Disparities in the prevalence of diabetes: is it race/ethnicity or socioeconomic status? Results from the Boston Area Community Health (BACH) survey

Abstract

Objectives: Many researchers and clinicians continue to believe that non-modifiable race/ ethnicity is a major contributor to diabetes, prompting a well-intentioned search for genetic and bio-physiological explanations. We seek to reinforce earlier findings showing that socioeconomic status is more strongly associated with diabetes prevalence than race/ ethnicity and suggests a very different and potentially modifiable etiologic pathway.

Methods: A community-based epidemiologic survey of 5503 Boston residents aged 30-79 years (1767 Black, 1877 Hispanic, 1859 White; 2301 men and 3202 women).

Results: After adjusting for age and sex, Blacks and Hispanics have statistically significantly increased odds of having diabetes: Black (OR, 2.0; 95% CI, 1.4-2.9) and Hispanic (2.4; CI 1.6-3.4) compared to Whites. If socioeconomic status, a combination of education and income, is added to the model, these odds are reduced for both Blacks (OR 1.6; CI, 1.1-2.2) and Hispanics (OR 1.6; CI, 1.1-2.3). In a multivariate logistic regression adjusting for age, sex, socioeconomic status, obesity, hypertension, gestational diabetes, physical activity, trouble paying for basics, health insurance status, and family history of diabetes, these odds are reduced further: Black (OR 1.0; CI, 0.7-1.5) and Hispanic (OR 1.3; CI, 0.9-2.1) and are no longer statistically significant.

Conclusions: Consistent with other reports, we find socioeconomic status has a much stronger association with diabetes prevalence than race/ethnicity. Continuing to focus on race/ethnicity as a primary determinant of diabetes prevalence overemphasizes the importance of biomedical factors and diverts effort from socio-medical interventions such as improving social circumstances, access to effective care, and upstream redistributive social policies.

Figure 1

Odds ratios for the prevalence of diabetes (with 95% confidence intervals) for three models ((1) age, gender, race/ethnicity; (2) age, gender, socioeconomic status (SES), race/ethnicity), and (3) age, gender, socioeconomic status, trouble paying for basics, health insurance status, hypertension, gestational diabetes, and family history of diabetes, race/ethnicity). The p value (for race/ethnicity) is from a Wald F test with 2 degrees of freedom in the numerator.

Figure 2

Proportion of variation in the prevalence of diabetes by modifiable (BMI, SES, physical activity, health insurance status) and non-modifiable (age, family history of diabetes, history of high blood pressure, history of gestational diabetes, gender, race/ethnicity) risk factors.