1. Meet the Author Webcast Public Health Reports Meet the Author Webcast Socioeconomic Status and Risk of Diabetes-Related Morality in the United States With Author: Sharon Saydah, PhD Centers for Disease Control and Prevention TODAY - 1:00-2:00ET To join the conference call, dial: 1-866-951-1151 Access Code: 8768832 Instruction for one credit in Certified in Public Health Continuing Education Practice will be given when the webcast concludes

2. Socioeconomic Status and Risk of Diabetes-Related Morality in the United States May-June 2010, Volume 125-3 Meet the Author Webcast Public Health Reports Meet the Author Webcast Sharon Saydah, PhD Centers for Disease Control and Prevention

3. Sharon Saydah, PhD Division of Diabetes Translation Centers for Disease Control and Prevention Socioeconomic Status and Risk of Diabetes-Related Morality in the United States

4. Disclaimer The views and interpretations presented in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

5. Objectives Examine socioeconomic (SES) differences in diabetes mortality in the United States. Highlight the importance of SES in assessing the social determinants of diabetes mortality. Discuss the strengths and challenges of using national data to examine SES of diabetes.

6. Trends in diabetes-related mortality in the United States Saydah S. Eberhardt M. Chapter 12 “Diabetes and Mortality” in Diabetes Public Health: From Data to Policy, In press, Figure 1.

7. Background Diabetes was the 7 th leading cause of death in the United States 2007. Diabetes mortality is a focus area of Healthy People 2010. –Goal to eliminate health disparities. –Tracks diabetes-related mortality for different education groups. Few prospective studies on socioeconomic differences in diabetes-related mortality.

8. Previous studies American Cancer Society cohorts (1959 - 1972 and 1982 -1996) –Inverse gradient for education and diabetes mortality –No information on race/ethnicity or income National Longitudinal Mortality Study (1979 -1989) –Strong inverse relationship with income and diabetes mortality

9. Methods: Data sources National Health Interview Survey (NHIS) –In-person survey –Years included 1990 through 2000 Linked mortality files –National death index –Follow-up through December 31, 2002

10. Methods: Analytic sample Inclusion criteria –Aged 25 years and older at time of interview –Non-Hispanic white, non-Hispanic black, and Hispanic –Complete information on all variables of interest –Final sample size n = 527,426

11. Methods: Socioeconomic measures Education –< high school –High school graduate –Some college –College graduate or greater Income (Federal Poverty Level, [FPL]) –< 1.00 –1.00 - 1.99 –2.00 - 3.99 –4.00 + Approximately 18% of the sample had unknown income. Imputed income used for these participants.

12. Methods: Covariates Sex Race/ethnicity Martial status –Married –Divorced/separated/widowed –Never married Body mass index (BMI) kg/m 2 –Based on self reported height and weight –Underweight, normal, overweight, obese and extremely obese

13. Methods: Outcome Deaths ascertained from time of interview to December 31, 2002 Diabetes-related mortality –Includes deaths with diabetes indicated as an underlying or contributing cause Number of diabetes deaths = 5,613 Mean follow-up = 6.4 person years

14. Analysis Age adjusted diabetes mortality Proportional hazards models with age as the time scale All analysis weighted to the U.S. population and accounts for the NHIS complex survey design

15. Analysis Calculated percentage explained by the covariates in the model: % explained = (RH unadjusted – RH adjusted ) (RH unadjusted – 1)

16. Baseline characteristics aged 25 years and older in NHIS 1990- 2000, United States Overall< High school High schoolSome college College degree Age, yrs 48.456.245.445.248.9 Male, %* 48.047.345.646.753.2 NH white, %* 81.867.383.483.089.6 NH black, %* 11.216.311.311.46.9 Hispanic, %* 7.016.45.35.63.5 Married, %* 67.558.768.868.172.0 Divorced/widowed, %* 20.631.020.919.612.8 Never married, %* 12.010.310.412.415.2 Underweight, %* 2.32.92.22.12.2 Normal, %* 42.136.140.841.849.0 Overweight, %* 35.736.536.035.734.8 Obese, %* 13.216.013.813.39.8 Extremely obese, %* 6.78.47.2 4.2 * Statistically different across the Federal Poverty Level (FPL) groups based on  2 p < 0.001

17. Baseline characteristics aged 25 years and older in NHIS 1990- 2000, United States < 100% FPL100-199% FPL200-299% FPL300-399% FPL≥ 400% FPL Age, yrs48.951.448.646.647.3 Male, %*37.544.348.249.852.2 NH white, %*57.374.583.086.990.0 NH black, %*26.315.010.58.36.4 Hispanic, %*16.410.56.64.83.6 Married, %*41.059.369.875.174.7 Divorced/widowed, %*39.328.819.614.813.8 Never married, %*19.711.910.610.111.5 Underweight, %*3.62.82.32.11.8 Normal, %*37.940.141.743.444.1 Overweight, %*32.334.735.736.237.2 Obese, %*15.614.313.712.411.9 Extremely obese, %*10.68.26.75.95.1 * Statistically different across the Federal Poverty Level (FPL) groups based on  2 p < 0.001

18. Percentage of adults by education and poverty level, NHIS 1990-2000 < 100% FPL100-199% FPL 200-299% FPL 300-399% FPL ≥ 400% FPL < High school * 48.834.017.910.35.2 High school graduate * 32.139.941.336.126.2 Some college * 14.018.425.127.426.8 College graduate * 5.27.715.726.241.8 * Statistically different across the education groups based on  2 p < 0.001 FPL = Federal Poverty Level

19. Diabetes-related mortality by education level Age adjusted to the 2000 U.S. standard population Rates per 100,000 person years

20. Diabetes-related mortality by Federal Poverty Level (FPL) Age adjusted to the 2000 U.S. standard population Rates per 100,000 person years

21. Risk of diabetes-related mortality by education level Education level Model 1: RH (95% CI) Model 2: RH (95% CI) Model 3: RH (95% CI) % explained (model 3 compared to 1) < HS2.46 (2.15, 2.82) 2.27 (1.98, 2.61) 2.05 (1.78, 2.35) 28% HS grad1.60 (1.39, 1.83) 1.65 (1.44, 1.90) 1.57 (1.37, 1.80) 5% Some college1.48 (1.27, 1.74) 1.52 (1.30, 1.70) 1.46 (1.25, 1.71) 4% College grad1.00 (reference) Relative hazards (RH) based on proportional hazards model with age as the time scale. Model 1: adjusted for socioeconomic status indicator only Model 2: model 1 additionally adjusted for demographic characteristics Model 3: model 2 additionally adjusted for BMI

22. Risk of diabetes-related mortality by education level Education levelModel 3: RH (95% CI) Model 4: RH (95% CI) % explained (model 4 compared to 3) < HS2.05 (1.78, 2.35) 1.55 (1.34, 1.80) 48% HS grad1.57 (1.37, 1.80) 1.32 (1.15, 1.53) 44% Some college1.46 (1.25, 1.71) 1.33 (1.13, 1.56) 28% College grad1.00 (reference) Relative hazards (RH) based on proportional hazards model with age as the time scale. Model 3: adjusted for socioeconomic status indicator, demographics and BMI Model 4: model 3 additionally adjusted for FPL

23. Risk of diabetes-related mortality by Federal Poverty Level Federal Poverty Level Model 1: RH (95% CI) Model 2: RH (95% CI) Model 3: RH (95% CI) % explained (model 3 compared to 1) < 100%2.94 (2.53, 3.42) 2.64 (2.25, 3.10) 2.41 (2.05, 2.84) 27% 100-199%2.21 (1.92, 2.54) 2.11 (1.83, 2.43) 1.98 (1.71, 2.28) 19% 200-299%1.81 (1.56, 2.10) 1.78 (1.53, 2.06) 1.70 (1.47, 1.97) 14% 300-399%1.24 (1.05, 1.46) 1.23 (1.04, 1.45) 1.20 (1.02, 1.42) 17% ≥ 400%1.00 (reference) Relative hazards (RH) based on proportional hazards model with age as the time scale. Model 1: Adjusted for socioeconomic status indicator only Model 2: Model 1 additionally adjusted for demographic characteristics Model 3: Model 2 additionally adjusted for BMI

24. Risk of diabetes-related mortality by Federal Poverty Level Federal Poverty Level Model 3: RH (95% CI) Model 4: RH (95% CI) % explained (model 4 compared to 3) < 100%2.41 (2.05, 2.84) 2.07 (1.73, 2.46) 27% 100-199%1.98 (1.71, 2.28) 1.73 (1.48, 2.02) 19% 200-299%1.70 (1.47, 1.97) 1.55 (1.33, 1.81) 14% 300-399%1.20 (1.02, 1.42) 1.14 (0.96, 1.35) 17% ≥ 400%1.00 (reference) 1.00 (reference) Relative hazards (RH) based on proportional hazards model with age as the time scale. Model 3: adjusted for socioeconomic status indicator, demographics and BMI Model 4: model 3 additionally adjusted for education levels

25. Discussion Socioeconomic gradient exists with diabetes-related mortality Increased risk of mortality for all income groups compared to the highest income group Increased risk of morality for all education groups compared to college graduates

26. Limitations Possible underreporting of diabetes morality on death certificates –Not known whether underreporting differs by socio-economic status in U.S. –U.K.P.D.S. study found lower social class more likely to have diabetes coded on death certificate Education and income only measured at baseline

27. Strengths Nationally representative Recent data Included more than one SES indicator Large sample allows examination of both lower and upper ends of SES

28. Conclusions Reducing overall diabetes mortality and disparities in diabetes mortality an important goal for federal programs. –Healthy People 2010 –National Diabetes Education Program Diabetes mortality research provides guidance for primary, secondary tertiary diabetes prevention efforts

29. Socioeconomic Status and Risk of Diabetes-Related Morality in the United States Questions and Answers Sharon Saydah, PhD Centers for Disease Control and Prevention

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