The Effects of Social Determinants of Health on Cardiovascular Outcomes in Lebanese with Type 2 Diabetes

Abstract

Background: Type 2 Diabetes Mellitus (T2DM) is one of the most prevalent chronic diseases in Lebanon and is known to increase the risks of cardio-metabolic events. Diabetes self-management is essential for glycemic control and prevention of cardiovascular complications. Recent interest has emerged in studying social determinants factors that affect self-care and diabetes outcomes. Objective: The aim of this study is to assess the effect of different social determinants of health on cardiovascular risk factors in Lebanese people with T2DM. Design: A sample of 300 Lebanese patients with T2DM (aged 60.30 ± 12y, 48% females) was recruited from different primary health care centers in Lebanon (Beirut, Mount Lebanon and North Lebanon) and surveyed. Data regarding demographics, social determinants of health (subjective diabetes self-care activities, quality of life, depression, fatalism, diabetes knowledge, food security, adverse childhood experience and health literacy) and anthropometric measurements like weight, height, body mass index, blood pressure, waist circumference and A1C were taken. Results: Waist circumference, a potent cardiovascular risk factor, was set as the primary outcome based on the data and on the literature. Results in the bivariate analyses showed a significant associations (p<0.05) between waist circumference and the following variables in the demographics (age, school years, work hours, number of rooms, home owning, generator subscription as a source of electricity, public and car transportation, and diabetes family history), anthropometrics and other characteristics (weight, systolic blood pressure, BMI, A1C) and social determinants of health (health literacy and adverse childhood score ACE). After stepwise multivariate analysis, only work hours (β= -0.187, p=0.002), A1C (β= 0.135, p=0.021), diabetes family history (β= 0.121, p=0.039) and BMI (β= 0.594, p=0.00) predicted waist circumference. A path analyses was conducted based on a hypothetical model from the literature to explore possible mediators affecting this relationship. ACE, diabetes family history, age were found to be significantly and indirectly linked to the primary outcome (waist circumference) through A1C as a mediator, unlike health literacy that was significantly and directly linked to the primary outcome (χ2= 8.30 with p= 0.1405, CFI = .94 and RMSEA = .049 with PCLOSE of .44) Discussion: Patients that were health literate, working fewer hours with positive diabetes family history, and higher BMI and A1C levels were shown to have higher waist circumference and higher risk for cardiovascular risk factors. Additionally, results of the path analyses showed significant direct and indirect interactions affecting waist circumference with A1C as the primary mediator. Conclusion: Future studies are required to further investigate other social determinants of health, to target modifiable risk factors and educate patients with type 2 diabetes for better disease management and protection against cardiovascular complications.