A Growing Disparity in Diabetes-Related Mortality: U.S. Trends, 1989–2005

doi:10.1016/j.amepre.2008.09.041

American Journal of Preventive Medicine

Volume 36, Issue 2, February 2009, Pages 126-132

https://doi.org/10.1016/j.amepre.2008.09.041 Get rights and content

Background

Whether a disparity in diabetes-related death across education levels is widening, narrowing, or stable is not known. This analysis examined trends in diabetes-related death by education levels over a 17-year period.

Methods

The first part of the analysis calculated diabetes-related mortality rates for adults aged 40–64 years and adults aged 65–79 years using U.S. Vital Statistics data from 1989 to 2005 to provide the number of deaths per year in the U.S. (the numerator) and also U.S. Census data to provide the population size (the denominator). The second part of the analysis examined trends by education level in possible mechanisms that link education and diabetes-related mortality using the U.S. National Health and Nutrition Examination Surveys (NHANES) program in 1988–1994 and 1999–2004.

Results

Disparity in diabetes-related mortality across education levels widened from the late 1980s to 2005 overall and in the subgroups of men, women, blacks, whites, and Hispanics. Analysis of NHANES data indicated that progress in diabetes care and management (as indicated by HbA1c levels less than 8%) has helped people of all education levels but has been of greater benefit to those with higher education.

Conclusions

The reduction of disparities in diabetes-related mortality requires improved policies and interventions that redress the slower pace of improvement in diabetes care and self-management among people with lower education.

Section snippets

Background

In the Year 2000, diabetes was the sixth leading cause of death in the U.S.,¹ contributing to approximately 3.6% of all deaths. Whether disparities in diabetes-related mortality by SES have grown, diminished, or remain unchanged in recent decades is not known but is important to evaluate the success of recent efforts by the Department of Health and Human Services to reduce health disparities.²

To address this question the analysis examined trends over the past 2 decades in diabetes-related

Surveys

The first analyses drew on the U.S. Vital Statistics, which provided the number of diabetes-related deaths per year in the U.S. (the numerator) and also from the U.S. Census to provide the population size (the denominator). This study used data starting in 1989, the first year in which the mortality data contained information on educational attainment. All deaths that listed diabetes as the underlying cause or a contributing cause were coded as diabetes-related. Age, race/ethnicity, and gender

Results

Trends in diabetes-related mortality over the past 17 years by four education levels and age groups are presented in Figure 1. Among both age groups a disparity in diabetes-related mortality was present in 1989 and widened through 2005, as indicated by a widening gap between the mortality rates of the lowest and highest educated. In the lowest education category (less than a high school education) the rate of diabetes-related mortality increased for both age groups, by 75% among those aged

Comments

To our knowledge, this study is the first to document a widening disparity in diabetes-related mortality across education levels in recent years. Among both age groups (40–64 years and 65–79 years), the mortality rate increased for those with lower education and decreased for those with higher education. A substantial, widening disparity in diabetes-related mortality across education levels was present among the demographic subgroups of men, women, blacks, whites, and Hispanics.

We hypothesized

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The 2021 criteria exhibited marginally higher sensitivity (58.6%, 95% CI=55.5, 61.6 vs 52.9%, 95% CI=49.7, 56.0) and lower specificity (69.3%, 95% CI=65.7, 72.2 vs 76.4%, 95% CI=73.3, 79.2) than the 2015 criteria overall, and within each racial and ethnic group. Screening at lower age and BMI thresholds resulted in even greater sensitivity and lower specificity, especially among Hispanic, non-Hispanic Black, and Asian adults. Screening all adults aged 35–70 years regardless of BMI yielded the most equitable performance across all racial and ethnic groups.
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American Journal of Preventive Medicine

Background

Methods

Results

Conclusions

Section snippets

Background

Surveys

Results

Comments

References (21)

Recording of diabetes on death certificates: has it improved?

J Clin Epidemiol

Comparability of cause of death between ICD-9 and ICD-10: preliminary estimates

Natl Vital Stat Rep

Healthy People 2010

“Fundamental causes” of social inequalities in mortality: a test of the theory

J Health Soc Behav

Social conditions as fundamental causes of disease

J Health Soc Behav

Diffusion of innovations

National Health and Nutrition Examination survey dataUSDHHS

Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targetsA guidance statement from the American College of Physicians

Ann Intern Med

Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association

Circulation

Executive summary: standards of medical care in diabetes—2008 (Executive Summary)

Diabetes Care

Cited by (50)

Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program

Screening for Prediabetes and Diabetes: Clinical Performance and Implications for Health Equity

It's Not All Even: Health Disparities in Kidney Disease

Influence of educational attainments on long term glucose control and morbid events in patients with type 2 diabetes receiving integrated care from 15 China urban communities: The Beijing Community Diabetes Study 11

Explanatory models of diabetes in the U.S. and Mexico: The patient-provider gap and cultural competence

Measuring capability for healthy diet and physical activity

Research articleA Growing Disparity in Diabetes-Related Mortality: U.S. Trends, 1989–2005

Background

Methods

Results

Conclusions

Section snippets

Background

Surveys

Results

Comments

J Clin Epidemiol

Comparability of cause of death between ICD-9 and ICD-10: preliminary estimates

Natl Vital Stat Rep

Healthy People 2010

“Fundamental causes” of social inequalities in mortality: a test of the theory

J Health Soc Behav

Social conditions as fundamental causes of disease

J Health Soc Behav

Diffusion of innovations

National Health and Nutrition Examination survey dataUSDHHS

Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targetsA guidance statement from the American College of Physicians

Ann Intern Med

Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association

Circulation

Executive summary: standards of medical care in diabetes—2008 (Executive Summary)

Diabetes Care

Research article
A Growing Disparity in Diabetes-Related Mortality: U.S. Trends, 1989–2005