The association of unemployment with glucose metabolism: a systematic review and meta-analysis

Amputation Rates and Associated Social Determinants of Health in the Most Populous US Counties

Importance

Social Determinants of Health (SDOH) have been found to be associated with health outcome disparities in patients with peripheral artery disease (PAD). However, the association of specific components of SDOH and amputation has not been well described.

Objective

To evaluate whether individual components of SDOH and race are associated with amputation rates in the most populous counties of the US.

Design, Setting, and Participants

In this population-based cross-sectional study of the 100 most populous US counties, hospital discharge rates for lower extremity amputation in 2017 were assessed using the Healthcare Cost and Utilization Project State Inpatient Database. Those data were matched with publicly available demographic, hospital, and SDOH data. Data were analyzed July 3, 2022, to March 5, 2023.

Main outcome and Measures

Amputation rates were assessed across all counties. Counties were divided into quartiles based on amputation rates, and baseline characteristics were described. Unadjusted linear regression and multivariable regression analyses were performed to assess associations between county-level amputation and SDOH and demographic factors.

Results

Amputation discharge data were available for 76 of the 100 most populous counties in the United States. Within these counties, 15.3% were African American, 8.6% were Asian, 24.0% were Hispanic, and 49.6% were non-Hispanic White; 13.4% of patients were 65 years or older. Amputation rates varied widely, from 5.5 per 100 000 in quartile 1 to 14.5 per 100 000 in quartile 4. Residents of quartile 4 (vs 1) counties were more likely to be African American (27.0% vs 7.9%, P < .001), have diabetes (10.6% vs 7.9%, P < .001), smoke (16.5% vs 12.5%, P < .001), be unemployed (5.8% vs 4.6%, P = .01), be in poverty (15.8% vs 10.0%, P < .001), be in a single-parent household (41.9% vs 28.6%, P < .001), experience food insecurity (16.6% vs 12.9%, P = .04), or be physically inactive (23.1% vs 17.1%, P < .001). In unadjusted linear regression, higher amputation rates were associated with the prevalence of several health problems, including mental distress (β, 5.25 [95% CI, 3.66-6.85]; P < .001), diabetes (β, 1.73 [95% CI, 1.33-2.15], P < .001), and physical distress (β, 1.23 [95% CI, 0.86-1.61]; P < .001) and SDOHs, including unemployment (β, 1.16 [95% CI, 0.59-1.73]; P = .03), physical inactivity (β, 0.74 [95% CI, 0.57-0.90]; P < .001), smoking, (β, 0.69 [95% CI, 0.46-0.92]; P = .002), higher homicide rate (β, 0.61 [95% CI, 0.45-0.77]; P < .001), food insecurity (β, 0.51 [95% CI, 0.30-0.72]; P = .04), and poverty (β, 0.46 [95% CI, 0.32-0.60]; P < .001). Multivariable regression analysis found that county-level rates of physical distress (β, 0.84 [95% CI, 0.16-1.53]; P = .03), Black and White racial segregation (β, 0.12 [95% CI, 0.06-0.17]; P < .001), and population percentage of African American race (β, 0.06 [95% CI, 0.00-0.12]; P = .03) were associated with amputation rate.

Conclusions and Relevance

Social determinants of health provide a framework by which the associations of environmental factors with amputation rates can be quantified and potentially used to guide interventions at the local level.

Role of diet and exercise in aging, Alzheimer's disease, and other chronic diseases

Alzheimer's disease (AD) is a progressive neurodegenerative disease, characterized by memory loss and multiple cognitive impairments. Genetic mutations cause a small proportion (1-2%) of early-onset AD, with mutations in amyloid precursor protein (APP), presenilin 1 (PS1) and presenilin 2 (PS2). Major contributing factors of late-onset AD are ApoE4 genotype, traumatic brain injury, diabetes, obesity, hypertension, cardiovascular conditions, in addition to lifestyle factors, such as unhealthy diet and lack of physical exercise. Disease progression can be delayed and/or prevented to a greater extent by adopting healthy lifestyle with balanced and antioxidant enriched diet and daily exercise. The interaction and interplay of diet, exercise, age, and pharmacological interventions holds a crucial role in the progression, pathogenesis and management of AD and its comorbidities, including diabetes, obesity, hypertension and cardiovascular conditions. Antioxidant enriched diet contributes to brain health, glucose control, weight management, and cardiovascular well-being. Regular exercise removes toxins including free radicals and enhances insulin sensitivity, and supports cardiovascular function. In the current article, we discussed, the role of diet, and exercise in aging, AD and other conditions including diabetes, obesity, hypertension, cardiovascular conditions. This article also highlights the impact of medication, socioeconomic and lifestyle factors, and pharmacological interventions. These aspects were discussed in different races and ethnic groups in Texas, and the US.

Glucose Metabolism in Midlife Is Associated With Preceding 30-Year Employment Trajectories: A Northern Finland Birth Cohort 1966 Study

OBJECTIVE

The aim of the study is to evaluate how glucose metabolism in midlife is related to preceding 30-year-long employment trajectories.

METHODS

In the Northern Finland Birth Cohort 1966, we compared glucose metabolism at 46 to employment trajectories (previously defined for men and women and named as high-educated, traditional, self-employed, delayed, and floundering; n = 6399).

RESULTS

Compared with individuals in high-educated trajectories, odds ratios for type 2 diabetes (T2D, 95% confidence interval) in traditional and floundering trajectories in men were 1.65 (1.02-2.68) and 2.42 (1.38-4.23) and in women 1.89 (1.04-3.43) and 2.60 (1.46-4.62), respectively. In self-employed trajectory in women, odds ratios for prediabetes and T2D were 1.66 (1.09-2.51) and 2.47 (1.21-5.04).

CONCLUSIONS

The highest risks for T2D in midlife were associated after traditional and floundering trajectories in men and women and after self-employment trajectory in women.

Perspective: Acknowledging a Hierarchy of Social Needs in Diabetes Clinical Care and Prevention

The evidence of suboptimal social determinants of health (SDoH) on poor health outcomes has resulted in widespread calls for research to identify ways to measure and address social needs to improve health outcomes and reduce disparities. While assessing SDoH has become increasingly important in diabetes care and prevention research, little guidance has been offered on how to address suboptimal determinants in diabetes-related clinical care, prevention efforts, medical education and research. Not surprisingly, many patients experience multiple social needs - some that are more urgent (housing) than others (transportation/resources), therefore the order in which these needs are addressed needs to be considered in the context of diabetes care/outcomes. Here we discuss how conceptualizing diabetes related health through the lens of Maslow's hierarchy of needs has potential to help prioritize individual social needs that should be addressed to improve outcomes in the context of population-level determinants in the communities where people live.

Voluntary Unemployment Is Associated With Increased Prevalence of Stroke and its Risk Factors in Middle-Aged Adults

OBJECTIVE

The aim of the study is to investigate the association between the prevalence of stroke, its risk factors, and occupational status, with a differentiation between voluntary and involuntary unemployment.

METHODS

This is a cross-sectional study, which included 3013 individuals aged 40 to 65 years. We compared the prevalence of stroke, comorbidities, self-reported stroke-like symptoms, healthy behaviors, and knowledge about stroke among the voluntarily and involuntarily unemployed versus the employed.

RESULTS

Voluntary unemployment was associated with increased chances of stroke (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.05-3.57), hypertension (OR, 1.18; 95% CI, 1.06-1.32), diabetes (OR, 1.16; 95% CI, 1.01-1.35), and obesity (OR, 1.16; 95% CI, 1.05-1.29). Involuntary job loss was associated with increased odds of hypertension (OR, 1.69; 95% CI, 1.16-2.50) and more frequent self-reported stroke-like symptoms.

CONCLUSIONS

We found higher chances of stroke among the voluntarily unemployed middle-aged adults, presumably because of increased prevalence of hypertension, diabetes, and obesity.

The Relative Contribution of Social Determinants of Health Among Health Resources and Services Administration-Funded Health Centers

Frameworks for identifying and assessing social determinants of health (SDOH) are effective for developing long-term societal policies to promote health and well-being, but may be less applicable in clinical settings. The authors compared the relative contribution of a specific set of SDOH indicators with several measures of health status among patients served by health centers (HCs). The 2014 Health Center Patient Survey was used to identify a sample of HC patient adults 18 years and older that reported the HC as their usual source of care (n = 5024). The authors examined the relationship between SDOH indicators organized in categories (health behaviors, access and utilization, social factors, economic factors, quality of care, physical environment) with health status measures (fair or poor health, diabetes, hypertension, cardiovascular disease, depression, or anxiety) using logistic regressions and predicted probabilities. Findings indicated that access to care and utilization indicators had the greatest relative contribution to all health status measures, but the relative contribution of other SDOH indicators varied. For example, access indicators had the highest predicted probability in the model with fair or poor health as the dependent variable (72.4%) and the model with hypertension as the dependent variable (47.4%). However, the second highest predicted probability was for social indicators (54.1%) in the former model and physical environment (44.7%) indicators in the latter model. These findings have implications for HCs that serve as the primary point of access to medical care in underserved communities and to mitigate SDOH particularly for patients with diabetes, depression, or anxiety.

Smoking and alcohol use in unemployed populations: a systematic review and meta-analysis

Unemployment is an economic and social phenomenon that has economic, social, personal, and health consequences. This study aimed to investigate the relationship between unemployment and alcohol use and smoking as a systematic review and meta-analysis.

The two databases PubMed and Scopus were selected for the search and using a set of keywords, these two sources of scientific information were searched from 2004 to June 2021 and 1996 until June 2021, respectively. To meta-analyze the relationship between unemployment and smoking and alcohol use, odds ratio and confidence interval were calculated for this relationship. The meta-analysis was performed based on a random-effects. Subgroups were also performed for men and women. Heterogeneity in studies as well as publication bias were also examined.

A total of 52 cross-sectional and cohort studies were included in the meta-analysis. In the relationship between unemployment and alcohol use, the odds ratio was 1.25 and the confidence interval was between 1.12 and 1.41. In the relationship between unemployment and smoking, the odds ratio was 1.43 and the confidence interval was between 1.13 and 1.81.

According to the results, it can be said that unemployment increases the likelihood of alcohol use and smoking. Therefore, policymakers must pay more attention to the health consequences of economic problems, especially unemployment.

Incidence of liver-related morbidity and mortality in a population cohort of non-alcoholic fatty liver disease

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) increases morbidity and mortality. However, patients in biopsy-based cohorts are highly selected and the absolute risks of liver- and non-liver outcomes in NAFLD in population remains undefined. We analysed both liver-related and non-liver-related outcomes in Finnish population cohorts of NAFLD.

METHODS

We included 10 993 individuals (6707 men, mean age 53.3 ± 12.6 years) with NAFLD (fatty liver index ≥60) from the Finnish population-based FINRISK and Health 2000 studies. Liver fibrosis was assessed by the dAAR score, and genetic risk by a recent polygenic risk score (PRS-5). Incident liver-related outcomes, cardiovascular disease (CVD), cancer and chronic kidney disease (CKD) were identified through linkage with national registries.

RESULTS

Mean follow-up was 12.1 years (1128 069 person-years). The crude incidence rate of liver-related outcomes in NAFLD was 0.97/1000 person-years. The cumulative incidence increased with age, being respectively 2.4% and 1.5% at 20 years in men and women aged 60 years at baseline, while the relative risks for CVD and cancer were 9-16 times higher. The risk of CKD exceeded that of liver outcomes at a baseline age around 50 years. 20-year cumulative incidence of liver-related outcomes was 4.3% in the high, and 1.5% in the low PRS-5 group. The dAAR score associated with liver outcomes, but not with extra-hepatic outcomes.

CONCLUSION

The absolute risk of liver-related outcomes in NAFLD is low, with much higher risk of CVD and cancer, emphasizing the need for more individualized and holistic risk-stratification in NAFLD.

Unemployment associated with major depression disorder and depressive symptoms: a systematic review and meta-analysis

Objectives. This study investigated the association between unemployment and depressive symptoms and major depression disorder worldwide using a systematic review and meta-analysis. Methods. Search time was limited to all articles published in English until December 2020. In the association between unemployment and depression, first, the results of qualified studies were extracted and, then, the results of each study were pooled with each other using the random effects method. Results. The prevalence of depression in the unemployed is 21%, 95% confidence interval (CI) [18, 24%]. This prevalence for depression symptoms is 24%, 95% CI [20, 28%] and for major depressive disorder is 16%, 95% CI [9-24%]. The association between unemployment and depressive symptoms was odds ratio (OR) 2.06, 95% CI [1.85, 2.30] and the association for major depressive disorder was OR 1.88, 95% CI [1.57, 2.25]. The association between unemployment and depression in men was OR 2.27, 95% CI [1.76, 2.93] and in women was OR 1.62, 95% CI [1.40, 1.87]. Conclusions. What is clear from the present study is that unemployment can lead to a higher prevalence of depressive symptoms and major depressive disorder, thereby undermining the mental health of the unemployed.

Non-financial social determinants of diabetes among public assistance recipients in Japan: A cohort study

AIMS/INTRODUCTION

Poverty is an important social determinant of diabetes. Poverty is a multidimensional concept including non-financial difficulties, such as social isolation and exclusion from communities. Many countries provide financial social assistance programs for those in need. This study aimed to explore non-financial social determinants of diabetes among public assistance recipients in Japan, by using linkage data of two municipal public assistance databases and medical assistance claim data.

MATERIALS AND METHODS

We carried out a retrospective cohort study. Public assistance is provided to households below the poverty line to ensure their income security. We extracted recipients' sociodemographic factors of January 2016 (household number and employment status as non-financial social determinants of diabetes) and identified the incidence of diabetes diagnosis until December 2016 as the outcome.

RESULTS

We included the data of 2,698 younger individuals (aged <65 years) and 3,019 older individuals (aged >65 years). A multivariable Poisson regression, with a robust standard error estimator, showed that among 2,144 younger recipients at risk, unemployment and living alone were slightly associated with 1-year cumulative incidence of diabetes diagnosis (adjusted incidence ratio 1.20, 95% confidence interval 0.93-1.54 and adjusted incidence ratio 1.15, 95% confidence interval 0.89-1.48, respectively). Among 2,181 older recipients at risk, there was no strong association between their sociodemographic factors and incidence of diabetes diagnosis.

CONCLUSIONS

Unemployment and living alone might be additional risk factors for diabetes among younger public assistance recipients. Multidimensional supports assuring financial and non-financial securities are required to prevent diabetes among people living in poverty.

Implications of the COVID-19 Pandemic for Cardiovascular Disease and Risk-Factor Management

COVID-19 and our public health responses to the pandemic may have far-reaching implications for cardiovascular (CV) risk, affecting the general population and not only survivors of COVID-19. In this narrative review, we discuss how the pandemic may affect general CV risk for years to come and explore the mitigating potential of telehealth interventions. From a health care perspective, the shift away from in-person office visits may have led many to defer routine risk- factor management and may have had unforeseen effects on continuity of care and adherence. Fear of COVID-19 has led some patients to forego care for acute CV events. Curtailment of routine outpatient laboratory testing has likely delayed intensification of risk-factor–modifying medical therapy, and drug shortages and misinformation may have negative impacts on adherence to antihypertensive, glucose-lowering, and lipid-lowering agents. From a societal perspective, the unprecedented curtailment of social and economic activities has led to loss of income, unemployment, social isolation, decreased physical activity, and increased frequency of depression and anxiety, all of which are known to be associated with worse CV risk-factor control and outcomes. We must embrace and evaluate measures to mitigate these potential harms to avoid an epidemic of CV morbidity and mortality in the coming years that could dwarf the initial health effects of COVID-19.

Glucose metabolism in midlife predicts participation in working life: a Northern Finland Birth Cohort 1966 study

Objective

To evaluate how clinically measured glucose metabolism categories predict registered participation in working life.

Methods

In the 46-year follow-up of Northern Finland Birth Cohort 1966 (n=5328, 2342 men and 2986 women), we used oral glucose tolerance tests, surveys and glycated haemoglobin to determine glucose metabolism categorised as normal, pre-diabetes, screen-detected and previous type 2 diabetes (T2D). Consequent participation in working life during the 2-year follow-up period was measured as registered disability, unemployment and employment days, for which incidence rate ratios (IRRs) with 95% CIs were calculated using Poisson regression, adjusted for baseline employment and socioeconomic, health-related and behavioural factors.

Results

In comparison to normal glucose, all categories of impaired glucose metabolism were associated with poorer participation in working life in the unadjusted models. After adjustments, the risks (IRR (95% CI)) of disability days remained heightened by both screen-detected and previous T2D among men (1.3 (1.3 to 1.4) and 1.5 (1.4 to 1.5), respectively), whereas among women the risks were lowered (0.9 (0.8 to 0.9) and 0.9 (0.9 to 1.0), respectively). The risks of unemployment were consistently higher in all categories of impaired glucose metabolism, and were the highest among women with previous T2D (1.6 (1.5 to 1.6)). Correspondingly, the rates of total employment days were lower in relation to screen-detected T2D among men and women (5% and 6%, respectively), and previous T2D (6% and 3%).

Conclusions

Overall, impaired glucose metabolism associated with deteriorated working life participation already in middle age. The high prevalence of impaired glucose metabolism emphasises the need for actions to support sustainable working careers.

The Next Generation of Diabetes Translation: A Path to Health Equity

Disparities in diabetes burden exist in large part because of the social determinants of health (SDOH). Translation research and practice addressing health equity in diabetes have generally focused on changing individual behavior or providing supportive approaches to compensate for, rather than directly target, SDOH. The purpose of this article is to propose a pathway for addressing SDOH as root causes of diabetes disparities and as an essential target for the next generation of interventions needed to achieve health equity in diabetes prevention and treatment. This review describes ( a) the current burden of diabetes disparities, ( b) the influence of SDOH on diabetes disparities, ( c) gaps in and implications of current translation research, and ( d) approaches to achieving health equity in the next generation of diabetes translation.

Health Effects of Late-Career Unemployment

Objective: Job loss has a demonstrated negative impact on physical and mental health. Involuntary retirement has also been linked to poorer physical and mental health outcomes. This study examined whether late-career unemployment is related to involuntary retirement and health declines postretirement. Method: Analysis was conducted using the 2000-2012 U.S. Health and Retirement Study (HRS) survey data with unemployment months regressed with demographic and baseline health measures on physical and mental health. Results: Individuals with late-career unemployment reported more involuntary retirement timing (47.0%) compared with those reporting no unemployment (27.9%). Late-career unemployment had no significant effect on self-reported physical health (β = .003, p = .84), but was significantly associated with lower levels of mental health (β = .039; p < .01). Conclusion: Self-reports of late-career unemployment are not associated with physical health in retirement, but unemployment is associated with involuntary retirement timing and mental health declines in retirement. Unemployment late in the working career should be addressed as a public mental health concern.