The cumulative impact of social determinants of health factors on mortality in adults with diabetes and chronic kidney disease

Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

Race, Social Determinants of Health, and Risk of All-Cause and Cardiovascular Mortality in the United States

OBJECTIVE

To examine the independent and interdependent effects of race and social determinants of health (SDoH) and risk of all-cause and cardiovascular disease (CVD) mortality in the US.

DATA SOURCE/STUDY DESIGN

Secondary analysis of pooled data for 252,218 participants of the 2006-2018 National Health Interview Survey, linked to the National Death Index.

METHODS

Age-adjusted mortality rates (AAMR) were reported for non-Hispanic White (NHW) and non-Hispanic Black (NHB) individuals overall, and by quintiles of SDoH burden, with higher quintiles representing higher cumulative social disadvantage (SDoH-Qx). Survival analysis was used to examine the association between race, SDoH-Qx, and all-cause and CVD mortality.

FINDINGS

AAMRs for all-cause and CVD mortality were higher for NHB and considerably higher at higher levels of SDoH-Qx, however, with similar mortality rates at any given level of SDoH-Qx. In multivariable models, NHB experienced 20-25% higher mortality risk relative to NHW (aHR = 1.20-1.26); however, no association was observed after adjusting for SDoH. In contrast, higher SDoH burden was associated with up to nearly threefold increased risk of all-cause (aHR, Q5 vs Q1 = 2.81) and CVD mortality (aHR, Q5 vs Q1 = 2.90); the SDoH effect was observed similarly for NHB (aHR, Q5:all-cause mortality = 2.38; CVD mortality = 2.58) and NHW (aHR, Q5:all-cause mortality = 2.87; CVD mortality = 2.93) subgroups. SDoH burden mediated 40-60% of the association between NHB race and mortality.

CONCLUSIONS

These findings highlight the critical role of SDoH as upstream drivers of racial inequities in all-cause and CVD mortality. Population level interventions focused on addressing adverse SDoH experienced by NHB individuals may help mitigate persistent disparities in mortality in the US.

Association between adult food insecurity and mortality among adults aged 20-79 years with diabetes: A population-based retrospective cohort study

AIMS

There is limited research on the relationship between food insecurity and mortality among individuals with diabetes. This study aims to investigate the impact of food insecurity on all-cause and cause-specific mortality in adults with diabetes.

RESEARCH DESIGN AND METHODS

This study included 5749 adults with diabetes from the National Health and Nutrition Examination Survey cycles 2003-2018 and followed up until 31 December 2019. Food insecurity was measured by the Food Security Survey Module. Cox proportional hazard models were employed to estimate hazard ratios (HRs) and 95% confidence intervals for both all-cause mortality and cause-specific mortality.

RESULTS

The weighted prevalence of full food security, marginal food security, low food security, and very low food security was 70.8%, 11.0%, 10.4%, and 7.8%, respectively. Food insecurity demonstrated a significant correlation with diminished diet quality and reduced consumption of healthy foods. Over the course of 42,272.0 person-years of follow-up, we documented 1091 deaths, of which 370 were attributed to cardiovascular disease and 180 to cancer. After adjusting for multiple variables, food insecurity scores were significantly and linearly associated with increased all-cause mortality. Comparing to full food security, participants experiencing very low food security had a multivariate-adjusted HR of 1.48 (1.12, 1.95) for all-cause mortality (ptrend  = 0.010).

CONCLUSIONS

Food insecurity was associated with increased all-cause mortality and compromised diet quality, especially in individuals experiencing very low food security. Future strategies may necessitate the monitoring of and interventions for food insecurity among individuals with diabetes.

Food Insecurity Prevalence and Risk Factors at a Large Academic Medical Center in Michigan

Importance

Health care systems are increasingly adopting methods to screen for and integrate food insecurity and other social risk factors into electronic health records. However, there remain knowledge gaps regarding the cumulative burden of food insecurity in large clinical settings, which patients are most at risk, and the extent to which patients are interested in social assistance through their health care system.

Objective

To evaluate the 5-year prevalence and associated risk factors of food insecurity among adult primary care patients, and to examine factors associated with patients' interest in social assistance among those with food insecurity.

Design, Setting, and Participants

This cross-sectional analysis of a retrospective cohort study took place at a tertiary care academic medical center (encompassing 20 primary care clinics) in Michigan. Participants included adult patients who completed screening for social risk factors between August 1, 2017, and August 1, 2022. Data analysis was performed from November 2022 to June 2023.

Exposure

Food insecurity was assessed using the Hunger Vital Sign.

Main Outcomes and Measures

The primary outcome was patients' interest in social assistance, and associated factors were examined using multivariate logistic regression models, adjusting for patients' demographic and health characteristics.

Results

Over the 5-year period, 106 087 adult primary care patients (mean [SD] age, 52.9 [17.9] years; 61 343 women [57.8%]) completed the standardized social risk factors questionnaire and were included in the analysis. The overall prevalence of food insecurity was 4.2% (4498 patients), with monthly trends ranging from 1.5% (70 positive screens) in August 2018 to 5.0% (193 positive screens) in June 2022. Food insecurity was significantly higher among patients who were younger, female, non-Hispanic Black or Hispanic, unmarried or unpartnered, and with public health insurance. Food insecurity was significantly associated with a higher cumulative burden of social needs, including social isolation, medical care insecurity, medication nonadherence, housing instability, and lack of transportation. Only 20.6% of patients with food insecurity (927 patients) expressed interest in social assistance. Factors associated with interest in social assistance including being non-Hispanic Black, unmarried or unpartnered, a current smoker, and having a higher burden of other social needs.

Conclusions and Relevance

In this retrospective cohort study, the overall prevalence of food insecurity was 4.2%, of whom approximately 1 in 5 patients with food insecurity expressed interest in assistance. This study highlights ongoing challenges in ensuring all patients complete routine social determinants of health screening and gaps in patients' interest in assistance for food insecurity and other social needs through their health care system.

Food insecurity and kidney disease: a systematic review

BACKGROUND

The risk of developing and worsening chronic kidney disease (CKD) is associated with unhealthy dietary patterns. Food insecurity is defined by a limited or uncertain availability of nutritionally adequate and safe food; it is also associated with several chronic medical conditions. The aim of this systematic review is to investigate the current knowledge about the relationship between food insecurity and renal disease.

METHODS

We selected the pertinent publications by searching on the PubMed, Scopus, and the Web of Science databases, without any temporal limitations being imposed. The searching and selecting processes were carried out through pinpointed inclusion and exclusion criteria and in accordance with the Prisma statement.

RESULTS

Out of the 26,548 items that were first identified, only 9 studies were included in the systemic review. Eight out of the nine investigations were conducted in the US, and one was conducted in Iran. The studies evaluated the relationship between food insecurity and (i) kidney disease in children, (ii) kidney stones, (iii) CKD, (iv) cardiorenal syndrome, and (v) end stage renal disease (ESRD). In total, the different research groups enrolled 49,533 subjects, and food insecurity was reported to be a risk factor for hospitalization, kidney stones, CKD, ESRD, and mortality.

CONCLUSIONS

The relationship between food insecurity and renal disease has been underestimated. Food insecurity is a serious risk factor for health problems in both wealthy and poor populations; however, the true prevalence of the condition is unknown. Healthcare professionals need to take action to prevent the dramatic effect of food insecurity on CKD and on other chronic clinical conditions.

Unfavorable social determinants of health and risk of mortality in adults with diabetes: findings from the National Health Interview Survey

INTRODUCTION

Understanding the role of social determinants of health as predictors of mortality in adults with diabetes may help improve health outcomes in this high-risk population. Using population-based, nationally representative data, this study investigated the cumulative effect of unfavorable social determinants on all-cause mortality in adults with diabetes.

RESEARCH DESIGN AND METHODS

We used data from the 2013-2018 National Health Interview Survey, linked to the National Death Index through 2019, for mortality ascertainment. A total of 47 individual social determinants of health were used to categorize participants in quartiles denoting increasing levels of social disadvantage. Poisson regression was used to report age-adjusted mortality rates across increasing social burden. Multivariable Cox proportional hazards models were used to assess the association between cumulative social disadvantage and all-cause mortality in adults with diabetes, adjusting for traditional risk factors.

RESULTS

The final sample comprised 182 445 adults, of whom 20 079 had diabetes. In the diabetes population, mortality rate increased from 1052.7 per 100 000 person-years in the first quartile (Q1) to 2073.1 in the fourth quartile (Q4). In multivariable models, individuals in Q4 experienced up to twofold higher mortality risk relative to those in Q1. This effect was observed similarly across gender and racial/ethnic subgroups, although with a relatively stronger association for non-Hispanic white participants compared with non-Hispanic black and Hispanic subpopulations.

CONCLUSIONS

Cumulative social disadvantage in individuals with diabetes is associated with over twofold higher risk of mortality, independent of established risk factors. Our findings call for action to screen for unfavorable social determinants and design novel interventions to mitigate the risk of mortality in this high-risk population.

Food Insecurity and Chronic Kidney Disease: Considerations for Practitioners

The coronavirus disease 2019 pandemic has exacerbated existing health disparities related to food security status. Emerging literature suggests individuals with Chronic Kidney Disease (CKD) who are also food insecure have a greater likelihood of disease progression compared to food secure individuals. However, the complex relationship between CKD and food insecurity (FI) is understudied relative to other chronic conditions. The purpose of this practical application article is to summarize the recent literature on the social-economic, nutritional, to care through which FI may negatively impact health outcomes in individuals with CKD. While several studies have reported on the cross-sectional prevalence of FI among persons with CKD, literature is lacking about the severity and duration of exposure to FI on CKD outcomes. Future research is needed to better understand how FI impairs CKD care, nutritional and structural barriers that impact disease prevention and disease progression, and effective strategies to support patients.

Disentangling Social Determinants of Health and Rurality in Head and Neck Cancer 2-Year Mortality

Social determinants of health (SDoH) and rurality are known factors that may influence outcomes in head and neck squamous cell carcinoma (HNSCC). Patients residing in remote locations or those with multiple SDoH may encounter barriers to initial diagnosis, adherence to multidisciplinary treatments, and posttreatment surveillance, which may impact their overall survival. However, previous studies have shown mixed results associated with rural residence. The aim of this study is to identify the impact of rurality and SDoH on 2-year survival in HNSCC. The study was conducted using a Head and Neck Cancer Registry at a single institution from June 2018 through July 2022. Rurality, defined by US census scores, and individual measures of SDoH were used. Our results indicate that each additional adverse SDoH factor results in 1.5 times the odds of mortality at 2 years. Individualized measures of SDoH, rather than rurality alone, better reflect patient prognosis in HNSCC.

Social determinants of health impact mortality from HCC and cholangiocarcinoma: a population-based cohort study

BACKGROUND AND AIMS

The social determinants of health can pose barriers to accessing cancer screening and treatment and have been associated with cancer mortality. However, it is not clear whether area deprivation is independently associated with mortality in HCC and cholangiocarcinoma when controlling for individual-level social determinants of health.

APPROACH AND RESULTS

The cohort included individuals over 18 years old diagnosed with HCC (N=3460) or cholangiocarcinoma (N=781) and reported to the Indiana State Cancer Registry from 2009 to 2017. Area disadvantage was measured using the social deprivation index (SDI). SDI was obtained by linking addresses to the American Community Survey. Individual social determinants of health included race, ethnicity, sex, marital status, and insurance type. The primary outcome was mortality while controlling for SDI and individual social determinants of health by means of Cox proportional hazard modeling. In HCC, living in a neighborhood in the fourth quartile of census-track SDI (most deprived) was associated with higher mortality (HR: 1.14, 95% CI, 1.003-1.30, p=0.04) than living in a first quartile SDI neighborhood. Being uninsured (HR: 1.64, 95% CI, 1.30-2.07, p<0.0001) and never being married (HR: 1.31, 95% CI, 1.15-1.48, p<0.0001) were also associated with mortality in HCC. In cholangiocarcinoma, SDI was not associated with mortality.

CONCLUSIONS

Social deprivation was independently associated with mortality in HCC but not cholangiocarcinoma. Further research is needed to better understand how to intervene on both area and individual social determinants of health and develop interventions to address these disparities.

Dietary Factors and All-Cause Mortality in Individuals With Type 2 Diabetes: A Systematic Review and Meta-analysis of Prospective Observational Studies

BACKGROUND

Type 2 diabetes is a major health concern associated with mortality. Diet may influence the progression of diabetes; however, systematic reviews are lacking.

PURPOSE

This study systematically summarized the evidence on diet and all-cause mortality in individuals with type 2 diabetes.

DATA SOURCES

PubMed and Web of Science were searched until June 2022.

STUDY SELECTION

Prospective observational studies investigating dietary factors in association with all-cause mortality in individuals with type 2 diabetes were selected.

DATA SYNTHESIS

We identified 107 studies. Moderate certainty of evidence was found for inverse associations of higher intakes of fish (summary risk ratios per serving/week: 0.95; 95% CI 0.92, 0.99; n = 6 studies), whole grain (per 20 g/day: 0.84; 95% CI 0.71, 0.99; n = 2), fiber (per 5 g/day: 0.86; 95% CI 0.81, 0.91; n = 3), and n-3 polyunsaturated fatty acids (per 0.1 g/day: 0.87; 95% CI 0.82, 0.92; n = 2) and mortality. There was low certainty of evidence for inverse associations of vegetable consumption (per 100 g/day: 0.88; 95% CI 0.82, 0.94; n = 2), plant protein (per 10 g/day: 0.91; 95% CI 0.87, 0.96; n = 3), and for positive associations of egg consumption (per 10 g/day: 1.05; 95% CI 1.03, 1.08; n = 7) and cholesterol intake (per 300 mg/day: 1.19; 95% CI 1.13, 1.26; n = 2). For other dietary factors, evidence was uncertain or no association was observed.

CONCLUSIONS

Higher intake of fish, whole grain, fiber, and n-3 polyunsaturated fatty acids were inversely associated with all-cause mortality in individuals with type 2 diabetes. There is limited evidence for other dietary factors, and, thus, more research is needed.

Multiple social risk factors are adversely associated with diabetes management and psychosocial outcomes among adults with diabetes

Adults from structurally marginalized populations have disproportionately higher rates of diabetes, highlighting the importance of addressing social risk factors in diabetes prevention and management. This study examined the correlations among multiple social risk factors and their respective burden on diabetes management and psychosocial health outcomes among adults with diabetes. Data came from the baseline assessment of an ongoing randomized controlled trial evaluating approaches to addressing unmet social needs among 579 adults with diabetes. Four social risks (food insecurity, financial insecurity, housing insecurity, and utility insecurity) were assessed, dichotomized and summed to create a score of cumulative social risk factors. The outcomes of interest were: hemoglobin A1c, cost-related non-adherence for diabetes, diabetes distress, and anxiety or depression. Multivariate regression models were used to examine the associations between cumulative social risk factors and health outcomes, adjusting for sociodemographic characteristics and diabetes duration. Approximately 18% of study participants reported one social risk, 18% reported two social risks, and 23% reported three or four social risks. After multivariate adjustment, adults with three or four social risk factors had a greater likelihood of cost-related non-adherence (OR 2.81, 95% CI 1.95, 4.06), diabetes distress (OR 3.03, 95% CI 2.13, 4.31), and anxiety or depression (OR 5.36, 95% CI 3.39, 8.47), compared to adults with no social risk factors. Significant dose-response relationships were observed with greater social risk factors and poorer diabetes-related outcomes. These findings support efforts to address systemic contributors to diabetes management and care to better promote individual and population health.

The power of partnerships: state public health department multisector collaborations in major chronic disease programme areas in the United States

BACKGROUND

Multisector collaboration between state public health departments (SHDs) and diverse community partners is increasingly recognized as important for promoting positive public health outcomes, addressing social determinants of health, and reducing health inequalities. This study investigates collaborations between SHDs in the United States and different types of organizations addressing chronic disease in and outside of the health sector.

METHODS

SHD employees were randomly selected from the National Association of Chronic Disease Directors membership list for participation in an online survey. Participants were asked about their primary chronic disease work unit (cancer, obesity, tobacco, diabetes, cardiovascular disease, and others), as well as their work unit collaborations (exchange of information/cooperation in activities) with organizations in health and non-health sectors. As a measure of the different organizations SHDs collaborated with in health and non-health sectors, a collaboration heterogeneity score for each programme area was calculated. One-way analysis of variance (ANOVA) with Tukey's post hoc tests were used to assess differences in collaborator heterogeneity between programme areas.

RESULTS

A total of 574 participants were surveyed. Results indicated that the cancer programme area, along with diabetes and cardiovascular disease, had significantly less collaboration heterogeneity with organizations outside of the health sector compared to the obesity and tobacco programme areas.

CONCLUSIONS

While collaborations with health sector organizations are commonly reported, public health departments can increase collaboration with sectors outside of health to more fully address chronic disease prevention.

Complications in Diabetes Mellitus: Social Determinants and Trends

Conditions that impact an individual's health are referred to as social determinants of health. Through a retrospective study (January 2017-February 2022) and statistical analysis, researchers looked at the relationship between social demands and type 2 diabetes mellitus (T2DM) diagnosis. All social demands, with the exception of childcare, were more typically documented in patients with T2DM. Prescription expense, conveyance, and health literacy were the domains with the greatest relationships. These results might help health systems and social service providers develop collaborations to help in certain areas.

Frailty as an Independent Risk Factor for Depression in Patients With End-Stage Renal Disease: A Cross-Sectional Study

Background

Depression confers substantial disease burden globally, especially among those with chronic kidney disease (CKD). The presence of depression significantly impairs one's quality of life. Risk factors for depression in patients with CKD remain under-appreciated, and whether frailty, a geriatric phenotype, constitutes a risk factor for depression in this population is unknown.

Methods

We prospectively enrolled patients with end-stage renal disease (ESRD) undergoing hemodialysis for >3 months from National Taiwan University Hospital Yunlin Branch between 2019 and 2021. Clinical, physical, functional, and performance parameters were recorded, followed by frailty/sarcopenia assessment. Depression was screened for using the Geriatric Depression Scale. We analyzed the independent relationship between frailty and depression in these patients, using multiple regression analyses.

Results

Totally 151 patients with ESRD were enrolled (mean 61.1 years, 66.9% male), among whom 16.6% had screening-identified depression. ESRD participants with depression did not differ from those without regarding most parameters except serum creatinine, functional indices, and sarcopenia/frailty status. We found that having greater frail severities was independently associated with a higher probability of depression; having FRAIL- (odds ratio [OR] 5.418) and SOF-based (OR 2.858) frailty independently correlated with a higher depression probability. A linear relation exists between a greater frail severity and the probability of depression. Using a more relaxed criterion for detecting depression, higher SOF scores remained significantly associated with an increased depression risk.

Conclusions

In patients with CKD, frailty independently correlated with a higher probability of having depression. Strategies aiming to attenuate frailty may be able to benefit those with depression simultaneously in this population.

Sex-Based Differences in Risk Factors and Complications of Chronic Kidney Disease

Globally, females are ∼30% more likely to have pre-dialysis chronic kidney disease (CKD) than males for reasons that are not fully understood. CKD is associated with numerous adverse health outcomes which makes understanding and working to eradicating sex based disparities in CKD prevalence essential. This review maps both what is known, and what is unknown, about the way sex and gender impacts (1) the epidemiology and risk factors for CKD including age, diabetes, hypertension, obesity, smoking, and cerebrovascular disease, and (2) the complications from CKD including kidney disease progression, cardiovascular disease, CKD mineral and bone disorders, anaemia, quality-of-life, cancer and mortality. This mapping can be used to guide future research.

Social determinants of health and obesity: Findings from a national study of US adults

OBJECTIVE

This study examined the association between social determinants of health (SDOH) burden and overweight/obesity in a nationally representative sample of adults in the United States.

METHODS

Data for 161,795 adults aged ≥18 years from the 2013 to 2017 National Health Interview Survey were used. A total of 38 SDOH were aggregated to create a cumulative SDOH score, which was divided into quartiles (Q1-Q4) to denote levels of SDOH burden. Prevalence of overweight and obesity was examined across SDOH quartiles in the total population and by age, sex, and race/ethnicity. Multinomial logistic regression models were used to analyze the association between SDOH quartiles and overweight/obesity, adjusting for relevant covariates.

RESULTS

There was a graded increase in obesity prevalence with increasing SDOH burden. At nearly each quartile, overweight and obesity rates were higher for middle-aged and non-Hispanic Black adults compared with their counterparts; additional differences were observed by sex. In fully adjusted models, SDOH-Q4 was associated with 15%, 50%, and 70% higher relative prevalence of overweight, obesity class 1 and 2, and obesity class 3, respectively, relative to SDOH-Q1.

CONCLUSIONS

Cumulative social disadvantage, denoted by higher SDOH burden, was associated with increased odds of obesity, independent of clinical and demographic factors.