Background: Evidence exists that socioeconomic status influences health, however, there is no consensus on the best measures to use when concerned with clinical outcomes. The aim of this analysis was to better understand the individual and cumulative influence of financial hardship on glycemic control in older adults with diabetes.

Methods: Using nationally representative data from 2012 and 2014 Health and Retirement Survey, we investigated 2,682 older adults with self-reported diabetes. Measures of financial hardship included 1) difficulty paying bills, 2) ongoing financial strain over 12 months or longer, 3) decreasing food intake due to lack of money, and 4) taking less medication than prescribed due to cost. Each measure was investigated individually, then a cumulative score of hardships for each person was created. Linear models for the relationship on continuous HbA1c were run unadjusted, then adjusted for age, gender, race/ethnicity, education, marital status, employment status, household income and asset quartiles, and comorbidity count.

Results: 58.5% of the sample reported at least 1 financial hardship, 37.5% reported 2+. After adjustment, a significant relationship existed with an increasing number of hardships associated with a 0.10 increase in HbA1c (95% CI 0.04, 0.15). While the adjusted relationship between ongoing financial strain and decreasing food intake due to money was no longer significant, difficulty paying bills (0.25, 95% CI 0.14, 0.36) and decreased medication usage due to cost (0.22, 95% CI 0.07, 0.36) remained significant. Once fully adjusted, the relationship with income lost its significance.

Conclusion: Financial hardship had a cumulative influence on glycemic control, with an increasing number of hardships associated with worse HbA1c. Difficulty paying bills and cost related non-adherence were independently associated with glycemic control, suggesting these may be better measures than income when considering the influence on clinical outcomes.


R.J. Walker: None. E. Garacci: None. L.E. Egede: Consultant; Self; Novo Nordisk Inc. Research Support; Self; National Institute of Diabetes and Digestive and Kidney Diseases.


National Institutes of Health

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