Association between socioeconomic status and self-reported diabetes in India: a cross-sectional multilevel analysis

Abstract

Objectives: To quantify the association between socioeconomic status (SES) and type 2 diabetes in India.

Design: Nationally representative cross-sectional household survey.

Setting: Urban and rural areas across 29 states in India.

Participants: 168 135 survey respondents aged 18-49 years (women) and 18-54 years (men).

Primary outcome measure: Self-reported diabetes status.

Results: Markers of SES were social caste, household wealth and education. The overall prevalence of self-reported diabetes was 1.5%; this increased to 1.9% and 2.5% for those with the highest levels of education and household wealth, respectively. In multilevel logistic regression models (adjusted for age, gender, religion, marital status and place of residence), education (OR 1.87 for higher education vs no education) and household wealth (OR 4.04 for richest quintile vs poorest) were positively related to self-reported diabetes (p<0.0001). In a fully adjusted model including all socioeconomic variables and body mass index, household wealth emerged as positive and statistically significant with an OR for self-reported diabetes of 2.58 (95% credible interval (CrI): 1.99 to 3.40) for the richest quintile of household wealth versus the poorest. Nationally in India, a one-quintile increase in household wealth was associated with an OR of 1.31 (95% CrI 1.20 to 1.42) for self-reported diabetes. This association was consistent across states with the relationship found to be positive in 97% of states (28 of 29) and statistically significant in 69% (20 of 29 states).

Conclusions: The authors found that the highest SES groups in India appear to be at greatest risk for type 2 diabetes. This raises important policy implications for addressing the disease burdens among the poor versus those among the non-poor in the context of India, where >40% of the population is living in poverty.

Figure 1

Flow diagram showing exclusions and final sample sizes, 2005–2006 National Family Health Survey (NFHS). *Two thousand three hundred and thirty-three individuals reported unknown diabetes status; in 40 individuals, diabetes status was not reported/missing. Of the 2333 individuals who reported unknown diabetes status, 2210 (94.7%) had complete data for BMI and were included in sensitivity analyses. **Analyses involving body mass index (BMI) as an independent variable were restricted to 158 936 individuals.

Figure 2

State-level prevalence of self-reported diabetes in India for men aged 18–54 years (left) and women aged 18–49 years (right). Darker colours indicate higher prevalence. State name abbreviations: AP, Andhra Pradesh; AR, Arunachal Pradesh; AS, Assam; BR, Bihar; CT, Chhattisgarh; DL, Delhi; GA, Goa; GJ, Gujarat; HR, Haryana; HP, Himachal Pradesh; JK, Jammu & Kashmir; JH, Jharkhand; KA, Karnataka; KL, Kerala; MP, Madhya Pradesh; MH, Maharashtra; MN, Manipur; ML, Meghalaya; MZ, Mizoram; NL, Nagaland; OR, Orissa; PB, Punjab; RJ, Rajasthan; SK, Sikkim; TN, Tamil Nadu; TR, Tripura; UP, Uttar Pradesh; UK, Uttarakhand (Uttaranchal); WB, West Bengal.

Figure 3

ORs for self-reported diabetes by state of residence in India. Horizontal lines are 95% credible intervals; adjusted for age, gender, marital status, religion, social caste, household wealth, education, body mass index and place of residence.

Figure 4

OR for self-reported diabetes for a one-quintile increase in household wealth for men (aged 18–54 years) and women (aged 18–49 years) in India and 29 states. Adjusted for age, gender, marital status, religion, social caste, education, body mass index and place of residence.

Figure 5

Mean body mass index (BMI) across three possible responses for self-reported diabetes. Vertical lines represent 95% confidence intervals. BMI (in kg/m²) was calculated from measured height and weight values. Horizontal line represents overall mean BMI (21.2 kg/m², SD 3.9).