Socioeconomic status and diagnosed diabetes incidence

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Abstract

Aims:

To investigate the association between socioeconomic status (SES) and incidence of diabetes.

Methods:

We investigated three measures of SES and incidence of diagnosed diabetes among women and men in the NHANES I Epidemiologic Followup Study, 1971–1992, who were free of diagnosed diabetes in 1980.

Results:

Among women, diabetes incidence was inversely associated with income (measured as percent of the poverty level), education, and occupational status, adjusting for age and race/ethnicity. The hazard ratio (HR) for women with >16 years education was 0.26 (95% confidence interval (CI) 0.13–0.54) relative to those with <9 years of education. Adjustment for potential mediators, including body size variables, diet, physical activity, and alcohol and tobacco use, substantially attenuated the associations with income and education. Among men a trend toward lower diabetes incidence with higher income and higher education was evident (the HR for men with household income >5 times the poverty level was 0.44 (95% CI 0.19–0.98) relative to those under the poverty line), but there was no inverse association of diabetes incidence with occupational status.

Conclusions:

SES, assessed with any of three common measures, is a risk factor for diagnosed diabetes in women. Among men these associations are less consistent.

Introduction

There is substantial evidence that socioeconomic status (SES) has a strong, inverse association with type 2 diabetes prevalence among women across several different SES measures and populations [1], [2], [3], [4], although this association is less consistent among men [1], [5], [6]. This relationship developed during the mid-to-late twentieth century, reversing an earlier pattern of excess diabetes among the wealthy [7]. Information linking SES to incidence of diabetes is more limited and inconsistent [5], [8], [9], [10], [11], [12], [13], [14].

We examined the association between three measures of socioeconomic status and incidence of diagnosed diabetes in the NHANES I Epidemiologic Followup Study (NHEFS) [5], [11], [15], [16], [17]. Detailed information on a number of socioeconomic indicators and other risk factors for diabetes was collected at the cohort inception (1971–1975), and diagnosed diabetes incidence was followed through 1992, providing a unique opportunity to examine this study question. We examined several measures of obesity as well as a number of health-related behaviors as possible mediators of an association between SES and diabetes incidence [18], [19].

Section snippets

Materials and methods

NHEFS includes data on subjects who were age 25–74 when examined between 1971 and 1975. Follow-up surveys were conducted in 1982–1984, 1986, 1987, and 1992 [20]. This incidence study was limited to the 11,069 subjects who were documented as not having died or been diagnosed with diabetes prior to 1980, when standardized diagnostic criteria for diabetes were established [21], [22], [23]. Mean follow-up time after 1980 was 10.0 years. Analyses were stratified by gender and adjusted for single

Results

Baseline characteristics of the study sample are shown in Table 1. There were 460 incident cases of diagnosed diabetes among 6825 women and 306 among 4024 men in the NHEFS cohort.

Among women, increasing PIR was associated with decreasing hazard ratios (HR) for diabetes incidence after adjustment for age and race/ethnicity (Fig. 1). The HR for women with incomes at least five times the poverty level relative to those below the poverty line was 0.60 (95% CI 0.32–1.15). Education and occupational

Conclusions

Our results indicate that low socioeconomic status, assessed using three different measures, is associated with risk of diabetes. This supports the conclusion that the inverse association between SES and diabetes prevalence described in the United States and other developed countries [4], [12], [29], [30], [31] is not solely a result of the impact of diabetes on SES (for example, lower ability to work) or longer survival among diabetes patients of higher SES, but reflects an increased risk of

Acknowledgments

This study was supported by US Public Health Service grant 5-T32MH 1435 from the National Institute of Mental Health. An earlier version was published in abstract form as “Education, Income, and Occupational Status as Predictors of Diabetes Diagnosis among Women in the NHANES I Epidemiologic Followup Study,” Diabetes 50 Supplement 2: A216–A217, June 2001.

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