{"id":1094,"date":"2016-07-13T16:06:47","date_gmt":"2016-07-13T16:06:47","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1094"},"modified":"2017-08-21T10:51:09","modified_gmt":"2017-08-21T10:51:09","slug":"primary-care-corner-with-geoffrey-modest-md-ses-and-mortality","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/07\/13\/primary-care-corner-with-geoffrey-modest-md-ses-and-mortality\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: SES and Mortality"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>A recent Swedish study found that socioeconomic status (SES) was independently associated with mortality, cardiovascular disease, and cancer in patients with type 2 diabetes (see\u00a0doi:10.1001\/jamainternmed.2016.2940).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>217,364 people &lt;70 yo, with type 2 diabetes in the Sweden National Diabetes Register (from 2001-2011), assessing all-cause, cardiovascular, diabetes-related and cancer mortality.<\/li>\n<li>Median age 58, 60% male<\/li>\n<li>10%\u00a0from non-Western countries: of these,\u00a010% Latin America\/Caribbean, 17% East or South Asia, 60% Middle East\/North Africa, 14% sub-Saharan Africa<\/li>\n<li>Results (all adjusted\u00a0for age, sex, duration of diabetes, marital status, income level, educational level, country of birth. further adjustment for smoking, HbA1c, eGFR, BMI, diabetes treatment, albuminuria, heart failure, MI, stroke, stage 5 CKD, and baseline cancer did not affect the associations much):\n<ul>\n<li>19,105 all-cause deaths: 60% cardiovascular, 37% diabetes-related, 34% cancer-related<\/li>\n<li>Marital status: comparing\u00a0married vs single,\u00a0overall 13.0 deaths \/1000 vs 18.82 deaths\/1000\n<ul>\n<li>27% decreased all-cause mortality [HR 0.73 (0.70-0.77)]<\/li>\n<li>33% decreased cardiovasc\u00a0mortality [HR 0.67 (0.63-0.71)]<\/li>\n<li>38% decreased diabetes-related\u00a0mortality [HR 0.62 (0.57-0.67)]<\/li>\n<li>No difference in cancer-related mortality, other than 33% decreased risk\u00a0for prostate cancer [HR 0.67 (0.50-0.90)]<\/li>\n<\/ul>\n<\/li>\n<li>Income: comparing lowest to highest\u00a0income quintiles, overall 8.92 deaths \/1000 vs 18.33 deaths\/1000. This risk varied continuously\u00a0as income level changes\n<ul>\n<li>71% increased all-cause mortality [HR1.71\u00a0(1.60-1.83)]<\/li>\n<li>87% increased\u00a0cardiovasc\u00a0mortality [HR\u00a01.87\u00a0(1.72-2.05)]<\/li>\n<li>80% increased diabetes-related\u00a0mortality [HR 1.80\u00a0(1.61-2.01)]<\/li>\n<li>28% increased cancer-related\u00a0mortality [HR 1.28\u00a0(1.14-1.44)]<\/li>\n<\/ul>\n<\/li>\n<li>Income: comparing non-Western\u00a0immigrants to native Swedes (with covariate adjustment)\n<ul>\n<li>45% decreased all-cause mortality [HR 0.55\u00a0(0.48-0.63)]<\/li>\n<li>54% decreased\u00a0cardiovasc\u00a0mortality [HR\u00a00.46\u00a0(0.38-0.56)]<\/li>\n<li>62% decreased diabetes-related\u00a0mortality [HR 0.38\u00a0(0.29-0.49)]<\/li>\n<li>28% decreased cancer-related\u00a0mortality [HR 0.72 (58-88)]<\/li>\n<\/ul>\n<\/li>\n<li>Education: comparing college\/university degree vs 9 yrs or less education. this risk varied continuously as educational level increased\n<ul>\n<li>15% decreased all-cause mortality [HR 0.85\u00a0(0.80-0.90)]<\/li>\n<li>16% decreased\u00a0cardiovasc\u00a0mortality [HR\u00a00.84\u00a0(0.78-0.91)]<\/li>\n<li>16% decreased cancer-related\u00a0mortality [HR\u00a00.84 (0.76-0.93)]<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>This study complements many prior studies from many countries over the past many decades\u00a0showing that SES is a powerful predictor of morbidity and mortality,\u00a0including both the development of\u00a0and mortality from diabetes<\/li>\n<li>Sweden provides not just a large and\u00a0rigorous database for analysis (clinical as well as individual-level data on risk factors and socioeconomic variables), but a country where SES has minimal effect on access to and use of health care services. For example, being hospitalized in Sweden costs approximately $10\/day independent of the level of care or the number\/type of interventions done. Immigrants in general receive\u00a0evidence-based treatments earlier than native Swedes!!!<\/li>\n<li>Clearly there are limits to drawing definitive conclusions from an observational study. For example, some important covariates were not measured (e.g., alcohol intake, amount of smoking). Perhaps others as well.<\/li>\n<li>So, an important aspect of this study in Sweden was that\u00a0there appeared to be relatively equal access to medical care in all groups. This again reinforces the concept that health care is much more than medical care, and health outcomes\u00a0really depend a lot\u00a0on broader social issues (and, this is in a country with a much larger social safety net and more extensive\u00a0social programs\/support networks than the United States, for example). In terms of the potential\u00a0mechanism leading to increased mortality in those with lower SES,\u00a0one might posit that their\u00a0attendant stress is associated with many potentially adverse\u00a0hormonal changes (especially as mediated by the known stress-related\u00a0increase in cortisol), coupled with perhaps less healthy eating habits, lack of social supports\/community cohesion: all possibly\u00a0leading to increased morbidity and mortality.<\/li>\n<\/ul>\n<p>Some other SES blogs:<\/p>\n<p><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/04\/28\/primary-care-corner-with-geoffrey-modest-md-bmi-height-and-socioeconomic-status\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/04\/28\/primary-care-corner-with-geoffrey-modest-md-bmi-height-and-socioeconomic-status\/<\/a> which found (through Mendelian randomization) that SES was related both to the individual&#8217;s height and BMI, and that part of the association was mediated through genetics, but mostly through social factors.<\/p>\n<p><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/04\/26\/primary-care-corner-with-geoffrey-modest-md-life-expectancy-and-income\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/04\/26\/primary-care-corner-with-geoffrey-modest-md-life-expectancy-and-income\/<\/a> found a striking relationship in the US between income and life expectancy.<\/p>\n<p>And, for those readers who are\u00a0microbiome-oriented,\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/08\/11\/primary-care-corner-with-geoffrey-modest-md-early-life-stress-in-mice-changes-in-microbiome-and-later-anxiety\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/08\/11\/primary-care-corner-with-geoffrey-modest-md-early-life-stress-in-mice-changes-in-microbiome-and-later-anxiety\/<\/a> which showed that early life stresses in mice leads\u00a0to long-lasting adverse changes in\u00a0microbiota<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: SES and Mortality  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/07\/13\/primary-care-corner-with-geoffrey-modest-md-ses-and-mortality\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1094","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1094","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1094"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1094\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1094"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1094"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1094"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}