied more than 4400 women with children living in five United States cities who were randomly assigned to vouchers and help moving to a more affluent neighborhood, a relocation voucher without restricting location, or no assistance.

"Results at 10 to 15 years of follow-up showed that both socioeconomic measures (the first more than the second) were related to a reduction in the prevalence of diabetes and obesity when compared with the no-assistance control group."

Ms Bonilla et al also note there is little movement toward more studies with such interventions. In a detailed search this year of ClinicalTrials.gov and Grants.gov, they said they found only one such trial under way and only three NIH initiatives to fund similar studies.

"We need to do something now, regardless of how difficult it is or how complicated it is," Ms Bonilla said.

"A lot of these interventions happen outside the research setting, but we don't have measurable outcomes. In healthcare, we look at the outcomes but only do clinical approaches, and outside of healthcare, people do interventions but don't necessarily do health outcomes."

Better collaboration between the two worlds could inform policy and move diabetes prevention ahead, she concluded.

This study was financed by the Swedish National Diabetes Register (NDR), which is funded by the Swedish Association of Local Authorities and Regions. The study was also financed by the Swedish government under the agreement with county councils for financial support of research and education of medical practitioners, the Swedish Heart and Lung Foundation, Diabetes Wellness, the Swedish Research Council, the Swedish Council for Working Life and Social Research, and Diabetesfonden. Authors of the study and viewpoint report no relevant financial relationships.

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JAMA Intern Med. Published online June 27, 2016. Abstract, Editorial

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