Social determinants of health and progression to cardio-renal-metabolic multimorbidity and mortality in people with prediabetes: A prospective cohort study.

AIMS

Social determinants of health (SDHs) have been increasingly recognised as upstream drivers of preventable health disparities. However, it is unclear what the role of SDHs is in the whole progression of prediabetes. We aimed to delineate the impact of SDHs on the progression from prediabetes to subsequent cardio-renal-metabolic disease (CRMD), cardio-renal-metabolic multimorbidity (CRMM) and mortality.

MATERIALS AND METHODS

37 098 participants with prediabetes and free of any CRMD (i.e., type 2 diabetes, cardiovascular disease and chronic kidney disease [CKD]) at baseline from the UK Biobank were included. A combined SDH score was assessed by a sum of 17 items including financial, education, healthcare, neighbourhood, and social domains, and was categorised into favourable, medium, and unfavourable groups by tertile. Outcomes included first CRMD, CRMM (the coexistence of at least two CRMDs) and death during follow-up. Five transition paths were considered, and multistate models were performed.

RESULTS

Compared with the favourable SDH group, the unfavourable SDH group consistently showed elevated risks for different transition stages, except for the CRMM-to-death transition. Lifestyle partially mediated the associations, while the mediation proportions at each stage explained less than 20%. Among disease-specific associations, unfavourable SDHs disproportionally increased the risks of three CRMDs, with the highest risk observed for the CKD-to-death transition (hazard ratio = 2.22, 95% confidence interval: 1.16-4.26).

CONCLUSIONS

Unfavourable SDHs were associated with increased risks of progression from prediabetes. Resource allocation and lifestyle promotion should be prioritised for those with unfavourable SDHs to mitigate disparities in progression to CRMM and death in diabetes care, especially in the early disease stage.