Diabetes, hypertension, obesity, and long-term risk of renal disease mortality: Racial and socioeconomic differences

A Review of Racial Differences and Disparities in ECG

The electrocardiogram (ECG) is a widely used, non-invasive tool for diagnosing a range of cardiovascular conditions, including arrhythmia and heart disease-related structural changes. Despite its critical role in clinical care, racial and ethnic differences in ECG readings are often underexplored or inadequately addressed in research. Variations in key ECG parameters, such as PR interval, QRS duration, QT interval, and T-wave morphology, have been noted across different racial groups. However, the limited research in this area has hindered the development of diagnostic criteria that account for these differences, potentially contributing to healthcare disparities, as ECG interpretation algorithms largely developed from major population data may lead to misdiagnoses or inappropriate treatments for minority groups. This review aims to help cardiac researchers and cardiovascular specialists better understand, explore, and address the impact of racial and ethnic differences in ECG readings. By identifying potential causes-ranging from genetic factors to environmental influences-and exploring the resulting disparities in healthcare outcomes, we propose strategies such as the development of race-specific ECG norms, the application of artificial intelligence (AI) to improve diagnostic accuracy, and the diversification of ECG databases. Through these efforts, the medical community can advance toward more personalized and equitable cardiovascular care.

Impact of body mass index on pathological response after neoadjuvant chemotherapy: results from the I-SPY 2 trial

PURPOSE

Increased body mass index (BMI) has been associated with poor outcomes in women with breast cancer. We evaluated the association between BMI and pathological complete response (pCR) in the I-SPY 2 trial.

METHODS

978 patients enrolled in the I-SPY 2 trial 3/2010-11/2016 and had a recorded baseline BMI prior to treatment were included in the analysis. Tumor subtypes were defined by hormone receptor and HER2 status. Pretreatment BMI was categorized as obese (BMI ≥ 30 kg/m2), overweight (25 ≤ BMI < 30 kg/m2), and normal/underweight (< 25 kg/m2). pCR was defined as elimination of detectable invasive cancer in the breast and lymph nodes (ypT0/Tis and ypN0) at the time of surgery. Logistic regression analysis was used to determine associations between BMI and pCR. Event-free survival (EFS) and overall survival (OS) between different BMI categories were examined using Cox proportional hazards regression.

RESULTS

The median age in the study population was 49 years. pCR rates were 32.8% in normal/underweight, 31.4% in overweight, and 32.5% in obese patients. In univariable analysis, there was no significant difference in pCR with BMI. In multivariable analysis adjusted for race/ethnicity, age, menopausal status, breast cancer subtype, and clinical stage, there was no significant difference in pCR after neoadjuvant chemotherapy for obese compared with normal/underweight patients (OR = 1.1, 95% CI 0.68-1.63, P = 0.83), and for overweight compared with normal/underweight (OR = 1, 95% CI 0.64-1.47, P = 0.88). We tested for potential interaction between BMI and breast cancer subtype; however, the interaction was not significant in the multivariable model (P = 0.09). Multivariate Cox regression showed there was no difference in EFS (P = 0.81) or OS (P = 0.52) between obese, overweight, and normal/underweight breast cancer patients with a median follow-up time of 3.8 years.

CONCLUSION

We found no difference in pCR rates by BMI with actual body weight-based neoadjuvant chemotherapy in this biologically high-risk breast cancer population in the I-SPY2 trial.

Impact of Body Mass Index on Pathological Response after Neoadjuvant Chemotherapy: Results from the I-SPY 2 trial

Purpose

Increased body mass index (BMI) has been associated with poor outcomes in women with breast cancer. We evaluated the association between BMI and pathological complete response (pCR) in the I-SPY 2 trial.

Methods

978 patientsenrolled in the I-SPY 2 trial 3/2010-11/2016 and had a recorded baseline BMI prior to treatment were included in the analysis. Tumor subtypes were defined by hormone receptor and HER2 status. Pretreatment BMI was categorized as obese (BMI≥30 kg/m2), overweight (25≤BMI < 30 kg/m2), and normal/underweight (< 25 kg/m2). pCR was defined as elimination of detectable invasive cancer in the breast and lymph nodes (ypT0/Tis and ypN0) at the time of surgery. Logistic regression analysis was used to determine associations between BMI and pCR. Event-free survival (EFS) and overall survival (OS) between different BMI categories were examined using Cox proportional hazards regression.

Results

The median age in the study population was 49 years. pCR rates were 32.8% in normal/underweight, 31.4% in overweight, and 32.5% in obese patients. In univariable analysis, there was no significant difference in pCR with BMI. In multivariable analysis adjusted for race/ethnicity, age, menopausal status, breast cancer subtype, and clinical stage, there was no significant difference in pCR after neoadjuvant chemotherapy for obese compared with normal/underweight patients (OR = 1.1, 95% CI: 0.68-1.63, p = 0.83), and for overweight compared with normal/underweight (OR = 1, 95% CI: 0.64-1.47, p = 0.88). We tested for potential interaction between BMI and breast cancer subtype; however, the interaction was not significant in the multivariable model (p = 0.09). Multivariate Cox regression showed there was no difference in EFS (p = 0.81) or OS (p = 0.52) between obese, overweight, and normal/underweight breast cancer patients with a median follow-up time of 3.8 years.

Conclusions

We found no difference in pCR rates by BMI with actual body weight based neoadjuvant chemotherapy in this biologically high-risk breast cancer population in the I-SPY2 trial.

The association between tea consumption and blood pressure in the adult population in Southwest China

OBJECTIVES

Prior research on the effect of tea consumption on blood pressure (BP) generated inconsistent findings. The objective of this study was to explore the effects of different types of tea consumption on BP.

METHODS

We included 76,673 participants aged 30-79 from the baseline data of the China Multi-Ethnic Cohort (CMEC) study. Binary logistic regression was used to analyze the influences of different types of tea consumption on the risk of hypertensive BP. Moreover, multiple linear regression was used to examine the association between tea drinking and BP.

RESULTS

Tea consumption was associated with a reduced risk of hypertensive BP by 10% (AOR: 0.90, 95%CI: 0.86-0.94). While dark tea was related to a 1.79-5.31 mmHg reduction in systolic blood pressure (SBP) and a 0.47-1.02 mmHg reduction in diastolic blood pressure (DBP), sweet tea, regardless of the duration, frequency, or amount of consumption, significantly was associated with a reduced SBP by 3.19-7.18 mmHg. Green tea also was associated with a reduced SBP by 1.21-2.98 mmHg. Although scented tea was related to reduced SBP by 1.26-2.48 mmHg, the greatest effect came from the long duration (> 40 years:β=-2.17 mmHg, 95%CI=-3.47 mmHg --0.87 mmHg), low frequency (1-2 d/w: β = -2.48 mmHg, 95%CI=-3.76 mmHg--1.20 mmHg), and low amount (≤ 2 g/d: β=-2.21 mmHg, 95%CI=-3.01 mmHg--1.40 mmHg). Additionally, scented tea was correlated to a decrease in DBP at the frequency of 1-2 d/w (β=-0.84 mmHg, 95%CI=-1.65 mmHg--0.02 mmHg). Drinking black tea only was associated with lowered SBP. The protective effect of black tea on SBP was characterized by the long-duration (> 15 years, -2.63--5.76 mmHg), high frequency (6-7 d/w, -2.43 mmHg), and medium amount (2.1-4.0 g/d, -3.06 mmHg).

CONCLUSION

Tea consumption was associated with lower SBP and a reduced risk of hypertensive BP. The antihypertensive effect varies across types of tea consumed.

Serum Aldosterone and Urine Electrolytes Dynamics in Response to DASH Diet Intervention – an Inpatient Mechanistic Study

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Increasing trends in obesity prevalence from 2013 to 2019 and associated factors in Brazil

OBJECTIVE

To investigate the variation of anthropometric indicators from 2013 to 2019 and the factors associated with obesity in Brazil, using information from the National Health Survey.

METHODS

Cross-sectional study with cluster sampling and simple random sampling in the three stages. Measurements of weight and height among participants in 2013 (n=59,592) and in 2019 (n=6,672) were used. Differences in obesity prevalence were tested by Student's t test for independent samples. To identify the sociodemographic factors and health problems associated with obesity, we used Poisson regression models with robust variance and crude and age-adjusted prevalence ratios to test the associations.

RESULTS

From 2013 to 2019, prevalence of obesity increased significantly, from 20.8 to 25.9%. Among men, the greatest increases were found in the 40-59 age group (9.1%) and in the median income category (8.3%). Among women, the greatest rises were found among those with low education (8.7%) and non-white ones (6.0%). For both males and females, factors associated with obesity were age, to live with a partner, level of instruction directly associated among men, and inversely associated among women. In 2019, for males, the crude and adjusted prevalence ratios were significant for high cholesterol, high blood pressure and at least one chronic non-communicable disease and, for females, for poor self-rated health, high blood pressure, diabetes, and at least one chronic non-communicable.

CONCLUSION

It is necessary to implement intersectoral policies to promote changes in eating habits and encourage the practice of physical activity, taking into account economic, social, cultural, and environmental aspects.

Factors associated with long-term graft survival in pediatric kidney transplant recipients

Pediatric kidney transplant recipients generally have good outcomes post-transplantation. However, the younger age and longer life span after transplantation in the pediatric population make understanding the multifactorial nature of long-term graft survival critical. This investigation analyzes factors associated with 10-year survival to identify areas for improvement in patient care. Kaplan-Meier with log-rank test and univariable and multivariable logistic regression methods were used to retrospectively analyze 7785 kidney transplant recipients under the age of 18 years from January 1, 1998, until March 9, 2008, using United Network for Organ Sharing (UNOS) data. Our end-point was death-censored 10-year graft survival after excluding recipients whose grafts failed within one year of transplant. Recipients aged 5-18 years had lower 10-year graft survival, which worsened as age increased: 5-9 years (OR: 0.66; CI: 0.52-0.83), 10-14 years (OR: 0.43; CI: 0.33-0.55), and 15-18 years (OR: 0.34; CI: 0.26-0.44). Recipient African American ethnicity (OR: 0.67; CI: 0.58-0.78) and Hispanic donor ethnicity (OR: 0.82; CI: 0.72-0.94) had worse outcomes than other donor and recipient ethnicities, as did patients on dialysis at the time of transplant (OR: 0.82; CI: 0.73-0.91). Recipient private insurance status (OR: 1.35; CI: 1.22-1.50) was protective for 10-year graft survival. By establishing the role of age, race, and insurance status on long-term graft survival, we hope to guide clinicians in identifying patients at high risk for graft failure. This study highlights the need for increased allocation of resources and medical care to reduce the disparity in outcomes for certain patient populations.

Developing the Tribal Resource Guide and the Poverty and Culture Training: The We RISE (Raising Income, Supporting Education) Study

The We RISE Study aimed to support young American Indian mothers on a tribal reservation by addressing social determinants of health at an individual and community-wide level. To address community-based barriers, the study developed the Tribal Resource Guide, a comprehensive list of available resources that was created through partnerships with community programs and staff. In addition to the guide, the study also developed the Poverty and Culture Training in order to train program staff at numerous community programs to better understand and serve lower socioeconomic and/or Native clients. The two projects facilitated collaboration between community programs and provided tools for programs to address barriers and ultimately better serve their target audience. Despite challenges, the transdisciplinary approach used with the local community maximized potential for success. This process and model could be duplicated in communities with similar demographics, resources, and barriers.

Comparison of clinical outcomes and characteristics between patients with and without hypertension in moyamoya disease

OBJECTIVE

Our study aimed to compare the disparity of patients with moyamoya disease (MMD) between hypertension group and non-hypertension group. And we attempt to explore the risk factors for MMD with hypertension.

METHODS

We retrospectively analyze 542 adult patients with moyamoya disease admitted to our hospital from 2009 to 2016. In view of inclusion criteria, we divided patients with moyamoya disease into two groups (hypertension group and non-hypertension group) and summarized their clinical characteristics. Furthermore, we explore the risk factors for unfavorable outcomes in hypertension group.

RESULTS

Of 542 adult patients with moyamoya disease, we identified 156 patients (28.8%) with hypertension and 386 patients (71.2%) without hypertension. During follow-up, we hold the views that the prognosis of non-hypertension group was obviously better than hypertension group (P = 0.005) and the complications were prone to occurring to patients with hypertension (P = 0.037). In the multivariate analysis, severe hypertension (OR, 2.746; 95% CI, 1.096-6.822; P = 0.031) and no anti-hypertensive medication (OR, 0.342; 95% CI, 0.131-1.895; P = 0.029) were the independent predictors for postoperative unfavorable outcomes. The common surgical modalities of moyamoya disease (direct and indirect bypass) had no significant difference in future unfavorable outcomes prevention in adult MMD patients with hypertension.

CONCLUSIONS

We suggested severe hypertension and no anti-hypertensive medication as the independent risk factors for unfavorable clinical outcomes in adult MMD with hypertension.

Understanding America: Unequal Economic Returns of Years of Schooling in Whites and Blacks

BACKGROUND

Higher schooling is associated with higher economic wellbeing. Marginalization-related Diminished Returns (MDRs) framework, however, refers to smaller returns of schooling for non-Hispanic Blacks (NHBs) compared to non-Hispanic Whites (NHWs).

AIM

Using a national sample of American adults, the current study compared NHBs and NHWs for the effects of each incremental increase in the years of schooling (gradient of educational level) on economic wellbeing of American adults.

METHODS

Data came from the Understanding America Study (UAS), a national online survey with a nationally representative sample. A total of 5715 adults (18+ years old) were included. From this number, 4,826 (84.4%) were NHWs, and 889 (15.6%) were NHBs. Years of schooling was the independent variable. Economic wellbeing was the main outcome. Age and gender were the covariates. Race was the moderator.

RESULTS

Overall, each additional year of schooling was associated with higher economic wellbeing, net of age, and gender. A statistically significant interaction was found between race and years of schooling on the outcome, indicating a smaller boosting effect of any incremental increase in the years of education on the economic wellbeing of NHBs compared to NHWs.

CONCLUSION

In line with MDRs, highly educated Black people experience low economic wellbeing. The MDRs of education on economic wellbeing may be why highly educated, and middle-class Black Americans still report poor health. Policy solutions should address multi-level causes of MDR-related health disparities.

Baseline Obesity Increases 25-Year Risk of Mortality due to Cerebrovascular Disease: Role of Race

Background: Although obesity may have a role as a risk factor for cerebrovascular mortality, less is known about how demographic and social groups differ in this regard. Aims: This study had two aims: first to investigate the predictive role of baseline obesity on long-term risk of mortality due to cerebrovascular disease, and second, to test racial variation in this effect. Methods: the Americans' Changing Lives Study (ACL) 1986-2011 is a state of the art 25-year longitudinal cohort study. ACL followed a nationally representative sample of Blacks (n = 1156) and Whites (n = 2205) for up to 25 years. Baseline obesity was the main predictor of interest, time to cerebrovascular death was the main outcome of interest. Demographic characteristics, socioeconomic status (educational attainment and household income), health behaviors (exercise and smoking), and health (hypertension and depressive symptoms) at baseline were covariates. Cox proportional hazards models were used to test additive and multiplicative effects of obesity and race on the outcome. Results: From the total 3,361 individuals, 177 people died due to cerebrovascular causes (Whites and Blacks). In the pooled sample, baseline obesity did not predict cerebrovascular mortality (hazard ratio (HR) = 0.86, 0.49-1.51), independent of demographic, socioeconomic, health behaviors, and health factors at baseline. Race also interacted with baseline obesity on outcome (HR = 3.17, 1.09-9.21), suggesting a stronger predictive role of baseline obesity on cerebrovascular deaths for Black people compared to White individuals. According to the models that were run specific to each race, obesity predicted risk of cerebrovascular mortality for Blacks (HR = 2.51, 1.43-4.39) but not Whites (HR = 0.69, 0.31-1.53). Conclusions: Baseline obesity better predicts long-term risk of cerebrovascular death in Black individuals compared to White people. More research should explore factors that explain why racial differences exist in the effects of obesity on cerebrovascular outcome. Findings also have implications for personalized medicine.

Minorities' Diminished Returns of Educational Attainment on Hospitalization Risk: National Health Interview Survey (NHIS)

BACKGROUND

As suggested by the Minorities' Diminished Returns (MDRs) theory, educational attainment shows a weaker protective effect for racial and ethnic minority groups compared to non-Hispanic Whites. This pattern, however, is never shown for hospitalization risk.

OBJECTIVES

This cross-sectional explored racial and ethnic variation in the association between educational attainment and hospitalization in the US.

METHODS

Data came from the National Health Interview Survey (NHIS 2015). The total sample was 28,959 American adults. Independent variables were educational attainment and hospitalization. The main outcome was hospitalization during the last 12 months. Age, gender, employment, marital status, region, obesity, and the number of cardiovascular conditions were covariates. Race and ethnicity were the effect modifiers. Logistic regression models were utilized to analyze the data.

RESULTS

From all participants, 16.2% were Black and 11.6 were Hispanic, with a mean age of 51 years old. Overall, higher education levels were associated with lower odds of hospitalization, independent of all confounders. Educational attainment showed significant interactions with race (OR =1.04, 95% CI = 1.01 - 1.08) and ethnicity (OR = 1.04, 95% CI =1.01 -1.07) on hospitalization, indicating smaller protective effects of educational attainment on hospitalization of Hispanics and Blacks than non-Hispanic Whites.

CONCLUSION

The protective effect of educational attainment on population health is smaller for Blacks and Hispanics compared to non-Hispanic Whites. To prevent health disparities, there is a need to minimize diminished returns of educational attainment for racial and ethnic minorities. To do so, there is a need for innovative and bold economic, public, and social policies that do not limit themselves to equalizing socioeconomic status but also help minorities leverage their available resources and gain tangible outcomes.

Educational Attainment Better Reduces Disability for Non-Hispanic than Hispanic Americans

Objectives: Minorities’ Diminished Returns (MDRs) refers to the weaker protective health effects of socioeconomic status (SES) for minorities, particularly educational attainment for racial and ethnic minorities, compared to the general population. This pattern has been documented among African-Americans compared to Whites, however, we know very little about MDRs for educational attainment on disability among Hispanics compared to Non-Hispanic Whites. Aims: This cross-sectional study explored ethnic variation in the effects of educational attainment on severity of disability in the United States of America (USA). Materials and Methods: The 2015 National Health Interview Survey (NHIS) was a national survey of the general population in the USA. The total sample was 1021 American adults that reported some disability. Of the 1021 participants, 855 identified as Non-Hispanic and 165 identified as Hispanic. The independent variable was educational attainment. The main outcome was severity of disability measured using self-reported data. Age, gender, and race were covariates. Ethnicity was the effect modifier. Results: Among individuals with a disability, higher levels of educational attainment were associated with fewer disabilities, independent of all confounders. When ethnicity and educational attainment were interacted on severity of disability, the results indicated a smaller protective effect for Hispanics than for Non-Hispanics with a disability. Ethnicity-stratified models showed an effect for Non-Hispanics but not for Hispanics. Conclusions: The protective effects of educational attainment against severity of disability are smaller for Hispanics than for Non-Hispanics. To prevent health disparities, there is a need to minimize MDRs of SES for ethnic minorities. To do so, there is a need for innovative economic, public, and social policies that are not limited to equalizing educational attainment but that also help minorities leverage their resources and gain tangible outcomes.

Prevalence and predictors of co-occurring diabetes and hypertension in community-dwelling older adults

AIM

The objectives of the present study were to estimate the prevalence of co-occurring diabetes and hypertension among older adults, examine predictors of co-occurring diabetes and hypertension, and ascertain whether predictors varied by race.

METHODS

A retrospective analysis was carried out using a statewide survey of Alabama community-dwelling older adults (n = 1204). Measures of central tendency and frequency distributions were used for univariate analysis. Logistic regression was used to predict co-occurring diabetes and hypertension.

RESULTS

The prevalence of co-occurring diabetes and hypertension among older adults was 17%. African American race (OR 2.28, 95% CI 1.596-3.255), body mass index ≥30 (OR 2.45, 95% CI 1.732-3.463), heart disease (OR 1.93, 95% CI 1.355-2.756) and eye disease (OR 1.44, 95% CI 1.018-2.024) were associated positively with co-occurring diabetes and hypertension.

CONCLUSIONS

The prevalence of co-occurring diabetes and hypertension among older adults was alarmingly high. The notable difference in the likelihood of co-occurring diabetes and hypertension is representative of a racial health disparity that largely disfavors African American older adults. Findings from the present study highlight a need for identification of older adults who have and who are at risk of co-occurring diabetes and hypertension in the general population and in clinical settings, and the development and implementation of suitable interventions, particularly targeting older African American adults. Geriatr Gerontol Int 2018; 18: 1356-1360.

Income Gradient in Renal Disease Mortality in the United States

Background

Non-communicable diseases and associated mortality follow a social gradient and chronic kidney disease is not an exception to this rule. Intermediate behavioral and medical factors that may explain such social gradients are, however, still unknown.

Objectives

Using nationally representative data in the United States, this study was conducted to investigate the mediating effect of medical and behavioral risk factors on the association between socioeconomic status (SES) and renal disease mortality.

Patients and methods

Americans’ Changing Lives Study (ACL), 1986–2011, is a 25-year nationally representative prospective cohort study. ACL followed 3,361 adults for up to 25 years. Income, education, and unemployment were the main predictors of interest. Death due to renal disease was the main outcome. Health behaviors (smoking, drinking, and exercise) and medical risk factors (diabetes, hypertension, and obesity) were the mediators. Cox proportional hazards models were used for data analysis.

Results

Higher income (HR = 0.75; 95% CI = 0.62–0.89) was associated with lower risk of death due to renal disease over the 25-year follow-up period. Although health behaviors and medical risk factors at baseline were also predictors of the outcome, they failed to explain the effect of income on death due to renal disease. That is, income was associated with death due to renal disease above and beyond all potential mediators including behavioral and medical risk factors.

Conclusion

Socioeconomic inequalities in the United States cause disparities in renal disease mortality; however, such differences are not due to health behaviors (smoking and drinking) and medical risk factors (hypertension and diabetes). To reduce disparities in renal disease mortality in the United States, policies should go beyond health behaviors and medical risk factors. While programs should help low-income individuals maintain exercise and avoid smoking, reduction of income disparities should be regarded as a strategy for reduction of disparities in renal disease mortality. By increasing minimum pay and minimizing the income gap, we may reduce disparities in renal disease mortality.

Socioeconomic Status and Glycemic Control in Type 2 Diabetes; Race by Gender Differences

Background: This study aimed to investigate differences in the association between socioeconomic status (SES) and glycemic control in type 2 diabetes mellitus (DM) across race by gender groups. Methods: Using a convenient sampling strategy, participants were 112 patients with type 2 DM who were prescribed insulin (ns = 38 Black women, 34 Black men, 14 White women, and 26 White men, respectively). Linear regression was used to test the associations between sociodemographic variables (race, gender, SES, governmental insurance) and Hemoglobin A1c (HbA1c) in the pooled sample and within subgroups defined by race and gender. Results: In the pooled sample, neither SES nor governmental insurance were associated with HbA1c. However, the race by gender interaction approached statistical significance (B = 0.34, 95% CI = −0.24–3.00, p =0.094), suggesting higher HbA1c in Black women, compared to other race by gender groups. In stratified models, SES (B = −0.33, 95% CI = −0.10–0.00, p = 0.050), and governmental insurance (B = 0.35, 95% CI = 0.05–2.42, p = 0.042) were associated with HbA1c for Black men, but not for any of the other race by gender subgroups. Conclusion: Socioeconomic factors may relate to health outcomes differently across race by gender subgroups. In particular, SES may be uniquely important for glycemic control of Black men. Due to lack of generalizability of the findings, additional research is needed.

Diabetes, hypertension, obesity, and long-term risk of renal disease mortality: Racial and socioeconomic differences

AIMS/INTRODUCTION

Diabetes, hypertension, and obesity increase the risk of chronic kidney disease and associated mortality. Race and socioeconomic status (SES) differences in the effects of these risk factors are, however, still unknown. The current study aimed to investigate whether or not race and SES alter the effects of diabetes, hypertension, and obesity on mortality due to renal disease.

MATERIALS AND METHODS

Data came from the Americans' Changing Lives Study, 1986-2011, a nationally representative prospective cohort of adults with 25 years of follow up. The study included 3,361 adults aged 25 years and older who were followed for up to 25 years. The outcome was death from renal disease. Diabetes, hypertension, and obesity were the main predictors. Race and SES (education, income, and employment) were moderators. Health behaviors and health status at baseline were covariates. We used Cox proportional hazards models for data analysis.

RESULTS

In separate models, diabetes, hypertension, and obesity at baseline were associated with a higher risk of death from renal disease. From our SES indicators, education and income interacted with diabetes, hypertension, and obesity on death from renal disease. In a consistent pattern, diabetes, hypertension, and obesity showed stronger effects on the risk of death from renal disease among high-SES groups compared with low-SES individuals. Race and employment did not alter the effects of diabetes, hypertension and obesity on the risk of death from renal disease.

CONCLUSIONS

Social groups differ in how diabetes, hypertension, and obesity influence health outcomes over long-term periods. Elimination of disparities in renal disease mortality in the USA requires understanding of the complex and non-linear effects of socioeconomic and medical risk factors on health outcomes. Multidisciplinary programs and policies are required to reduce social inequality in renal disease burden caused by diabetes, hypertension, and obesity.