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  1. 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

  2. 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

  3. 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

  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 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.

  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/m2 • 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 * 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 * 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 • * 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 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 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 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 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

  30. Public Health ReportsMeet the Author Webcast • http://www.publichealthreports.org • Next Webcast: December 7th, 1:00 ET • Tracking Parent's Concerns about Childhood Vaccines – • A Public Health Surveillance System • With: • Philip Smith, PhD • CDC, National Center for Immunization and Respiratory Disease • Edgar Marcuse, MD, MPH • Washington University School of Public Health • Certification in Public Health Continuing Education Practice, please go to: • http://www.shoppublichealth.org/ • Link to the CE credits is on the left side of the page