Dr. Marla Shapiro: More than 350 million worldwide have diabetes

More than 350 million people worldwide have diabetes according to a newly published article in Diabetes Care. We know that with the dramatic rise in obesity and our aging population, this number is expected to climb. It is felt that the recent change in practice that uses more complex drug regimens and behavioural changes in the management of this chronic disease could prevent as many as one half of cardiovascular events among high risk groups with diabetes.

As we have gotten better with newer medications to manage diabetes - we have seen the rate of death drop from this illness. But not all benefit from these newer treatments. If you have a lower socioeconomic status, the gap between survival and death widens.

An interesting study released this week looks at whether or not provision of universal drug coverage at age 65 reduces some of the known income disparities in both diabetes related morbidity and diabetes related mortality.

This study was undertaken in Ontario and looked at more than 600,000 adults with diabetes followed from April 2002 through March of 2008. They were followed for a group of outcomes such as death, non fatal heart attacks and non fatal stroke.

The researchers found that socioeconomic status was a very strong predictor of all these outcomes in diabetics younger than age 65 but for those over 65, the SES status exerted much less of a predictor effect, This kind of socioeconomic impact was seen for all age groups under 65.

For those who had a heart attack, the one year mortality rate under age 65 was also impacted by this status.

Escalating drug costs can have adverse consequences on diabetes care for low income groups without adequate insurance coverage. Cost can restrict the use of these medications and is associated with poor health outcomes. This statement is true even for us Canadians who have universal access to health care but not universal access to medication based on age.

The study does highlight that socially disadvantaged groups with diabetes have a significantly higher risk of nonfatal heart attack, stroke or death compared with more affluent individuals. There are many reasons why being socially disadvantaged can lead to poorer health care outcomes but among those reasons is the cost and access to these medications.

As many as 5,000 deaths and nearly 2,700 heart attacks or strokes could be prevented among those under 65 if the wealth gap was closed.

The study points out that those with a lower SES show a better outcome with respect to death in the 30 days following an acute heart attack. That would be because they had been admitted to hospital and would have access to life saving therapies. But longer term survival is affected by ongoing risk reduction strategies and the chronic use of expensive ongoing medications. At 1 year again the mortality increases in the disadvantaged group under 65.

Other factors according to the researchers that contribute to the SES gradient in cardiovascular disease includes higher hypertension, abdominal obesity and an unhealthy lifestyle. Studies show that lower SES have more visits to doctors and doctors behave the same when it comes to prescribing.

Perhaps universal drug coverage in diabetes could close the outcome gap.