Diabetics Pay a Higher Price for Health Inequities

Globally, diabetes is a leading cause of morbidity and mortality and is among the top 10 leading causes of death in the U.S.. Often occurring alongside obesity and hypertension, diabetes further increases the risk of cardiovascular disease, chronic kidney disease and vision disorders. Social determinants of health (SDOH) such as low income, poor access to healthcare, neighborhood disadvantage and food insecurity, are significant contributors to the inequities in diabetes and associated complications that contribute to worse health outcomes for these patients. Understanding the role of SDOH as predictors of mortality in adults with diabetes could improve life expectancy and overall wellbeing in this high-risk population. SDOH interact with one another to impact health outcomes, yet the current strategies to assess mortality risk rely on traditional measures of socioeconomic well-being (e.g., education or income), without a comprehensive assessment of social disadvantage across multiple SDOH domains. While there are known associations between SDOH and diabetes, SDOH and mortality, and diabetes and mortality, the cumulative effects of social disadvantage on mortality risk in adults with diabetes have not been examined. Similarly, demographic disparities such as racial/ethnic and gender in both diabetes and mortality are well documented, but their intersectional effects on mortality in diabetes are not fully understood.

Our findings demonstrate the need to improve SDOH screening for unfavorable social determinants and design novel interventions to mitigate persistent disparities in mortality.

Zulqarnain Javed, MD, PhD

Assistant Research Professor of Cardiology

In a recently published study, a Houston Methodist team led by Zulqarnain Javed, MD, PhD, Assistant Research Professor of Cardiology, examined the cumulative impact of social disadvantage—measured using a comprehensive, validated SDOH framework—on all-cause mortality in a nationally representative sample of U.S. adults with diabetes. They also examined potential racial/ethnic and gender disparities in SDOH—mortality association. Due to the abundance of SDOH information and available mortality data linked to the National Death Index (NDI), Javed’s team used data from the 2013-2018 National Health Interview Survey (NHIS). All 2013–2018 NHIS participants ≥18 years of age with death record information in the NDI were included. Those with an invalid response to the diabetes screening question, unavailable death status or insufficient identifying data were excluded. The primary exposure variable was social disadvantage as measured using quartiles of aggregate SDOH burden. Javed’s group organized the available SDOH information into six domains: (1) economic stability; (2) neighborhood, physical environment and social cohesion; (3) community and social context; (4) food; (5) education; and (6) healthcare system. A list of 47 individual SDOH was constructed across the six domains and classified as either favorable or unfavorable with an assigned value of 0 or 1, respectively. An aggregate SDOH index was created by combining the 47 individual SDOH and dividing the range of values of the resulting index into quartiles, with the most favorable (i.e., lowest) SDOH scores in the first quartile (Q1) and the most unfavorable (i.e., highest) scores in the fourth quartile (Q4).

Distribution of individual social determinants of health characteristics by diabetes status. While people with diabetes were more likely to be insured than those without diabetes, they were also more likely to experience other adverse conditions, such as limited transportation, food insecurity, and low-income status. All differences listed were statistically significant, with p values <0.001. Not all 47 SDOH are shown.

The final sample included 182,445 adults, of which 20,079 reported diabetes. The results showed that after fully accounting for traditional cardiovascular risk factors, cumulative social disadvantage in individuals with diabetes is independently associated with significantly increased mortality risk. “In adults with diabetes, we found that those with the highest level of social disadvantage—assessed using 47 individual SDOH—had over twofold higher mortality risk independent of traditional clinical risk factors, compared to those with the most favorable SDOH profiles,” said Javed. He further explained “health systems should pay greater attention to utilizing existing validated tools for SDOH screening and developing evidence-based community navigation pathways to address outstanding SDOH risk factors.” Screening patients for adverse socioeconomic conditions that impact diabetes and mortality risk would improve risk stratification and guide more effective clinical care. “Efficient SDOH screening may highlight important barriers to diabetes care, such as food insecurity, pharmacy deserts, transportation barriers or prohibitively high prescription costs,” noted Javed, “Our findings demonstrate the need to improve SDOH screening for unfavorable social determinants and design novel interventions to mitigate persistent disparities in mortality.”

Ryan Chang, Jerrin Philip, Umair Javed, Anoop Titus, Syed Karam Gardezi, Harun Kundi, Raman Yousefzai, Adnan A Hyder, Elias Mossialos, Khurram Nasir, Zulqarnain Javed

Callie Rainosek Wren, MS

December 2024

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