Diabetes Metab J.  2024 Nov;48(6):1073-1083. 10.4093/dmj.2023.0380.

Social Determinants of Health and Cardiovascular Risk among Adults with Diabetes: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Affiliations
  • 1Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
  • 2Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
  • 3Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
  • 4Department of Family Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
  • 5Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
  • 6Department of Medicine, University of Arizona, Tucson, AZ, USA

Abstract

Background
Social determinants of health (SDOH) have been associated with diabetes risk; however, their association with cardiovascular disease (CVD) events in individuals with diabetes is poorly described. We hypothesized that a greater number of SDOH among individuals with diabetes would be associated with a higher risk of CVD events.
Methods
The REasons for Geographic and Racial Differences in Stroke (REGARDS) study is a national, biracial cohort of 30,239 individuals ≥45 years old recruited in 2003–2007. We included 6,322 participants with diabetes at baseline, defined as healthcare professional diagnosis, diabetes medication use, or blood glucose values. Seven SDOH that were individually associated with CVD events were included (P<0.20). The outcome was CVD events, a composite of expert-adjudicated myocardial infarction, stroke, or cardiovascular death. We estimated Cox proportional hazard models to examine associations between number of SDOH (0, 1, 2, ≥3) and CVD events.
Results
In an age and sex adjusted model, the presence of multiple SDOH significantly increased the risk of any CVD event (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.26 to 1.74 for two SDOH; HR, 1.68; 95% CI, 1.43 to 1.96 for ≥3 SDOH). This finding was attenuated but remained statistically significant in a fully adjusted model (HR, 1.19; 95% CI, 1.01 to 1.40 for two SDOH; HR, 1.27; 95% CI, 1.07 to 1.50 for ≥3 SDOH).
Conclusion
Having multiple SDOH was independently associated with an increased risk of CVD events, a finding driven by cardiovascular death. Identifying individuals with diabetes who have multiple SDOH may be helpful for detecting those at higher risk of experiencing or dying from CVD events.

Keyword

Cardiovascular diseases; Diabetes mellitus; Myocardial infarction; Social determinants of health; Stroke

Figure

  • Fig. 1. Number of social determinants of health (SDOH) and incidence of (A) composite endpoint, (B) myocardial infarction, (C) stroke, and (D) cardiovascular death in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.

  • Fig. 2. Hazard ratios of composite endpoint, myocardial infarction (MI), stroke, and cardiovascular (CV) death from minimally and fully adjusted models, by number of social determinants of health (SDOH), in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Black square=fully adjusted; white circle=minimally adjusted. Minimally adjusted model adjusts for age and sex. Fully adjusted model adjusts for sociodemographics, medical conditions, medications, health status, health behaviors, and physiological factors. HR, hazard ratio; CI, confidence interval.


Reference

1. Centers for Disease Control and Prevention. National diabetes statistics report, 2020. Atlanta: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services;2020.
2. Einarson TR, Acs A, Ludwig C, Panton UH. Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol. 2018; 17:83.
Article
3. Centers for Disease Control and Prevention. National diabetes statistics report, 2014. Atlanta: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services;2014.
4. Recarti C, Sep SJ, Stehouwer CD, Unger T. Excess cardiovascular risk in diabetic women: a case for intensive treatment. Curr Hypertens Rep. 2015; 17:554.
Article
5. Morrish NJ, Wang SL, Stevens LK, Fuller JH, Keen H. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia. 2001; 44 Suppl 2:S14–21.
Article
6. Walker RJ, Strom Williams J, Egede LE. Influence of race, ethnicity and social determinants of health on diabetes outcomes. Am J Med Sci. 2016; 351:366–73.
Article
7. Walker RJ, Smalls BL, Campbell JA, Strom Williams JL, Egede LE. Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review. Endocrine. 2014; 47:29–48.
Article
8. Joseph JJ, Bennett A, Echouffo Tcheugui JB, Effoe VS, Odei JB, Hidalgo B, et al. Ideal cardiovascular health, glycaemic status and incident type 2 diabetes mellitus: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Diabetologia. 2019; 62:426–37.
Article
9. Pinheiro LC, Reshetnyak E, Sterling MR, Levitan EB, Safford MM, Goyal P. Multiple vulnerabilities to health disparities and incident heart failure hospitalization in the REGARDS study. Circ Cardiovasc Qual Outcomes. 2020; 13:e006438.
Article
10. Safford MM, Reshetnyak E, Sterling MR, Richman JS, Muntner PM, Durant RW, et al. Number of social determinants of health and fatal and nonfatal incident coronary heart disease in the REGARDS study. Circulation. 2021; 143:244–53.
Article
11. Schroff P, Gamboa CM, Durant RW, Oikeh A, Richman JS, Safford MM. Vulnerabilities to health disparities and statin use in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. J Am Heart Assoc. 2017; 6:e005449.
Article
12. Sterling MR, Ringel JB, Pinheiro LC, Safford MM, Levitan EB, Phillips E, et al. Social determinants of health and 90-day mortality after hospitalization for heart failure in the REGARDS study. J Am Heart Assoc. 2020; 9:e014836.
Article
13. Ringel JB, Carson AP, Cummings DM, Pena J, Gamboa C, Schroff P, et al. Abstract MP01: Multiple social determinants of health disparities increase the risk of diabetes and mortality in the Reasons for Geographic and Racial Differences in Stroke Study. Circulation. 2020; 141(Suppl 1):AMP01.
Article
14. Reshetnyak E, Ntamatungiro M, Pinheiro LC, Howard VJ, Carson AP, Martin KD, et al. Impact of multiple social determinants of health on incident stroke. Stroke. 2020; 51:2445–53.
Article
15. Howard VJ, Cushman M, Pulley L, Gomez CR, Go RC, Prineas RJ, et al. The reasons for geographic and racial differences in stroke study: objectives and design. Neuroepidemiology. 2005; 25:135–43.
Article
16. Agency for Healthcare Research and Quality. 2021 National healthcare quality and disparities report. Rockville: Agency for Healthcare Research and Quality;2021.
17. Frieden TR; Centers for Disease Control and Prevention (CDC). CDC health disparities and inequalities report-United States, 2013. Foreword. MMWR Suppl. 2013; 62:1–2.
18. Office of Disease Prevention and Health Promotion. Healthy People 2030. Available from: https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes (cited 2024 May 10).
19. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986; 24:67–74.
Article
20. Van Buuren S, Groothuis-Oudshoorn K. Mice: multivariate imputation by chained equations in R. J Stat Softw. 2011; 45:1–67.
21. Aguinis H, Vassar M, Wayant C. On reporting and interpreting statistical significance and p values in medical research. BMJ Evid Based Med. 2021; 26:39–42.
Article
22. Amrhein V, Greenland S, McShane B. Scientists rise up against statistical significance. Nature. 2019; 567:305–7.
Article
23. Patel MR. Social determinants of poor management of type 2 diabetes among the insured. Curr Diab Rep. 2020; 20:67.
Article
24. Le-Scherban F, Ballester L, Castro JC, Cohen S, Melly S, Moore K, et al. Identifying neighborhood characteristics associated with diabetes and hypertension control in an urban AfricanAmerican population using geo-linked electronic health records. Prev Med Rep. 2019; 15:100953.
25. McDoom MM, Cooper LA, Hsu YJ, Singh A, Perin J, Thornton RL. Neighborhood environment characteristics and control of hypertension and diabetes in a primary care patient sample. J Gen Intern Med. 2020; 35:1189–98.
26. Walker RJ, Garacci E, Palatnik A, Ozieh MN, Egede LE. The longitudinal influence of social determinants of health on glycemic control in elderly adults with diabetes. Diabetes Care. 2020; 43:759–66.
27. Hill-Briggs F, Adler NE, Berkowitz SA, Chin MH, Gary-Webb TL, Navas-Acien A, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care. 2020; 44:258–79.
28. Cummings DM, Patil SP, Long DL, Guo B, Cherrington A, Safford MM, et al. Does the association between hemoglobin A1c and risk of cardiovascular events vary by residential segregation?: the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Diabetes Care. 2021; 44:1151–8.
Article
29. Preis SR, Pencina MJ, Hwang SJ, D’Agostino RB Sr, Savage PJ, Levy D, et al. Trends in cardiovascular disease risk factors in individuals with and without diabetes mellitus in the Framingham Heart Study. Circulation. 2009; 120:212–20.
Article
30. Chiha M, Njeim M, Chedrawy EG. Diabetes and coronary heart disease: a risk factor for the global epidemic. Int J Hypertens. 2012; 2012:697240.
Article
31. Glovaci D, Fan W, Wong ND. Epidemiology of diabetes mellitus and cardiovascular disease. Curr Cardiol Rep. 2019; 21:21.
Article
32. Dal Canto E, Ceriello A, Ryden L, Ferrini M, Hansen TB, Schnell O, et al. Diabetes as a cardiovascular risk factor: an overview of global trends of macro and micro vascular complications. Eur J Prev Cardiol. 2019; 26(2 suppl):25–32.
Article
33. Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015; 132:873–98.
Article
34. Christensen AJ, Smith TW. Cynical hostility and cardiovascular reactivity during self-disclosure. Psychosom Med. 1993; 55:193–202.
Article
35. Gruenewald TL, Karlamangla AS, Hu P, Stein-Merkin S, Crandall C, Koretz B, et al. History of socioeconomic disadvantage and allostatic load in later life. Soc Sci Med. 2012; 74:75–83.
Article
36. McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease. Ann N Y Acad Sci. 2010; 1186:190–222.
Article
37. Huh JH, Kwon S, Kim GO, Kim BY, Ha KH, Kim DJ. Long-term effectiveness of the national diabetes quality assessment program in South Korea. Diabetes Care. 2023; 46:1700–6.
Article
38. Rawshani A, Rawshani A, Franzen S, Eliasson B, Svensson AM, Miftaraj M, et al. Mortality and cardiovascular disease in type 1 and type 2 diabetes. N Engl J Med. 2017; 376:1407–18.
Article
39. Chamnan P, Simmons RK, Sharp SJ, Griffin SJ, Wareham NJ. Cardiovascular risk assessment scores for people with diabetes: a systematic review. Diabetologia. 2009; 52:2001–14.
Article
40. Cederholm J, Eeg-Olofsson K, Eliasson B, Zethelius B, Nilsson PM, Gudbjornsdottir S, et al. Risk prediction of cardiovascular disease in type 2 diabetes: a risk equation from the Swedish National Diabetes Register. Diabetes Care. 2008; 31:2038–43.
41. Stevens RJ, Kothari V, Adler AI, Stratton IM; United Kingdom Prospective Diabetes Study (UKPDS) Group. The UKPDS risk engine: a model for the risk of coronary heart disease in type II diabetes (UKPDS 56). Clin Sci (Lond). 2001; 101:671–9.
Article
42. Donnan PT, Donnelly L, New JP, Morris AD. Derivation and validation of a prediction score for major coronary heart disease events in a U.K. type 2 diabetic population. Diabetes Care. 2006; 29:1231–6.
Article
43. Read SH, van Diepen M, Colhoun HM, Halbesma N, Lindsay RS, McKnight JA, et al. Performance of cardiovascular disease risk scores in people diagnosed with type 2 diabetes: external validation using data from the national Scottish diabetes register. Diabetes Care. 2018; 41:2010–8.
Article
44. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010; 303:2043–50.
Article
45. Gu A, Yue Y, Desai RP, Argulian E. Racial and ethnic differences in antihypertensive medication use and blood pressure control among US adults with hypertension: the National Health and Nutrition Examination Survey, 2003 to 2012. Circ Cardiovasc Qual Outcomes. 2017; 10:e003166.
Article
Full Text Links
  • DMJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2025 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr