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标题：Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965–1999
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作者：Siobhan C. Maty ; Sherman A. James ; George A. Kaplan 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2010
卷号：100
期号：1
页码：137-145
DOI：10.2105/AJPH.2008.133892
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study. Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates. Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups. Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations. Diabetes mellitus is a major cause of morbidity and mortality in the United States.^{1 , 2} Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^{2 – 5} Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^{6 – 10} Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^{5 , 11} or physiological^{11 – 13} susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^{14 – 17} Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^{19 – 24} and incidence^{3 , 19 , 25 – 30} of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^{3 , 17 , 31} physically inactive,^{3 , 32} or have hypertension,^{33 , 34} all of which are conditions more common among people with lower SEP.^{16 , 35 – 37} Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^{4 , 12 , 19 , 30} For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^{19 , 30} Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965. We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).