Socioeconomic Inequality in Metabolic Control Among Children With Type 1 Diabetes: A Nationwide Longitudinal Study of 4,079 Danish Children

Abstract

To examine inequality in glycemic control by maternal educational level among children with type 1 diabetes in a setting with universal access to health care. RESEARCH DESIGN AND METHODS This was a longitudinal nationwide study of 4,079 Danish children with type 1 diabetes between the years 2000 and 2013. Children were divided into four groups based on mothers' education prebirth (£high school [n = 1,643], vocational or 2-year college [n = 1,548], bachelor's degree [n = 695], ‡master's degree [n = 193]). Means of socioeconomic and treatment characteristics were compared between groups. HbA 1c and the number of daily glucose tests were compared repeatedly from onset until 5 years after onset across groups. HbA 1c was compared across daily blood glucose testing frequency and groups. Linear regression was used to compare HbA 1c across groups with and without adjustment for socioeconomic and treatment characteristics. RESULTS Large differences in HbA 1c across maternal education were found. The mean level of HbA 1c during follow-up was 59.7 mmol/mol (7.6%) for children of mothers with ‡master's degrees and 68.7 mmol/mol (8.4%) for children of mothers with £high school (difference: 9.0 mmol/mol [95% CI 7.5, 10.6]; 0.8% [95% CI 0.7, 1.0]). The associations were attenuated but remained significant after adjustment. Observable characteristics explained 41.2% of the difference in HbA 1c between children of mothers with £high school and mothers with ‡master's degree; 22.5% of the difference was explained by more frequent blood glucose monitoring among the children with the highly educated mothers. CONCLUSIONS Family background is significantly related to outcomes for children with type 1 diabetes, even with universal access to health care. Aspects of family background such as socioeconomic status (1,2), household composition (3-5), and ethnicity (1) have been linked to metabolic controlda key determinant of diabetes-related complications (6-9)din children with type 1 diabetes. Specifically, children with well-educated or affluent parents (1,2,10,11

Association of type 1 diabetes and school wellbeing: a population-based cohort study of 436,439 Danish schoolchildren

“…For example, as shown in ESM Fig. 1, the association between headache and poor metabolic control is attenuated when controlling for SES, and lower SES has also previously been linked to poor glycaemic control [27]. Nevertheless, the fact that SES is controlled for and the lack of any stark Fig.…”

A Decade of Disparities in Diabetes Technology Use and HbA1c in Pediatric Type 1 Diabetes: A Transatlantic Comparison

“…As previously hypothesized, differences in child-rearing practices (24), access to and cost of device use (24), individual type 1 diabetes management practices (31), education (31), expectations (32) specific to device use, maternal education level (33), and patient and provider factors (34) may also contribute to the observed difference between the two registries. Cost of insulin is higher in the U.S. than other countries, and this cost continues to increase (35,36).…”

Uninterrupted continuous glucose monitoring access is associated with a decrease in HbA1c in youth with type 1 diabetes and public insurance

“…However, youth with public insurance in the United States use CGM at lower rates than those with private insurance 8,9 . In addition, data have consistently demonstrated that youth who have public insurance or are of low socioeconomic status (SES) have higher mean HbA1c, higher rates of diabetic ketoacidosis, and lower diabetes related quality of life measures 11‐17 . We have previously demonstrated that when youth with public insurance are provided CGM, they consistently use them 11 …”

“…8,9 In addition, data have consistently demonstrated that youth who have public insurance or are of low socioeconomic status (SES) have higher mean HbA1c, higher rates of diabetic ketoacidosis, and lower diabetes related quality of life measures. [11][12][13][14][15][16][17] We have previously demonstrated that when youth with public insurance are provided CGM, they consistently use them. 11 In this study, we describe CGM use in our publicly insured youth with T1D with a particular focus on understanding the effect of interrupted and uninterrupted CGM use and its association with HbA1c changes.…”