Adverse social determinants of health associated with prediabetes

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Adverse social determinants of health (SDOH) should be considered and recognized in clinical settings and used to guide efforts to reduce risk of youth-onset type 2 diabetes (T2D), as a recent study revealed SDOH were associated with higher prediabetes prevalence.

Investigators of a study published in JAMA Network Open sought to answer the question, "How does youth-onset prediabetes prevalence differ by exposure to adverse SDOH, independent of race and ethnicity?"

Race- and ethnicity-based screening for youth T2D is advised in several clinical practice guidelines because of a higher prevalence among American Indian and Alaska Native, Black, Asian, and Hispanic youths compared to White youths. The authors noted that the disparity likely reflects inequitable distribution of adverse SDOH rather than a biological risk.

To evaluate prediabetes prevalence by presence or absence of adverse SDOH in adolescents eligible for T2D screening based on weight status, the investigators developed a cross-sectional study and analysis. They used data from the 2011 to 2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Eligible individuals included adolescents aged 12 to 18 years with a body mass index (BMI) at or above the 85th percentile for age and sex without known diabetes, and available hemoglobin A_1c (HbA_1c).

HbA_1c level measurements were from 2-year survey cycle waves from 2011 to 2018 of NHANES, a program conducted by the National Center for Health Statistics that collects demographic, socioeconomic, and health-related surveys. Survey populations are designed to be representative of the US population after survey weighing.

The primary outcome was an elevated HbA_1c level greater than or equal to 5.7% (prediabetes or undiagnosed presumed T2D). Race, ethnicity, and adverse SDOH were independent variables. SDOH included:

• Food insecurity
• Non-health insurance
• Household income <130% of federal poverty level

Survey-weighted logistic regression was used to adjust for confounders of age, sex, and BMI z scores and to determine adjusted marginal prediabetes prevalence by race, ethnicity, and adverse SDOH.

The study featured 1563 adolescents, which represented 10,178,400 youths aged 12 to 18 years in the United States (50.5% female [95% CI, 47.1%-53.9%]), with a mean age of 15.5 years (95% CI, 15.3-15.6).

Participants' race and ethnicity:

• Asian: 3.0% (95% CI, 2.2%-3.9%)
• Black: 14.9% (95% CI, 11.6%-19.1%)
• Mexican American: 18.8% (95% CI, 15.4%-22.9%)
• Other Hispanic: 8.1% (95% CI, 6.5%-10.1%)
• White: 9.1% (95% CI, 43.2%-55.0%)
• More than 1 or other race: 6.1% (95% CI, 4.6%-8.0%)

After adjustment for race, ethnicity, and BMI z score, food insecurity (4.1% [95% CI, 0.7%-7.5%]), public insurance (5.3% [95% CI, 1.6%-9.1%]), and low income (5.7% [95% CI, 3.0%-8.3%]) were each independently associated with a higher prediabetes prevalence. Asian, Black, and Hispanic youths had higher prediabetes prevalence overall, while an increasing number of adverse SDOH were associated with higher prevalence among White youths (8.3% [95% CI, 4.9%-11.8%] for 3 vs 0.6% [95% CI, −0.7% to 2.0%] for 0 adverse SDOH).

Elevated HbA_1c level was present in 8.5% and varied by race and ethnicity:

• Black: 24.5% (95% CI, 19.4%-30.7%)
• Asian: 14.3% (95% CI, 8.8%-22.4%)
• Mexican American: 9.7% (95% CI, 5.9%-15.8%)
• Other Hispanic: 7.9% (95% CI, 4.6%-13.3%)
• More than 1 or other race: 6.6% (95% CI, 2.9%-14.1%)
• White: 3.1% (9% CI, 1.9%-4.9%)

Overall, diabetes-range HbA_1c levels were uncommon, occurring in 3 individuals.

Across and within racial and ethnic categories, adverse SDOH were associated with higher prevalence of prediabetes among adolescents in a nationally-representative cross-sectional study.

"Pediatric T2D screening guidelines should move beyond use of race and ethnicity and instead critically consider exposure to adverse SDOH," said the investigative team. "Such an approach would be well aligned with recent efforts by many pediatric health care organizations to make screening for health-related social needs standard of care."

The authors concluded that these approaches could reduce risks associated with youth onset T2D via prevention, early identification, and treatment.

Reference:

Harrison C, Peyyety V, Rodriguez Gonzalez A, et al. Prediabetes prevalence by adverse social determinants of health in adolescents. JAMA Netw Open. 2024;7(6):e2416088. doi:10.1001/jamanetworkopen.2024.16088