Quantifying the Impact of Adverse Social Conditions on Diabetes in America: A National Analysis of US Adults Open Access

Abstract

Diabetes is one of the top 10 leading causes of death affecting about 30 million Americans. Social determinants of health, such as education and income, have been identified as factors that influence an individual’s diabetes status. Specifically, adults with lower levels of education and income are more likely to develop diabetes. Education and income may therefore present important leverage points for policy interventions to prevent diabetes nationally. The purpose of this study was to quantify the potential impact of two social conditions – educational attainment and annual family income –  on the burden of diabetes nationally. We report the fraction of prevalent diabetes cases that could be prevented if all Americans were exposed to optimal social conditions, and examine which racial/ethnic groups stand to benefit the most from improvements in these conditions. We conducted a secondary data analysis of participants 20 years or older in the 2013-2014 National Health and Nutrition Examination Survey (NHANES). Taking into account the prevalence of each social condition and the association between the social condition and diabetes, we computed the hypothetical fraction of prevalent diabetes that could be prevented (i.e., the population attributable fraction) if all adults achieved a college degree or higher and earned an annual family income of 100,000 or above. We found that 43% of prevalent diabetes cases could be prevented if all Americans achieved a college degree or higher, whereas 15% of prevalent diabetes cases could be prevented if all Americans were exposed to an annual family income of 100,000 or above. Hispanic and non-Hispanic Black Americans were seen to benefit the most from achievement of these optimal social conditions, with PAFs of about 51% and 18.0% respectively for education, and 18.0% and 18.4% respectively for income. Results from this study exemplify that modifiable conditions in the social environment may prove to be very impactful in addressing the growing diabetes prevalence.

Table of Contents

CHAPTER 1: INTRODUCTION  1

Problem Definition     1

Diabetes Epidemiology           1

Social Determinants of Health           2

Education, Income, and Health Care Access as Social Determinants of Health       3

Disparities in Educational Attainment           4

Disparities in Income  5

Disparities in Health Care Access       6

Problem Justification  7

Theoretical Framework          8

Purpose of the Study  11

Research Questions    12

CHAPTER 2: LITERATURE REVIEW     13

Introduction    13

Education and Diabetes          14

Income, Socioeconomic Status, and Diabetes           17

Income and Diabetes Management   17

Prevalent Diabetes and Measures of SES and Income          18

Healthcare Access and Diabetes        21

Health Insurance Status and Diabetes Management            21

Risk Factor Modification        23

Race/Ethnicity and Diabetes  24

Summary        25

CHAPTER 3: METHODS           26

Data Source    26

Participants     27

Sampling Design         27

Study Participants       28

Procedures      28

Measures        29

Definition of Variables           29

Independent Variables (Social Conditions)    29

Outcome Variable (Diabetes) 30

Covariates       30

Definition of Optimal Social Conditions         31

Statistical Analysis     31

Preliminary Analyses  32

Univariate Analysis: Assessing Prevalence of Each Social Condition            32

Multiple Logistic Regression: Assessing Measures of Association   32

Main Analysis 34

Estimating Population Attributable Fractions           34

CHAPTER 4: RESULTS 36

Introduction    36

Sample Characteristics           37

Associations Between Social Conditions and Prevalent Diabetes     39

Relative Odds of Diabetes in the Total Population    39

Association Between Educational Attainment and Diabetes            39

Association Between Annual Family Income and Diabetes  41

Relative Odds of Diabetes in each Racial/Ethnic Category   43

Association Between Educational Attainment and Diabetes by Race/Ethnicity      43

Association Between Annual Family Income and Diabetes and by Race/Ethnicity  45

Population Attributable Fractions      47

Population Attributable Fraction in the Total Population      47

Population Attributable Fraction in Each Racial//Ethnic Category   48

CHAPTER 5: DISCUSSION        50

Introduction    50

Findings          51

Preliminary Results    51

Relative Odds of Diabetes in the Total Population    51

Relative Odds of Diabetes in Each Racial/Ethnic Category   53

Main Analyses 56

Population Attributable Fraction in the Total Population      56

Population Attributable Fraction in Each Racial/Ethnic Category     57

Strengths and Limitations      58

Implications and Recommendations 60

References      66

 

 

About this Master's Thesis

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School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Keyword	Income Social Determinants of Health Population Attributable Fraction Education Diabetes
Committee Chair / Thesis Advisor	Nehl, Eric, Emory University
Committee Members	Patel, Shivani A., Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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