Original Article
Social Determinants of Health on Glycemic Control in Pediatric Type 1 Diabetes

Portions of this article have been presented as posters at the American Diabetes Association 72nd Scientific Sessions, June 8-12, 2012 in Philadelphia, PA and the 15th Annual Canadian Diabetes Association Professional Conference (Vancouver, BC, October 10-13, 2012).
https://doi.org/10.1016/j.jpeds.2012.12.010Get rights and content

Objective

To evaluate the relationship between the social determinants of health (SDH) and glycemic control in a large pediatric type 1 diabetes (T1D) population.

Study design

Deprivation Indices (DI) were used to ascertain population-level measures of socioeconomic status, family structure, and ethnicity in patients with T1D followed at The Hospital for Sick Children August 2010-2011 (n = 854). DI quintile scores were determined for individual patients based on de-identified postal codes, and linked to mean patient A1Cs as a measure of glycemic control. We compared mean A1C between the most and least deprived DI quintiles. Associations were estimated controlling for age and sex, and repeated for insulin pump use.

Results

The T1D population evaluated in this study was most concentrated in the least and most deprived quintiles of the Material DI. A1C levels were highest in patients with the greatest degree of deprivation (fifth vs first quintile) on the Material DI (9.2% vs 8.3%, P < .0001), Social DI (9.1% vs 8.3%, P < .0001), and Ethnic Concentration Index (8.9% vs 8.4%, P = .03). These relationships between measures of the SDH and A1C were not evident for patients on insulin pumps. On regression analysis, higher A1C was predicted by older age, female sex, not using pump therapy, and being in the most deprived quintile for Material and Social Deprivation, but not Ethnic Concentration.

Conclusions

Measures of the SDH comprising Material and Social Deprivation were significantly associated with suboptimal glycemic control in our pediatric T1D cohort. Use of insulin pump therapy also predicted A1C and may have a moderating effect on these relationships.

Section snippets

Methods

We conducted a cross sectional study linking de-identified patient data with publicly available data sets of the Institut national de santé publique du Québec-DI (INSPQ-DI), measuring Material and Social Deprivation,13, 18, 19, 20 and the Ontario Marginalization Index (ON-Marg), measuring Ethnic Concentration.21

All patients diagnosed with T1D for ≥1 year who were followed at SickKids between August 2010 and August 2011 were included in our analysis. Information on patient postal code, age, sex,

Results

DAs were determined for 854 patients with T1D. Forty patients were excluded as their postal code did not correspond to a DA or was inconsistent throughout the study period. Patients had a mean age (±SD) of 12.6 ± 4.2 years (IQR, 9.7-16.0 years), 48.2% were female, and 32.3% were on insulin pump therapy. Patients who were not on insulin pump had variable insulin regimens. The mean A1C (±SD) for our patient population was 8.7% ± 1.5%, based on a median of 3 A1C levels (IQR = 2-4) measured over

Discussion

The greater concentration of our T1D population in the 2 extremes of Material Deprivation, compared with the background population of Toronto, is likely multifactorial. This may reflect referral patterns based upon the status of our hospital as the largest pediatric center in the city, which attracts affluent patients seeking high-level care, and our location in the downtown core, which is more accessible by public transportation from urban and suburban areas. The overall material divide in our

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    The authors declare no conflicts of interest.

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