Poverty Increases Type 2 Diabetes Incidence and Inequality of Care Despite Universal Health Coverage

Abstract

OBJECTIVEThe discrepancy of diabetes incidence and care between socioeconomic statuses has seldom been studied concurrently in nations with universal health coverage. We aimed to delineate whether income disparity is associated with diabetes incidence and inequality of care under a national health insurance (NHI) program in Asia.RESEARCH DESIGN AND METHODSFrom the Taiwan NHI database in 2000, a representative cohort aged ≥20 years and free of diabetes (n = 600,662) were followed up until 2005. We regarded individuals exempt from paying the NHI premium as being poor. Adjusted hazard ratios (HRs) were used to discover any excess risk of diabetes in the poor population. The indicators used to evaluate quality of diabetes care included the proportion of diabetic patients identified through hospitalization, visits to diabetes clinics, and completion of recommended diabetes tests.RESULTSThe incidence of type 2 diabetes in the poor population was 20.4 per 1,000 person-years (HR, 1.5; 95% CI, 1.3–1.7). Compared with their middle-income counterparts, the adjusted odds ratio (OR) for the poor population incidentally identified as having diabetes through hospitalization was 2.2 (P < 0.001). Poor persons with diabetes were less likely to visit any diabetes clinic (OR, 0.4; P < 0.001). The ORs for the poor population with diabetes to receive tests for glycated hemoglobin, low-density lipoprotein cholesterol, triglycerides, and retinopathy were 0.6 (0.4–0.9), 0.4 (0.2–0.7), 0.5 (0.4–0.8), and 0.4 (0.2–0.9), respectively.CONCLUSIONSPoverty is associated not only with higher diabetes incidence but also with inequality of diabetes care in a northeast Asian population, despite universal health coverage.

Diabetes among non-obese Filipino Americans: Findings from a large population-based study

“…Each of these factors is a well-known contributor to diabetes in the general population as well. 22,[26][27][28] The association between poverty and diabetes is consistent with previous findings that report socio-economic disadvantage as a key contributor to the high prevalence of diabetes among Filipino Americans. 29 Poverty in childhood is associated with poverty during adulthood.…”

“…The high prevalence of diabetes in this non-obese sample of Filipino Americans lends support to the recently proposed recommendation to lower the BMI cutpoint for diabetes screening in the US for AAPI populations, including Filipino Americans, to 23 kg/m 2 . 22 Such a strategy could substantially improve rates of primary prevention for those at risk who are notified of their pre-diabetic status in time to make appropriate lifestyle changes before they develop full-blown diabetes. 22 The lower cutpoint for screening could also help in secondary prevention efforts such that those who learn they have diabetes may be able to either prevent or reduce complications associated with diabetes through early intervention.…”

“…22 Such a strategy could substantially improve rates of primary prevention for those at risk who are notified of their pre-diabetic status in time to make appropriate lifestyle changes before they develop full-blown diabetes. 22 The lower cutpoint for screening could also help in secondary prevention efforts such that those who learn they have diabetes may be able to either prevent or reduce complications associated with diabetes through early intervention. 22 Logistic regression analyses confirmed that non-obese Filipino Americans had significantly higher odds of diabetes than nonHispanic whites even when many of the known risk factors for diabetes were taken into account (i.e., age, sex, education, poverty status, fruits and vegetable consumption, immigrant status, exercise, overweight status, and smoking).…”

“…22 The lower cutpoint for screening could also help in secondary prevention efforts such that those who learn they have diabetes may be able to either prevent or reduce complications associated with diabetes through early intervention. 22 Logistic regression analyses confirmed that non-obese Filipino Americans had significantly higher odds of diabetes than nonHispanic whites even when many of the known risk factors for diabetes were taken into account (i.e., age, sex, education, poverty status, fruits and vegetable consumption, immigrant status, exercise, overweight status, and smoking). It appears then that there must be other relevant factors influencing the higher prevalence of diabetes among non-obese Filipino Americans in comparison to non-Hispanic whites.…”

Desigualdad social y tendencias de mortalidad por diabetes

“…El cambio demográfico debido al aumento de la proporción de personas mayores de 65 años ha contribuido al incremento de la prevalencia de diabetes en todo el mundo 3 . Si bien se ha planteado la existencia de la regulación genética entre el metabolismo de lípidos, la acción y la resistencia de la insulina, así como el incremento de marcadores inflamatorios, como la proteína C reactiva y la interleucina 6, que contribuyen bioló-gicamente en la predisposición de los individuos a desarrollar diabetes en algún momento de su vida [4][5][6][7] , también son sus determinantes sociales los que establecen las diferencias en la incidencia, la prevalencia y la mortalidad de la enfermedad en los distintos grupos sociales [8][9][10][11] . En todo el mundo se ha identificado que las condiciones socioeconómicas, como la posición social, la educación y los ingresos, son determinantes importantes que contribuyen al incremento en la mortalidad relacionada con la diabetes [11][12][13][14] .…”