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

• Zhang L
• Reshetnyak E
• Ringel JB
• Pinheiro LC
• Carson A
• Cummings DM
• Durant RW
• Malla G
• Safford MM

• KMID: 2561791
• DOI: http://doi.org/10.4093/dmj.2023.0380

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

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  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.

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  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.

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