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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:

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Public health reports meet the author webcast l.jpg
Public Health ReportsMeet 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


Slide2 l.jpg

Public Health ReportsMeet the Author Webcast

Socioeconomic Status and Risk of

Diabetes-Related Morality

in the United States

Sharon Saydah, PhD

Centers for Disease Control

and Prevention

May-June 2010, Volume 125-3


Socioeconomic status and risk of diabetes related morality in the united states l.jpg
Socioeconomic Status and Risk of Diabetes-Related Morality in the United States

Sharon Saydah, PhD

Division of Diabetes Translation

Centers for Disease Control and Prevention


Disclaimer l.jpg
Disclaimer in the United States

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.


Objectives l.jpg
Objectives in the United States

  • 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.


Trends in diabetes related mortality in the united states l.jpg
Trends in diabetes-related mortality in the United States 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.


Background l.jpg
Background in the United States

  • Diabetes was the 7th 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.


Previous studies l.jpg
Previous studies in the United States

  • 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


Methods data sources l.jpg
Methods: Data sources in the United States

  • 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


Methods analytic sample l.jpg
Methods: Analytic sample in the United States

  • 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


Methods socioeconomic measures l.jpg
Methods: Socioeconomic measures in the United States

  • 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.


Methods covariates l.jpg
Methods: Covariates in the United States

  • Sex

  • Race/ethnicity

  • Martial status

    • Married

    • Divorced/separated/widowed

    • Never married

  • Body mass index (BMI) kg/m2

    • Based on self reported height and weight

    • Underweight, normal, overweight, obese and extremely obese


Methods outcome l.jpg
Methods: Outcome in the United States

  • 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


Analysis l.jpg
Analysis in the United States

  • 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


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Analysis in the United States

  • Calculated percentage explained by the covariates in the model:

    % explained = (RH unadjusted – RH adjusted)

    (RH unadjusted – 1)


Baseline characteristics aged 25 years and older in nhis 1990 2000 united states l.jpg
Baseline characteristics aged 25 years and older in NHIS 1990-2000, United States

* Statistically different across the Federal Poverty Level (FPL) groups based on 2 p < 0.001


Baseline characteristics aged 25 years and older in nhis 1990 2000 united states17 l.jpg
Baseline characteristics aged 25 years and older in NHIS 1990-2000, United States

* Statistically different across the Federal Poverty Level (FPL) groups based on 2 p < 0.001


Percentage of adults by education and poverty level nhis 1990 2000 l.jpg
Percentage of adults by education and poverty level, NHIS 1990-2000

  • * Statistically different across the education groups based on 2 p < 0.001

  • FPL = Federal Poverty Level


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Diabetes-related mortality by education level 1990-2000

Age adjusted to the 2000 U.S. standard population

Rates per 100,000 person years


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Diabetes-related mortality by Federal Poverty Level (FPL) 1990-2000

Age adjusted to the 2000 U.S. standard population

Rates per 100,000 person years


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Risk of diabetes-related mortality by education level 1990-2000

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


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Risk of diabetes-related mortality by education level 1990-2000

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


Risk of diabetes related mortality by federal poverty level l.jpg
Risk of diabetes-related mortality by Federal Poverty Level 1990-2000

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


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Risk of diabetes-related mortality by Federal Poverty Level 1990-2000

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


Discussion l.jpg
Discussion 1990-2000

  • 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


Limitations l.jpg
Limitations 1990-2000

  • 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


Strengths l.jpg
Strengths 1990-2000

  • Nationally representative

  • Recent data

  • Included more than one SES indicator

  • Large sample allows examination of both lower and upper ends of SES


Conclusions l.jpg
Conclusions 1990-2000

  • 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


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Socioeconomic Status and Risk of 1990-2000

Diabetes-Related Morality

in the United States

Questions and Answers

Sharon Saydah, PhD

Centers for Disease Control

and Prevention


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