Footing the Bill: Income Inequality and Disparities in Diabetic Limb Preservation in a Nationwide Population-Based Study

Footing the Bill: Income Inequality and Disparities in Diabetic Limb Preservation in a Nationwide Population-Based Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Footing the Bill: Income Inequality and Disparities in Diabetic Limb Preservation in a Nationwide Population-Based Study Yoon Jae Lee, Kyung-Do Han, Jun Hyeok Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6794725/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Dec, 2025 Read the published version in Scientific Reports → Version 1 posted 13 You are reading this latest preprint version Abstract Background Income inequality has a profound impact on health outcomes by limiting access to preventive care, early diagnosis, and effective treatment with chronic conditions such as diabetes. Our aim was to investigate the impact of income inequality on diabetic foot amputation rates, focusing on disparities in outcomes among income levels. Methods This retrospective cohort study used data from the Korean National Health Insurance Service database that tracked 2,580,585 diabetic patients from 2009 to 2019. Participants were categorized into income quartiles (Q1–Q4) with Q1 being the lowest-income group. The primary outcome was the first occurrence of diabetes-related lower extremity amputation (LEA). Results LEA performance rates were inversely related to income, with Q1 having the highest rate (0.64 per 1,000 person-years) and Q4 the lowest (0.45 per 1,000 person-years). Adjusted models revealed a protective effect of higher income on LEA. The difference appeared to be more pronounced in individuals younger than 65 years, based on stratified analysis . Conclusion Income inequality is strongly associated with disparities in diabetic foot outcomes, with higher income linked to improved limb preservation, especially among younger individuals. These findings underscore the importance of targeted interventions to mitigate structural inequities, reduce the socioeconomic burden of diabetes, and enhance quality of life in vulnerable populations. Health sciences/Diseases/Endocrine system and metabolic diseases/Diabetes/Diabetes complications Health sciences/Health care/Health care economics Health sciences/Risk factors income inequality diabetic foot lower extremity amputation type 2 diabetes socioeconomic disparities preventive care Figures Figure 1 Figure 2 Introduction Diabetes mellitus is a chronic disease with significant global health implications and affects an estimated 463 million adults worldwide. (1) One of the most severe complications of diabetes is diabetic foot ulcers, which can lead to lower extremity amputations (LEA) if not properly managed. (2) Income inequality significantly affects health outcomes by limiting access to preventive care, timely diagnosis, and effective treatment, particularly for chronic diseases such as diabetes. (3, 4) The burden of diabetic foot complications is disproportionately borne by low-income individuals who face a reduced quality of life and shorter life expectancy due to limited healthcare access. (5, 6) Without timely intervention, diabetic ulcers can progress to severe infections, tissue necrosis, and ultimately a need for LEA. (7) Recurrences are frequent, further increasing healthcare costs and causing substantial emotional, psychological, and financial strain on patients and their families. (8–10) Structural barriers, such as fragmented healthcare systems, limited insurance coverage, and out-of-pocket expenses, create significant obstacles for low-income patients and hinder access to essential preventive services. (11, 12) Socioeconomic disparities in healthcare access often result in delayed care, missed opportunities for early intervention, and suboptimal management of chronic conditions. This perpetuates a cycle of worsening health, increased hospitalizations, and higher rates of amputation in low-income populations. (13, 14) Existing research has highlighted the importance of addressing the social determinants of health, including income inequality, to achieve equitable health outcomes. (15, 16) However, addressing these disparities requires systemic reforms that extend beyond individual behavioral changes. This emphasizes the need for healthcare policy solutions that prioritize vulnerable populations. (17, 18) This study employs analysis of data from a nationwide population to explore the association between income inequality and diabetic foot amputation rates. By examining the impact of economic barriers on health outcomes, the study provides insights into the effect of early intervention and preventive care on reducing the need for amputation. Additionally, the study offers policy recommendations aimed at narrowing income-based disparities, enhancing diabetic care, and alleviating the financial burden associated with diabetic foot complications. (19, 20) The findings underscore the importance of addressing structural inequities in healthcare to achieve better outcomes for diabetic patients and prevent unnecessary amputations, particularly among socioeconomically disadvantaged groups. This research contributes to the growing body of evidence highlighting the need for comprehensive approaches to address health disparities rooted in socioeconomic factors. Patients and Methods Study Design and Population This retrospective cohort study used de-identified data from the Korean National Health Insurance Service (NHIS) database that covers approximately 97% of the Korean population. The study population included individuals diagnosed with type 2 diabetes mellitus (T2DM) between 2009 and 2012. Participants eligible for inclusion were 20 years or older and had no history of prior LEA. Patients with missing data or those who had less than one year of follow-up were excluded from the analysis. (Fig. 1 .) The follow-up period spanned a maximum of 10 years and had a primary outcome of the first occurrence of diabetes-related LEA during the study period. Definitions of Diabetes and Lower Extremity Amputation T2DM was defined according to NHIS criteria as at least one annual claim for diabetic medication under ICD-10 codes E11–E14 or a fasting blood glucose (FBG) level of 126 mg/dL or higher. (21) Diabetes-related LEA was defined as any surgical removal of part of the lower limb due to diabetic complications such as ischemia, infection, or gangrene. The procedures were identified using specific ICD-10 procedure codes (N0571–N0575, N0562, N0564–N0566). (22) Income Levels Income levels were classified into quartiles (Q1–Q4) based on annual health insurance premiums. Q1 represented the lowest-income group and Q4 was the highest-income group. Income level was the primary exposure variable for assessing disparities in diabetic foot outcomes. Covariates The study incorporated a wide range of covariates to control potential confounding factors. Sociodemographic variables included age and sex. Lifestyle factors included smoking status (non-smoker, ex-smoker, or current smoker), alcohol consumption (none, mild, or heavy), and physical exercise. Clinical variables included diabetes duration (≥ five years or < five years), use of insulin therapy, and the number of oral antidiabetic medications prescribed (categorized as 0, 1, 2, or ≥ 3). Anthropometric measures included body mass index (BMI), waist circumference, and blood pressure (systolic and diastolic). Laboratory data included fasting glucose levels and lipid profiles (total cholesterol, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], and triglycerides). Chronic comorbidities of hypertension, dyslipidemia, and chronic kidney disease (CKD) were included. CKD was defined as an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m² calculated using the CKD-MRDR equation or at least one claim of ESRD with special designation codes (‘V001’, ‘V003’, or ‘V005’) before the index date. Primary and Secondary Outcomes The primary outcome of interest was diabetes-related LEA. Secondary outcomes included the analysis of amputation rates stratified by age, sex, diabetes duration, and comorbidity burden. Subgroup analyses were performed to explore the interactions between income and these clinical characteristics. Statistical Analysis Occurrences of LEA were calculated per 1,000 person-years for each income quartile. Cox proportional hazards regression models were used to evaluate the association between income levels and amputation risk. Four models were constructed to progressively adjust for potential confounders. Model 1 was unadjusted. Model 2 was adjusted for age and sex. Model 3 incorporated additional adjustments for income, lifestyle factors (smoking status, alcohol consumption, and physical activity), BMI, comorbidities (hypertension and dyslipidemia), and eGFR. Model 4 included further adjustments for diabetes duration, insulin use, number of oral antidiabetic medications prescribed, and fasting glucose levels. Subgroup analyses were conducted to assess potential interaction effects between income level and key variables of age (< 65 years versus ≥ 65 years), sex, diabetes duration (≥ five years versus < five years), and CKD status. Kaplan-Meier survival curves were generated to visualize cumulative incidence of LEA by income quartile over time. Interaction terms were tested for statistical significance to determine the possible presence of a differential effect on outcomes across subgroups associated with income level. Lifestyle Behavior Assessment Lifestyle factors were assessed through standardized questionnaires during routine health examinations. Smoking status was categorized as non-smoker, ex-smoker, or current smoker. Alcohol consumption was classified into three groups: non-drinker, mild drinker (less than 30 grams of alcohol per day), and heavy drinker (30 grams or more per day). Regular physical activity was defined as moderate to vigorous exercise at least three times per week. Ethical Considerations The study was approved by the Institutional Review Board of The Catholic Medical Center Office of Human Research Protection Program (SC24ZISE0115). The need for informed consent was waived due to the retrospective nature of the study and the use of de-identified data. Data Availability The datasets analyzed during the current study are not publicly available due to restrictions from the Korean National Health Insurance Service (NHIS), which prohibits the public release of raw data to protect personal health information, even in de-identified form. However, aggregated data used in the analysis are fully presented in the tables of this article. Additional information may be available from the corresponding author upon reasonable request and with appropriate institutional approvals. Results Baseline Characteristics The study included 2,580,585 individuals diagnosed with diabetes and were categorized into four income quartiles (Q1–Q4). Key demographic and clinical characteristics varied significantly across income groups (p < 0.0001). (Table 1 .) The highest-income quartile (Q4) demonstrated healthier profiles with lower rates of smoking, hypertension, and CKD and higher levels of physical activity. In contrast, lower-income groups (Q1 and Q2) had higher insulin usage, a longer duration of diabetes, and increased prevalence of CKD. Table 1 Demographics of the Diabetic Foot Patients in the NHIS Cohort Income 95% Q1 Q2 Q3 Q4 n 541177 489224 655489 894695 Sex, Male 297930 (55.05) 295704 (60.44) 407841 (62.22) 546866 (61.12) < 0.0001 Smoking < 0.0001 Non 312910 (57.82) 262822 (53.72) 349994 (53.39) 509295 (56.92) Ex 87717 (16.21) 84232 (17.22) 125058 (19.08) 195011 (21.8) Current 140550 (25.97) 142170 (29.06) 180437 (27.53) 190389 (21.28) Drinking < 0.0001 Non 329121 (60.82) 271743 (55.55) 365664 (55.78) 524234 (58.59) Mild 165326 (30.55) 166182 (33.97) 221934 (33.86) 289221 (32.33) Heavy 46730 (8.63) 51299 (10.49) 67891 (10.36) 81240 (9.08) Regular exercise 106631 (19.7) 93684 (19.15) 132114 (20.16) 207560 (23.2) < 0.0001 DYS 234227 (43.28) 200591 (41) 277510 (42.34) 407884 (45.59) < 0.0001 HP 318154 (58.79) 271348 (55.46) 370581 (56.54) 534822 (59.78) < 0.0001 CKD 62066 (11.47) 48588 (9.93) 69502 (10.6) 114961 (12.85) < 0.0001 Insulin 47857 (8.84) 39540 (8.08) 54543 (8.32) 80809 (9.03) < 0.0001 DM Duration ≥ 5yrs 193065 (35.68) 158975 (32.5) 224686 (34.28) 355884 (39.78) < 0.0001 Number of oral antidiabetic drugs < 0.0001 0 230866 (42.66) 229572 (46.93) 291388 (44.45) 343266 (38.37) 1 84386 (15.59) 70200 (14.35) 100008 (15.26) 158445 (17.71) 2 144041 (26.62) 121077 (24.75) 169973 (25.93) 256884 (28.71) 3+ 81884 (15.13) 68375 (13.98) 94120 (14.36) 136100 (15.21) Age 58.11 ± 11.8 55.75 ± 12.69 56.85 ± 12.54 60.35 ± 12.08 < 0.0001 Weight 65.11 ± 11.69 66.27 ± 12.11 66.69 ± 12.08 66.29 ± 11.74 < 0.0001 Height 161.32 ± 9.07 162.54 ± 9.21 162.84 ± 9.36 162.57 ± 9.46 < 0.0001 Waist circumference 84.97 ± 8.95 84.97 ± 8.92 85.38 ± 8.67 85.61 ± 8.4 < 0.0001 Total cholesterol 193.91 ± 42.69 194.98 ± 42.65 194.21 ± 42.43 191.34 ± 41.84 < 0.0001 SBP 128.87 ± 16.11 128.91 ± 15.95 128.99 ± 15.68 128.67 ± 15.46 < 0.0001 DBP 78.74 ± 10.36 79.1 ± 10.33 79.01 ± 10.23 78.36 ± 10.1 < 0.0001 LDL-C 109.35 ± 39.71 109.76 ± 39.9 109.49 ± 39.68 108.68 ± 38.75 < 0.0001 HDL-C 51.91 ± 18.72 52 ± 18.81 51.44 ± 19.33 50.93 ± 18.52 < 0.0001 Fasting glucose 145.13 ± 49.43 146.39 ± 48.51 144.36 ± 46.48 140.5 ± 43.01 < 0.0001 BMI 24.94 ± 3.5 25 ± 3.53 25.06 ± 3.42 24.98 ± 3.23 < 0.0001 DM Duration 3.51 ± 3.72 3.21 ± 3.68 3.38 ± 3.71 3.88 ± 3.8 < 0.0001 eGFR 85.88 ± 34.75 87.42 ± 36.11 86.31 ± 35.01 83.83 ± 36.47 < 0.0001 Triglyceride * 141.7 (141.48, 141.91) 143.74 (143.51, 143.97) 145.01 (144.81, 145.21) 139.53 (139.37, 139.69) < 0.0001 Income and Amputation Events A total of 9,552 diabetic-related limb amputations occurred during the follow-up period, and the occurrence rate per 1,000 person-years varied inversely with income. Q1, the lowest-income group, exhibited the highest amputation rate (0.64 per 1,000 person-years), while Q4, the highest-income group, showed the lowest rate (0.45 per 1,000 person-years). (Table 2 .) Table 2 Income Quartile and Hazard Ratios of the Risk of Amputation in Patients with Diabetic Foot Income N Event Duration IR per 1,000 Model 1 Model 2 Model 3 Model 4 Q1 541177 2419 3775932.87 0.64 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.) Q2 489224 1956 3460213.71 0.57 0.881 (0.83, 0.935) 0.926 (0.873, 0.983) 0.933 (0.879, 0.99) 0.944 (0.89, 1.002) Q3 655489 2336 4645724.50 0.50 0.783 (0.74, 0.829) 0.785 (0.742, 0.831) 0.804 (0.76, 0.851) 0.815 (0.77, 0.863) Q4 894695 2841 6257787.13 0.45 0.709 (0.671, 0.748) 0.629 (0.596, 0.664) 0.662 (0.627, 0.699) 0.672 (0.636, 0.71) Model 1: Non-adjusted Model 2: Adjusted for Age and Sex Model 3: Model 2 + Income Status, Smoking, Drinking, Regular exercise, DYS, HP, BMI, eGFR Model 4: Model 3 + DM Duration ≥ 5 yrs, Number of oral antidiabetic drugs, Insulin, Fasting glucose In model 4, which incorporated full adjustments for clinical and behavioral covariates, the hazard ratio for Q4 was 0.672 (95% CI: 0.636–0.71), indicating a statistically significant lower amputation risk compared to Q1. This trend emphasizes the protective effect of higher income levels on diabetic limb preservation. Stratified Analysis: Age, Sex, and Diabetes Duration In subgroup analyses, the protective association between higher income and limb preservation was most pronounced among individuals aged < 65 years (p for interaction < 0.0001). (Table 3 .) The IR in Q4 for individuals younger than 65 years was 0.31 per 1,000 person-years compared to 0.57 in Q1 (HR: 0.586; 95% CI: 0.543–0.632). Among individuals aged ≥ 65 years, the protective effect was weaker (Q4 HR: 0.787; 95% CI: 0.725–0.854). Table 3 Hazard Ratio for Risk of Amputation in Diabetic Foot according to Age, Sex, Diabetes Duration, and Number of Oral Antidiabetic Drugs, Insulin use, and CKD Stratified by Income Quartile Subgroup Income N Event Duration IR per 1,000 Model 4 p for inter Age < 65 Q1 377134 1536 2693813.52 0.57 1 (ref.) < 0.0001 Q2 370859 1299 2681374.70 0.48 0.909 (0.844, 0.978) Q3 468885 1329 3402450.12 0.39 0.737 (0.685, 0.793) Q4 537473 1218 3877794.71 0.31 0.586 (0.543, 0.632) Age ≥ 65 Q1 164043 883 1082119.35 0.82 1 (ref.) Q2 118365 657 778839.01 0.84 0.996 (0.9, 1.102) Q3 186604 1007 1243274.38 0.81 0.948 (0.866, 1.037) Q4 357222 1623 2379992.42 0.68 0.787 (0.725, 0.854) Sex, Male Q1 297930 1844 2054929.52 0.90 1 (ref.) 0.4667 Q2 295704 1498 2075668.16 0.72 0.923 (0.862, 0.988) Q3 407841 1784 2866556.51 0.62 0.797 (0.747, 0.851) Q4 546866 2134 3785738.25 0.56 0.663 (0.622, 0.706) Sex, Female Q1 243247 575 1721003.35 0.33 1 (ref.) Q2 193520 458 1384545.55 0.33 1.018 (0.9, 1.151) Q3 247648 552 1779167.99 0.31 0.875 (0.778, 0.983) Q4 347829 707 2472048.88 0.29 0.702 (0.629, 0.784) DM Duration < 5 yrs Q1 348112 766 2493443.51 0.31 1 (ref.) 0.5293 Q2 330249 642 2391384.55 0.27 0.911 (0.821, 1.012) Q3 430803 708 3126077.51 0.23 0.768 (0.693, 0.85) Q4 538811 772 3865017.36 0.20 0.664 (0.601, 0.734) DM Duration ≥ 5 yrs Q1 193065 1653 1282489.36 1.29 1 (ref.) Q2 158975 1314 1068829.16 1.23 0.96 (0.893, 1.032) Q3 224686 1628 1519646.99 1.07 0.837 (0.782, 0.897) Q4 355884 2069 2392769.77 0.86 0.676 (0.634, 0.722) No oral antidiabetic drug Q1 230866 616 1676599.29 0.37 1 (ref.) 0.3574 Q2 229572 511 1682035.57 0.30 0.891 (0.792, 1.002) Q3 291388 585 2139686.77 0.27 0.792 (0.707, 0.887) Q4 343266 661 2488245.18 0.27 0.695 (0.623, 0.776) One oral antidiabetic drug Q1 84386 354 573955.39 0.62 1 (ref.) Q2 70200 274 482766.46 0.57 0.964 (0.823, 1.129) Q3 100008 373 691275.40 0.54 0.89 (0.77, 1.03) Q4 158445 514 1089721.81 0.47 0.75 (0.655, 0.859) Two oral antidiabetic drugs Q1 144041 759 976426.76 0.78 1 (ref.) Q2 121077 596 830951.42 0.72 0.935 (0.84, 1.041) Q3 169973 705 1173075.08 0.60 0.782 (0.706, 0.866) Q4 256884 886 1758037.92 0.50 0.631 (0.573, 0.696) More than three oral antidiabetic drugs Q1 81884 690 548951.44 1.26 1 (ref.) Q2 68375 575 464460.27 1.24 0.995 (0.891, 1.112) Q3 94120 673 641687.26 1.05 0.834 (0.75, 0.928) Q4 136100 780 921782.22 0.85 0.658 (0.594, 0.729) Insulin (-) Q1 493320 1581 3468454.70 0.46 1 (ref.) 0.3717 Q2 449684 1299 3203058.90 0.41 0.947 (0.88, 1.02) Q3 600946 1523 4287218.89 0.36 0.808 (0.753, 0.867) Q4 813886 1790 5732309.77 0.31 0.652 (0.609, 0.698) Insulin (+) Q1 47857 838 307478.17 2.73 1 (ref.) Q2 39540 657 257154.82 2.55 0.938 (0.847, 1.039) Q3 54543 813 358505.61 2.27 0.828 (0.752, 0.912) Q4 80809 1051 525477.36 2.00 0.709 (0.647, 0.777) CKD (-) Q1 479111 1758 3369149.00 0.52 1 (ref.) 0.7118 Q2 440636 1449 3137160.77 0.46 0.937 (0.874, 1.005) Q3 585987 1688 4179423.26 0.40 0.803 (0.751, 0.858) Q4 779734 1950 5493518.81 0.35 0.662 (0.62, 0.706) CKD (+) Q1 62066 661 406783.87 1.62 1 (ref.) Q2 48588 507 323052.94 1.57 0.951 (0.847, 1.067) Q3 69502 648 466301.24 1.39 0.847 (0.76, 0.944) Q4 114961 891 764268.33 1.17 0.704 (0.637, 0.779) In contrast, the differences in amputation risk associated with income were not statistically significant for other subgroups. These include sex (p for interaction = 0.4667), diabetes duration (p for interaction = 0.5293), use of oral medications (p for interaction = 0.3574), insulin use (p for interaction = 0.3717), and chronic kidney disease (CKD) status (p for interaction = 0.7118). Cumulative Incidence of Amputation by Income Group The Kaplan–Meier plot (Fig. 2 .) a persistently lower cumulative incidence of LEA among higher-income groups over the 10-year follow-up, supporting the inverse association observed in hazard models . Q1 consistently showed the highest occurrence rate across all time points, emphasizing the persistent impact of low socioeconomic status on poor outcomes. Interpretation Our findings indicate a clear socioeconomic gradient in diabetic limb preservation, with higher-income groups experiencing significantly fewer amputations. This association is particularly dramatic among younger individuals and those with longer diabetes duration. The results suggest that targeted interventions to improve access to care and resources among lower-income groups substantially reduce amputation rates and enhances quality of life in diabetic populations. Discussion This nationwide population-based study demonstrated an observed association between income inequality and disparities in diabetic limb preservation, with higher income levels correlating with better limb preservation outcomes. This observed trend appeared more pronounced among individuals younger than 65 years, suggesting a possible increased vulnerability of younger, lower-income diabetic patients to limb loss. These findings suggest a potential association between socioeconomic factors and diabetic limb outcomes, as demonstrated by differences in adjusted hazard ratios across income groups . (23–25) The inverse relationship between income levels and diabetic limb amputation rates observed in our study aligns with previous research on health disparities in diabetes care. (13, 26, 27) However, the magnitude of this disparity, especially among younger patients, adds a new dimension to our understanding. (14, 28, 29) This age-specific effect suggests that the impact of socioeconomic factors on health outcomes may be more profound during the working years, potentially due to competing priorities between work and health management. (30, 31) These disparities may have several causes. Lower-income individuals often face barriers to preventive care, including limited transportation options, inability to take time off work, and lack of health insurance or high out-of-pocket costs. (2, 32, 33) These factors can lead to delayed diagnoses and suboptimal management of diabetes and its complications. (34, 35) Additionally, lower health literacy and reduced access to diabetes education programs may contribute to poorer self-management practices among lower-income groups. (36, 37) The socioeconomic gradient in health behaviors is another crucial factor. (9, 19) Lower-income individuals may have limited access to healthy food options, safe environments for physical activity, and resources for stress management. These are all critical components of diabetes management. (10, 38, 39) The cumulative effect of these disadvantages over time may explain the more pronounced disparities observed in younger age groups. (40, 41) This study’s findings have significant clinical implications. These results highlight the need for targeted interventions and intensified care for lower-income diabetic patients, particularly those younger than 65 years. (7, 42) Clinicians should be aware of the heightened risk in this population and should perform more frequent follow-ups, comprehensive foot examinations, and earlier interventions to prevent complications. (43–45) Diabetic foot ulcers and their progression to amputation carry a significant risk of mortality, primarily due to complications such as infections, tissue necrosis, and cardiovascular disease. (46) Five-year mortality rates for patients with diabetic ulcers range between 42–44%, and this risk increases to 68–79% following LEA. (22, 47, 48) The high mortality after amputation reflects not only the physical burden of losing a limb, but also the systemic health decline associated with severe diabetes-related complications. (49) Patients with amputations frequently experience worsening cardiovascular conditions, infections, and other metabolic complications, further contributing to high mortality rates. (50, 51) These high mortality rates for patients with diabetic ulcers escalate significantly following LEA, underscoring the urgency of prevention and early intervention. (52, 53) From a policy perspective, our results stress the need for systemic changes to address health inequalities. (48, 54, 55) Proposed initiatives include expanding access to affordable healthcare, implementing community-based diabetes prevention programs in low-income areas, and developing policies to improve the social determinants of health. (52, 53, 55, 56) Addressing both socioeconomic barriers and clinical management is essential to reduce LEA and associated mortality rates. Effective policies that improve healthcare access such as subsidized diabetic care and preventive services can mitigate complications and lower mortality rates among vulnerable populations. Integrating regular screenings, patient education, and community-based interventions can further enhance outcomes for socioeconomically disadvantaged groups, and addressing disparities in healthcare access is crucial not only for improving survival rates, but also for advancing overall health equity. The pronounced disparities in amputation risk among patients younger than 65 years reflect the profound impact of socioeconomic barriers on health outcomes during working-age years. (57, 58) In this age group, physical function is essential not only for individual well-being, but also for workforce participation and national productivity. (59) The higher amputation rates observed among low-income individuals in this demographic group suggest that economic barriers impede access to preventive care and timely treatment. This results in more severe complications such as infections, tissue necrosis, and LEA. (60, 61) As these younger patients are typically active in the workforce, the rise in disability from diabetic complications can lead to a decline in national productivity and increase in healthcare costs. Socioeconomic inequality is exacerbated by limiting career progression opportunities and income stability. (47, 49) To address these disparities and improve outcomes, it is essential to strengthen workplace health programs and national screening efforts. (62) Enhanced participation in regular health examinations and national diabetes screening programs will assist in detection of early signs of diabetic foot complications in younger populations. (63) Expanding access to preventive services through workplace wellness programs that offer routine foot screenings and education can promote early intervention, especially for workers in high-risk or physically demanding jobs. (64, 65) National health policies should prioritize preventive interventions in younger patients. Reducing amputations in this age group has long-term benefits for both individual health and national productivity. (50) By minimizing disabilities, these policies will not only reduce healthcare costs, but also preserve workforce capacity, thereby promoting economic sustainability. (48, 51) Workplace wellness programs and policies supporting diabetes management for working-age adults could be particularly beneficial. (56, 66) The success of such programs is evident in studies showing reduced rates of hospitalization, lengths of hospital stay, and lower extremity amputations after implementation. (67, 68) The relationship between income and chronic disease management has been extensively studied in various healthcare systems worldwide. In the United States, a market-based system, research consistently shows that low-income individuals experience poorer health outcomes due to limited access to preventive care, fragmented insurance coverage, and high out-of-pocket costs. (3, 69) These economic barriers are linked to delayed diagnoses, poor disease management, and increased complications, particularly for chronic conditions like diabetes. (70, 71) In contrast, South Korea offers universal health coverage through the National Health Insurance Service (NHIS). However, our study reveals persistent income-related disparities in amputation risks, particularly among younger individuals and those with long-standing diabetes. This suggests that, while basic healthcare services are accessible to all, non-medical barriers such as financial stress, time constraints, and knowledge gaps continue to impact health outcomes. (72, 73) Another key difference lies in workplace dynamics and access to employer-based health programs. In South Korea, younger individuals in low-income groups are often engaged in physically demanding jobs with limited flexibility that may hinder their ability to seek timely medical care. (74) This differs from the United States context in which healthcare access is often tied to employment benefits, but coverage remains uneven across socioeconomic groups. (75) Moreover, cultural factors in Korea, such as a lack of emphasis on preventive care among younger adults, may further exacerbate the disparities in diabetic outcomes observed in this study. (76–78) European countries present a third model. These countries have varying degrees of universal healthcare and social support systems. For instance, the United Kingdom's National Health Service (NHS) provides comprehensive coverage; but socioeconomic disparities in diabetic outcomes persist, albeit to a lesser extent than in more market-driven systems. (79, 80) Sweden, with its strong emphasis on equity in healthcare, has shown smaller income-related disparities in diabetes management, Sweden still faces challenges in reaching certain vulnerable populations. (81, 82) These findings across different healthcare systems suggest that structural interventions beyond universal coverage are necessary to address socioeconomic disparities in diabetic care globally. (20, 83) Policies that target both financial and non-financial barriers are critical to closing the gap. For all countries, regardless of healthcare system structure, strengthening workplace health programs, ensuring flexible healthcare access for working-age adults, and providing targeted health education would mitigate the impact of income disparities, especially in younger populations at higher risk of complications. (19, 84) Additionally, community-based screening programs and subsidized preventive care for low-income patients would be universally beneficial in reducing diabetic complications and associated healthcare costs. (10) The strengths of our study lie in its nationwide scope and the novel insights gained from age-stratified analyses. (67, 68, 85) However, we acknowledge several limitations. First, our dataset lacked detailed clinical information that could have provided better insights into the progression of diabetic foot complications. (85, 86) The use of administrative claims data from the NHIS inherently restricts access to detailed clinical variables such as ulcer severity, wound classification, vascular imaging, or ambulatory function. These unmeasured variables may have influenced the outcomes but could not be controlled in our models. Second, income level was approximated using health insurance premium quartiles, which may not fully reflect individual socioeconomic status, particularly for dependents or non-wage earners. Third, residual confounding cannot be ruled out due to the absence of certain behavioral or contextual factors—such as education level, health literacy, healthcare-seeking behaviors, and quality of diabetic foot care—all of which may contribute to disparities in outcomes. Fourth, due to the retrospective observational design, the results demonstrate associations rather than causal relationships. (2, 87) Fifth, generalizability to populations outside Korea may be limited due to healthcare system differences. These factors may have introduced bias or affected the robustness of our findings, warranting caution in the interpretation of results. Future research should focus on longitudinal studies to better understand the temporal relationship among income, age, and diabetic limb preservation. (43, 88) Intervention studies targeting low-income, younger diabetic patients are needed to evaluate the effectiveness of tailored prevention strategies. (89, 90) Furthermore, investigating the interactions between income and other socioeconomic factors, such as education level and occupation type, could provide a more comprehensive understanding of health disparities in diabetes care. (91, 92) Conclusion This study provides empirical evidence on the impact of income inequality on healthcare equity and diabetic limb preservation rates. Income inequality was observed to be strongly associated with disparities in diabetic foot outcomes, with higher income linked amputation to improved limb preservation, especially among younger individuals. These findings suggest a need for targeted interventions to improve healthcare access for low-income patients, emphasizing the importance of workplace and national screening programs, leveraging digital health technologies, and expanding insurance coverage to address these disparities. These interventions may help improve patients’ quality of life and reduce amputation rates and could contribute to alleviating the individual and societal burden associated with diabetic foot complications. Declarations Conflicts of interest None to declare. ORCID Yoon Jae Lee https://orcid.org/0000-0002-8376-9135 Kyung-Do Han https://orcid.org/0000-0002-6096-1263 Jun Hyeok Kim https://orcid.org/0000-0003-4657-2090 Author Contribution Lee was responsible for drafting the manuscript. Han contributed by organizing the dataset and conducting statistical analyses. Kim conceived the study, acquired funding, and supervised the completion of the manuscript. Acknowledgment This research was supported by a grant from the Institute of Clinical Medicine Research in Yeouido St. Mary’s Hospital, The Catholic University of Korea and the Catholic Medical Center Research Foundation made in the program year of 2025. Data Availability The datasets analyzed during the current study were obtained from the Korean National Health Insurance Service (NHIS) under institutional data use agreements. Due to strict privacy and regulatory restrictions, the raw data cannot be shared publicly or deposited in a repository. However, the aggregated data that support the findings of this study are fully presented in the tables within the manuscript. Additional summary information may be available from the corresponding author upon reasonable request and with NHIS approval. References Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9(th) edition. Diabetes Res Clin Pract. 2019;157:107843. Epub 20190910. doi: 10.1016/j.diabres.2019.107843. PubMed PMID: 31518657. Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med. 2017;376(24):2367-75. doi: 10.1056/NEJMra1615439. PubMed PMID: 28614678. Walker RJ, Smalls BL, Campbell JA, Strom Williams JL, Egede LE. Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review. Endocrine. 2014;47(1):29-48. Epub 20140215. doi: 10.1007/s12020-014-0195-0. PubMed PMID: 24532079; PubMed Central PMCID: PMC7029167. Secrest AM, Costacou T, Gutelius B, Miller RG, Songer TJ, Orchard TJ. Associations between socioeconomic status and major complications in type 1 diabetes: the Pittsburgh epidemiology of diabetes complication (EDC) Study. Ann Epidemiol. 2011;21(5):374-81. doi: 10.1016/j.annepidem.2011.02.007. PubMed PMID: 21458731; PubMed Central PMCID: PMC3079455. Stevens CD, Schriger DL, Raffetto B, Davis AC, Zingmond D, Roby DH. Geographic clustering of diabetic lower-extremity amputations in low-income regions of California. Health Aff (Millwood). 2014;33(8):1383-90. doi: 10.1377/hlthaff.2014.0148. PubMed PMID: 25092840; PubMed Central PMCID: PMC4242846. Margolis DJ, Hoffstad O, Nafash J, Leonard CE, Freeman CP, Hennessy S, et al. Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes. Diabetes Care. 2011;34(11):2363-7. Epub 20110920. doi: 10.2337/dc11-0807. PubMed PMID: 21933906; PubMed Central PMCID: PMC3198303. Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288-93. doi: 10.2337/dc05-2425. PubMed PMID: 16732010. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-24. doi: 10.1016/S0140-6736(05)67698-2. PubMed PMID: 16291066. Kerr M, Rayman G, Jeffcoate WJ. Cost of diabetic foot disease to the National Health Service in England. Diabet Med. 2014;31(12):1498-504. Epub 20140801. doi: 10.1111/dme.12545. PubMed PMID: 24984759. Lazzarini PA, Hurn SE, Fernando ME, Jen SD, Kuys SS, Kamp MC, et al. Prevalence of foot disease and risk factors in general inpatient populations: a systematic review and meta-analysis. BMJ Open. 2015;5(11):e008544. Epub 20151123. doi: 10.1136/bmjopen-2015-008544. PubMed PMID: 26597864; PubMed Central PMCID: PMC4663442. Kominski GF, ProQuest, Kominski GF. Changing the U.S. health care system : key issues in health services policy and management. Fourth edition. ed. San Francisco: Jossey-Bass Wairīpaburisshingujapan; 2014. Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev. 2007;64(5 Suppl):101S-56S. doi: 10.1177/1077558707305409. PubMed PMID: 17881626; PubMed Central PMCID: PMC2367214. Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia. 2012;55(7):1919-25. Epub 20120308. doi: 10.1007/s00125-012-2468-6. PubMed PMID: 22398645. Wrobel JS, Mayfield JA, Reiber GE. Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population. Diabetes Care. 2001;24(5):860-4. doi: 10.2337/diacare.24.5.860. PubMed PMID: 11347744. Hill J, Nielsen M, Fox MH. Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill. Perm J. 2013;17(2):67-72. doi: 10.7812/TPP/12-099. PubMed PMID: 23704847; PubMed Central PMCID: PMC3662286. Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P, Consortium for the European Review of Social Determinants of H, et al. WHO European review of social determinants of health and the health divide. Lancet. 2012;380(9846):1011-29. Epub 20120908. doi: 10.1016/S0140-6736(12)61228-8. PubMed PMID: 22964159. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood). 2002;21(2):60-76. doi: 10.1377/hlthaff.21.2.60. PubMed PMID: 11900187. Marmot M, Friel S, Bell R, Houweling TA, Taylor S, Commission on Social Determinants of H. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-9. doi: 10.1016/S0140-6736(08)61690-6. PubMed PMID: 18994664. Paisey RB, Abbott A, Levenson R, Harrington A, Browne D, Moore J, et al. Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England. Diabet Med. 2018;35(1):53-62. Epub 20171011. doi: 10.1111/dme.13512. PubMed PMID: 29023974; PubMed Central PMCID: PMC5765400. Jeffcoate WJ, Vileikyte L, Boyko EJ, Armstrong DG, Boulton AJM. Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. Diabetes Care. 2018;41(4):645-52. doi: 10.2337/dc17-1836. PubMed PMID: 29559450. Baek JH, Park YM, Han KD, Moon MK, Choi JH, Ko SH. Comparison of Operational Definition of Type 2 Diabetes Mellitus Based on Data from Korean National Health Insurance Service and Korea National Health and Nutrition Examination Survey. Diabetes Metab J. 2023;47(2):201-10. Epub 20230208. doi: 10.4093/dmj.2022.0375. PubMed PMID: 36750233; PubMed Central PMCID: PMC10040628. Lee YJ, Han KD, Kim JH. Association among Current Smoking, Alcohol Consumption, Regular Exercise, and Lower Extremity Amputation in Patients with Diabetic Foot: Nationwide Population-Based Study. Endocrinol Metab (Seoul). 2022;37(5):770-80. Epub 20221012. doi: 10.3803/EnM.2022.1519. PubMed PMID: 36222086; PubMed Central PMCID: PMC9633221. Zhang P, Lu J, Jing Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017;49(2):106-16. Monteiro-Soares M, Boyko EJ, Ribeiro I. Predictive factors for diabetic foot ulceration: a systematic review. Diabetes Metab Res Rev. 2012;28(7):574-600. Stevens CD, Schriger DL, Raffetto B. Geographic clustering of diabetic lower-extremity amputations in low-income regions of California. Health Aff (Millwood). 2014;33(8):1383-90. Margolis DJ, Hoffstad O, Nafash J. Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes. Diabetes Care. 2011;34(11):2363-7. Nather A, Bee CS, Huak CY. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications. 2008;22(2):77-82. Gregg EW, Li Y, Wang J. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med. 2014;370(16):1514-23. Geiss LS, Li Y, Hora I. Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care. 2019;42(1):50-4. Narres M, Kvitkina T, Claessen H. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoS One. 2017;12(8):e0182081. Jeffcoate WJ, Vileikyte L, Boyko EJ. Current challenges and opportunities in the prevention and management of diabetic foot ulcers. Diabetes Care. 2018;41(4):645-52. Boyko EJ, Seelig AD, Ahroni JH. Limb- and person-level risk factors for lower-limb amputation in the prospective Seattle Diabetic Foot Study. Diabetes Care. 2018;41(4):891-8. Prompers L, Huijberts M, Apelqvist J. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50(1):18-25. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-24. Lavery LA, Armstrong DG, Wunderlich RP. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288-93. Hicks CW, Selvarajah S, Mathioudakis N. Trends and determinants of costs associated with the inpatient care of diabetic foot ulcers. J Vasc Surg. 2014;60(5):1247-54.e2. Skrepnek GH, Mills JL, Sr., Lavery LA. Health care service and outcomes among an estimated 6.7 million ambulatory care diabetic foot cases in the U.S. Diabetes Care. 2017;40(7):936-42. Lazzarini PA, Hurn SE, Kuys SS. Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study. BMJ Open. 2016;6(6):e010811. Jeffcoate WJ, Chipchase SY, Ince P. Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. Diabetes Care. 2006;29(8):1784-91. Prompers L, Schaper N, Apelqvist J. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008;51(5):747-54. Reiber GE, Vileikyte L, Boyko EJ. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999;22(1):157-62. Boyko EJ, Ahroni JH, Stensel V. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care. 1999;22(7):1036-42. Lazzarini PA, Pacella RE, Armstrong DG. Diabetes-related lower-extremity complications are a leading cause of the global burden of disability. Diabet Med. 2018;35(9):1297-9. Boulton AJM. The pathway to foot ulceration in diabetes. Med Clin North Am. 2013;97(5):775-90. Apelqvist J, Larsson J, Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med. 1993;233(6):485-91. Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic Foot Ulcers: A Review. JAMA. 2023;330(1):62-75. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J. 2016;13(5):892-903. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26(2):491-4. Chammas NK, Hill RL, Edmonds ME. Increased mortality in diabetic foot ulcer patients: the significance of ulcer type. J Diabetes Res. 2016;2016:2879809. Hoffmann M, Kujath P, Flemming A, Proß M, Begum N, Zimmermann M. Survival of diabetes patients with major amputation is comparable to malignant disease. Diab Vasc Dis Res. 2015;12(4):265-71. Morbach S, Furchert H, Gröblinghoff U, Hoffmeier H, Kersten K, Klauke GT. Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care. 2012;35(10):2021-7. Margolis DJ, Malay DS, Hoffstad OJ. Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: Data Points #2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011. Prompers L, Huijberts M, Schaper N. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia. 2008;51(10):1826-34. Brownrigg JR, Davey J, Holt PJ. The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis. Diabetologia. 2012;55(11):2906-12. Kerr M. Foot care for people with diabetes: the economic case for change. 2012. Armstrong DG, Wrobel J, Robbins JM. Guest Editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286-7. Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia. 2012;55(7):1919-25. Fakorede FA, Fakorede A, Hennebry TA. Reducing Disparities in Diabetic Amputations. NIDDK [Internet]. 2021. Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13:16. Bali V, Yermilov I, Koyama A, Legorreta AP. Secondary prevention of diabetes through workplace health screening. Occup Med (Lond). 2018;68(9):610-6. Ragnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis. 2004;39 Suppl 2:S132-S9. Hafez D, Fedewa A, Moran M, O'Brien M, Ackermann R, Kullgren JT. Workplace Interventions to Prevent Type 2 Diabetes Mellitus: a Narrative Review. Curr Diab Rep. 2017;17(12):121. Pu J, Chewning B, Johnson HM, Vanness DJ, Young HN, Kreling DH. Health Behavior Change After Blood Pressure Feedback. PLoS One. 2015;10(10):e0139644. Brown SA, García AA, Zuñiga JA, Lewis KA. Effectiveness of workplace diabetes prevention programs: A systematic review of the evidence. Patient Educ Couns. 2018;101(6):1036-50. Conn VS, Hafdahl AR, Mehr DR, LeMaster JW, Brown SA, Nielsen PJ. Metabolic effects of interventions to increase exercise in adults with type 2 diabetes. Diabetologia. 2007;50(5):913-21. Barshes NR, Sigireddi M, Wrobel JS. The system of care for the diabetic foot: objectives, outcomes, and opportunities. Diabet Foot Ankle. 2013;4. Lipsky BA, Berendt AR, Cornia PB. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e73. Hinchliffe RJ, Brownrigg JR, Andros G. Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. Diabetes Metab Res Rev. 2016;32 Suppl 1:136-44. Secrest AM, Costacou T, Gutelius B, Miller RG, Songer TJ, Orchard TJ. Associations between socioeconomic status and major complications in type 1 diabetes: the Pittsburgh epidemiology of diabetes complication (EDC) Study. Ann Epidemiol. 2011;21(5):374-81. Brown AF, Ettner SL, Piette J, Weinberger M, Gregg E, Shapiro MF. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev. 2004;26:63-77. Booth GL, Hux JE. Relationship between avoidable hospitalizations for diabetes mellitus and income level. Arch Intern Med. 2003;163(1):101-6. Kim D, Kang S, Kim J, Kim H, Min H, Lee H. Socioeconomic status and the prevalence of type 2 diabetes in South Korean adults: a population-based cross-sectional study. J Epidemiol. 2020;30(12):550-8. Ha R, Kim D, Choi J, Jung-Choi K. A national pilot program for chronic diseases and health inequalities in South Korea. BMC Public Health. 2021;21(1):1142. Kim D. Socioeconomic status and the prevalence of type 2 diabetes in South Korean adults: a population-based cross-sectional study. J Epidemiol. 2020;30(12):550-8. Walker RJ. Understanding the influence of psychological and socioeconomic factors on diabetes self-care using structured equation modeling. Patient Educ Couns. 2015;98(1):34-40. Cho NH. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018;138:271-81. Kang H. Diabetes management and self-care education for hospitalized patients with diabetes in Korea. Diabetes Metab J. 2018;42(5):425-36. Kim KS. Management of type 2 diabetes mellitus in older adults. Diabetes Metab J. 2012;36(5):336-44. Grintsova O, Maier W, Mielck A. Inequalities in health care among patients with type 2 diabetes by individual socio-economic status (SES) and regional deprivation: a systematic literature review. Int J Equity Health. 2014;13:43. Hippisley-Cox J, O'Hanlon S, Coupland C. Association of deprivation, ethnicity, and sex with quality indicators for diabetes: population based survey of 53,000 patients in primary care. BMJ. 2004;329(7477):1267-9. Agardh E, Allebeck P, Hallqvist J, Moradi T, Sidorchuk A. Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. Int J Epidemiol. 2011;40(3):804-18. Rawshani A, Svensson AM, Rosengren A, Eliasson B, Gudbjörnsdottir S. Impact of socioeconomic status on cardiovascular disease and mortality in 24,947 individuals with type 1 diabetes. Diabetes Care. 2015;38(8):1518-27. Marmot M, Friel S, Bell R, Houweling TA, Taylor S, Commission on Social Determinants of H. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-9. Patout CA, Jr., Birke JA, Horswell R, Williams D, Cerise FP. Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Diabetes Care. 2000;23(9):1339-42. Hingorani A, LaMuraglia GM, Henke P. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016;63 Suppl 2:3S-21S. Schaper NC, Van Netten JJ, Apelqvist J. Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes Metab Res Rev. 2016;32 Suppl 1:7-15. Jeffcoate WJ, Bus SA, Game FL. Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: required details and markers of good quality. Lancet Diabetes Endocrinol. 2016;4(9):781-93. Boulton AJM, Armstrong DG, Kirsner RS. Diagnosis and Management of Diabetic Foot Complications. Arlington (VA): American Diabetes Association; 2018. Rayman G, Vas PR, Baker N. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011;34(7):1517-8. Lavery LA, Higgins KR, Lanctot DR. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007;30(1):14-20. Bus SA, Lavery LA, Monteiro-Soares M. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36 Suppl 1:e3269. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998;21(5):855-60. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Dec, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 27 Aug, 2025 Reviews received at journal 19 Aug, 2025 Reviews received at journal 21 Jul, 2025 Reviews received at journal 18 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor assigned by journal 14 Jul, 2025 Editor invited by journal 17 Jun, 2025 Submission checks completed at journal 04 Jun, 2025 First submitted to journal 04 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6794725","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":485405719,"identity":"00048d05-0041-4391-a2c1-4673cf285925","order_by":0,"name":"Yoon Jae Lee","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Yoon","middleName":"Jae","lastName":"Lee","suffix":""},{"id":485405720,"identity":"d587cb82-06dd-4e2d-b10b-e56f0d8dca63","order_by":1,"name":"Kyung-Do Han","email":"","orcid":"","institution":"Soongsil University","correspondingAuthor":false,"prefix":"","firstName":"Kyung-Do","middleName":"","lastName":"Han","suffix":""},{"id":485405721,"identity":"6de2a62b-0ca9-4e18-abd5-99815f629b1d","order_by":2,"name":"Jun Hyeok Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYBACAygtB8RsDAwFEmAeYwMRWowZGJiBWgxI0JLYANHCQFiLuUTywYdffh1O728/f+zBBwMLeQb2ww8YZ+7BrcVyRlqysWzf4dwZZ5LZDWcYSBg28KQZMG54hsdhN3LMpCV7DuduYEhmk+YxkEhgYMhhYHxwAJ+W/G8gLekG/I+hWvjfENKSwyb54cfhBAMJmC0SQFs24NNy5pmxMWNDuuGMG4/NJEF+aZN4ZnBwBj4tx5MfPvzxx1qevz/xmcSHijp5fn6gSA8eLQwCCQzMvG3NCAFg7DDg08DAwH+AgfHHnzq8akbBKBgFo2CEAwAx11E23JqbiAAAAABJRU5ErkJggg==","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":true,"prefix":"","firstName":"Jun","middleName":"Hyeok","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2025-06-01 08:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6794725/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6794725/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-27511-x","type":"published","date":"2025-12-12T15:59:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87035203,"identity":"6ff73f03-b15c-40d9-a7f3-78d1800e6d3b","added_by":"auto","created_at":"2025-07-18 13:12:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1439540,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart showing the enrollment process for the study cohort. NHIS, National Health Insurance Service.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6794725/v1/db7af105c14cf4155fe0d6ad.png"},{"id":87035207,"identity":"536a22fa-2929-47ed-ac05-f442f3527af8","added_by":"auto","created_at":"2025-07-18 13:12:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1396546,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier Curve of Cumulative Incidence for Diabetic-Related Lower Extremity Amputation by Income Quartile over 10-Year Follow-Up\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-6794725/v1/dd78a2e1d7a1f46ecf3b2eea.png"},{"id":98244039,"identity":"e5c8f2a5-cd53-47de-bc5b-866d33dbec6c","added_by":"auto","created_at":"2025-12-15 16:12:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4438369,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6794725/v1/fffb5ab1-f060-45c0-a8da-3f023752db59.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Footing the Bill: Income Inequality and Disparities in Diabetic Limb Preservation in a Nationwide Population-Based Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes mellitus is a chronic disease with significant global health implications and affects an estimated 463\u0026nbsp;million adults worldwide. (1) One of the most severe complications of diabetes is diabetic foot ulcers, which can lead to lower extremity amputations (LEA) if not properly managed. (2) Income inequality significantly affects health outcomes by limiting access to preventive care, timely diagnosis, and effective treatment, particularly for chronic diseases such as diabetes. (3, 4) The burden of diabetic foot complications is disproportionately borne by low-income individuals who face a reduced quality of life and shorter life expectancy due to limited healthcare access. (5, 6) Without timely intervention, diabetic ulcers can progress to severe infections, tissue necrosis, and ultimately a need for LEA. (7) Recurrences are frequent, further increasing healthcare costs and causing substantial emotional, psychological, and financial strain on patients and their families. (8\u0026ndash;10)\u003c/p\u003e\u003cp\u003eStructural barriers, such as fragmented healthcare systems, limited insurance coverage, and out-of-pocket expenses, create significant obstacles for low-income patients and hinder access to essential preventive services. (11, 12) Socioeconomic disparities in healthcare access often result in delayed care, missed opportunities for early intervention, and suboptimal management of chronic conditions. This perpetuates a cycle of worsening health, increased hospitalizations, and higher rates of amputation in low-income populations. (13, 14) Existing research has highlighted the importance of addressing the social determinants of health, including income inequality, to achieve equitable health outcomes. (15, 16) However, addressing these disparities requires systemic reforms that extend beyond individual behavioral changes. This emphasizes the need for healthcare policy solutions that prioritize vulnerable populations. (17, 18)\u003c/p\u003e\u003cp\u003eThis study employs analysis of data from a nationwide population to explore the association between income inequality and diabetic foot amputation rates. By examining the impact of economic barriers on health outcomes, the study provides insights into the effect of early intervention and preventive care on reducing the need for amputation. Additionally, the study offers policy recommendations aimed at narrowing income-based disparities, enhancing diabetic care, and alleviating the financial burden associated with diabetic foot complications. (19, 20) The findings underscore the importance of addressing structural inequities in healthcare to achieve better outcomes for diabetic patients and prevent unnecessary amputations, particularly among socioeconomically disadvantaged groups. This research contributes to the growing body of evidence highlighting the need for comprehensive approaches to address health disparities rooted in socioeconomic factors.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Population\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study used de-identified data from the Korean National Health Insurance Service (NHIS) database that covers approximately 97% of the Korean population. The study population included individuals diagnosed with type 2 diabetes mellitus (T2DM) between 2009 and 2012. Participants eligible for inclusion were 20 years or older and had no history of prior LEA. Patients with missing data or those who had less than one year of follow-up were excluded from the analysis. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.) The follow-up period spanned a maximum of 10 years and had a primary outcome of the first occurrence of diabetes-related LEA during the study period.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDefinitions of Diabetes and Lower Extremity Amputation\u003c/h3\u003e\n\u003cp\u003eT2DM was defined according to NHIS criteria as at least one annual claim for diabetic medication under ICD-10 codes E11\u0026ndash;E14 or a fasting blood glucose (FBG) level of 126 mg/dL or higher. (21) Diabetes-related LEA was defined as any surgical removal of part of the lower limb due to diabetic complications such as ischemia, infection, or gangrene. The procedures were identified using specific ICD-10 procedure codes (N0571\u0026ndash;N0575, N0562, N0564\u0026ndash;N0566). (22)\u003c/p\u003e\n\u003ch3\u003eIncome Levels\u003c/h3\u003e\n\u003cp\u003eIncome levels were classified into quartiles (Q1\u0026ndash;Q4) based on annual health insurance premiums. Q1 represented the lowest-income group and Q4 was the highest-income group. Income level was the primary exposure variable for assessing disparities in diabetic foot outcomes.\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eThe study incorporated a wide range of covariates to control potential confounding factors. Sociodemographic variables included age and sex. Lifestyle factors included smoking status (non-smoker, ex-smoker, or current smoker), alcohol consumption (none, mild, or heavy), and physical exercise. Clinical variables included diabetes duration (\u0026ge;\u0026thinsp;five years or \u0026lt;\u0026thinsp;five years), use of insulin therapy, and the number of oral antidiabetic medications prescribed (categorized as 0, 1, 2, or \u0026ge;\u0026thinsp;3). Anthropometric measures included body mass index (BMI), waist circumference, and blood pressure (systolic and diastolic). Laboratory data included fasting glucose levels and lipid profiles (total cholesterol, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], and triglycerides). Chronic comorbidities of hypertension, dyslipidemia, and chronic kidney disease (CKD) were included. CKD was defined as an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m\u0026sup2; calculated using the CKD-MRDR equation or at least one claim of ESRD with special designation codes (\u0026lsquo;V001\u0026rsquo;, \u0026lsquo;V003\u0026rsquo;, or \u0026lsquo;V005\u0026rsquo;) before the index date.\u003c/p\u003e\n\u003ch3\u003ePrimary and Secondary Outcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of interest was diabetes-related LEA. Secondary outcomes included the analysis of amputation rates stratified by age, sex, diabetes duration, and comorbidity burden. Subgroup analyses were performed to explore the interactions between income and these clinical characteristics.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eOccurrences of LEA were calculated per 1,000 person-years for each income quartile. Cox proportional hazards regression models were used to evaluate the association between income levels and amputation risk. Four models were constructed to progressively adjust for potential confounders. Model 1 was unadjusted. Model 2 was adjusted for age and sex. Model 3 incorporated additional adjustments for income, lifestyle factors (smoking status, alcohol consumption, and physical activity), BMI, comorbidities (hypertension and dyslipidemia), and eGFR. Model 4 included further adjustments for diabetes duration, insulin use, number of oral antidiabetic medications prescribed, and fasting glucose levels.\u003c/p\u003e\u003cp\u003eSubgroup analyses were conducted to assess potential interaction effects between income level and key variables of age (\u0026lt;\u0026thinsp;65 years versus \u0026ge;\u0026thinsp;65 years), sex, diabetes duration (\u0026ge;\u0026thinsp;five years versus \u0026lt;\u0026thinsp;five years), and CKD status. Kaplan-Meier survival curves were generated to visualize cumulative incidence of LEA by income quartile over time. Interaction terms were tested for statistical significance to determine the possible presence of a differential effect on outcomes across subgroups associated with income level.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eLifestyle Behavior Assessment\u003c/h3\u003e\n\u003cp\u003eLifestyle factors were assessed through standardized questionnaires during routine health examinations. Smoking status was categorized as non-smoker, ex-smoker, or current smoker. Alcohol consumption was classified into three groups: non-drinker, mild drinker (less than 30 grams of alcohol per day), and heavy drinker (30 grams or more per day). Regular physical activity was defined as moderate to vigorous exercise at least three times per week.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of The Catholic Medical Center Office of Human Research Protection Program (SC24ZISE0115). The need for informed consent was waived due to the retrospective nature of the study and the use of de-identified data.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analyzed during the current study are not publicly available due to restrictions from the Korean National Health Insurance Service (NHIS), which prohibits the public release of raw data to protect personal health information, even in de-identified form. However, aggregated data used in the analysis are fully presented in the tables of this article. Additional information may be available from the corresponding author upon reasonable request and with appropriate institutional approvals.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eBaseline Characteristics\u003c/h2\u003e\u003cp\u003eThe study included 2,580,585 individuals diagnosed with diabetes and were categorized into four income quartiles (Q1\u0026ndash;Q4). Key demographic and clinical characteristics varied significantly across income groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.) The highest-income quartile (Q4) demonstrated healthier profiles with lower rates of smoking, hypertension, and CKD and higher levels of physical activity. In contrast, lower-income groups (Q1 and Q2) had higher insulin usage, a longer duration of diabetes, and increased prevalence of CKD.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics of the Diabetic Foot Patients in the NHIS Cohort\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eIncome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e95%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e541177\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e489224\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e655489\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e894695\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, Male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e297930 (55.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e295704 (60.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e407841 (62.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e546866 (61.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e312910 (57.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e262822 (53.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e349994 (53.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e509295 (56.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEx\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87717 (16.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84232 (17.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e125058 (19.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e195011 (21.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e140550 (25.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142170 (29.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e180437 (27.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e190389 (21.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrinking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e329121 (60.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e271743 (55.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e365664 (55.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e524234 (58.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e165326 (30.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e166182 (33.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e221934 (33.86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e289221 (32.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeavy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46730 (8.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51299 (10.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e67891 (10.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e81240 (9.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegular exercise\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e106631 (19.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93684 (19.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e132114 (20.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e207560 (23.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDYS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e234227 (43.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e200591 (41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e277510 (42.34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e407884 (45.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e318154 (58.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e271348 (55.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e370581 (56.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e534822 (59.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCKD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62066 (11.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48588 (9.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69502 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e114961 (12.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsulin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e47857 (8.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39540 (8.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e54543 (8.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e80809 (9.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDM Duration\u0026thinsp;\u0026ge;\u0026thinsp;5yrs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e193065 (35.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e158975 (32.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e224686 (34.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e355884 (39.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of oral antidiabetic drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e230866 (42.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e229572 (46.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e291388 (44.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e343266 (38.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e84386 (15.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70200 (14.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100008 (15.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e158445 (17.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e144041 (26.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e121077 (24.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e169973 (25.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e256884 (28.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81884 (15.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68375 (13.98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e94120 (14.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e136100 (15.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e58.11\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.75\u0026thinsp;\u0026plusmn;\u0026thinsp;12.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56.85\u0026thinsp;\u0026plusmn;\u0026thinsp;12.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.35\u0026thinsp;\u0026plusmn;\u0026thinsp;12.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.11\u0026thinsp;\u0026plusmn;\u0026thinsp;11.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.27\u0026thinsp;\u0026plusmn;\u0026thinsp;12.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66.69\u0026thinsp;\u0026plusmn;\u0026thinsp;12.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e66.29\u0026thinsp;\u0026plusmn;\u0026thinsp;11.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e161.32\u0026thinsp;\u0026plusmn;\u0026thinsp;9.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e162.54\u0026thinsp;\u0026plusmn;\u0026thinsp;9.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e162.84\u0026thinsp;\u0026plusmn;\u0026thinsp;9.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e162.57\u0026thinsp;\u0026plusmn;\u0026thinsp;9.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWaist circumference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e84.97\u0026thinsp;\u0026plusmn;\u0026thinsp;8.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84.97\u0026thinsp;\u0026plusmn;\u0026thinsp;8.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e85.38\u0026thinsp;\u0026plusmn;\u0026thinsp;8.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e85.61\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal cholesterol\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e193.91\u0026thinsp;\u0026plusmn;\u0026thinsp;42.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e194.98\u0026thinsp;\u0026plusmn;\u0026thinsp;42.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e194.21\u0026thinsp;\u0026plusmn;\u0026thinsp;42.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e191.34\u0026thinsp;\u0026plusmn;\u0026thinsp;41.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSBP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e128.87\u0026thinsp;\u0026plusmn;\u0026thinsp;16.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128.91\u0026thinsp;\u0026plusmn;\u0026thinsp;15.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e128.99\u0026thinsp;\u0026plusmn;\u0026thinsp;15.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e128.67\u0026thinsp;\u0026plusmn;\u0026thinsp;15.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDBP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e78.74\u0026thinsp;\u0026plusmn;\u0026thinsp;10.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e79.01\u0026thinsp;\u0026plusmn;\u0026thinsp;10.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e78.36\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDL-C\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109.35\u0026thinsp;\u0026plusmn;\u0026thinsp;39.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e109.76\u0026thinsp;\u0026plusmn;\u0026thinsp;39.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e109.49\u0026thinsp;\u0026plusmn;\u0026thinsp;39.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e108.68\u0026thinsp;\u0026plusmn;\u0026thinsp;38.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHDL-C\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51.91\u0026thinsp;\u0026plusmn;\u0026thinsp;18.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u0026thinsp;\u0026plusmn;\u0026thinsp;18.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.44\u0026thinsp;\u0026plusmn;\u0026thinsp;19.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e50.93\u0026thinsp;\u0026plusmn;\u0026thinsp;18.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFasting glucose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e145.13\u0026thinsp;\u0026plusmn;\u0026thinsp;49.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e146.39\u0026thinsp;\u0026plusmn;\u0026thinsp;48.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e144.36\u0026thinsp;\u0026plusmn;\u0026thinsp;46.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e140.5\u0026thinsp;\u0026plusmn;\u0026thinsp;43.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e24.98\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDM Duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;3.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.38\u0026thinsp;\u0026plusmn;\u0026thinsp;3.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eeGFR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e85.88\u0026thinsp;\u0026plusmn;\u0026thinsp;34.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.42\u0026thinsp;\u0026plusmn;\u0026thinsp;36.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e86.31\u0026thinsp;\u0026plusmn;\u0026thinsp;35.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e83.83\u0026thinsp;\u0026plusmn;\u0026thinsp;36.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTriglyceride *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e141.7 (141.48, 141.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e143.74 (143.51, 143.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e145.01 (144.81, 145.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e139.53 (139.37, 139.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eIncome and Amputation Events\u003c/h2\u003e\u003cp\u003eA total of 9,552 diabetic-related limb amputations occurred during the follow-up period, and the occurrence rate per 1,000 person-years varied inversely with income. Q1, the lowest-income group, exhibited the highest amputation rate (0.64 per 1,000 person-years), while Q4, the highest-income group, showed the lowest rate (0.45 per 1,000 person-years). (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIncome Quartile and Hazard Ratios of the Risk of Amputation in Patients with Diabetic Foot\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEvent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDuration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIR per 1,000\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eModel 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eModel 4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e541177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2419\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3775932.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e489224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1956\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3460213.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.881 (0.83, 0.935)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.926 (0.873, 0.983)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.933 (0.879, 0.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.944 (0.89, 1.002)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e655489\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2336\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4645724.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.783 (0.74, 0.829)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.785 (0.742, 0.831)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.804 (0.76, 0.851)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.815 (0.77, 0.863)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e894695\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2841\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6257787.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.709 (0.671, 0.748)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.629 (0.596, 0.664)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.662 (0.627, 0.699)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.672 (0.636, 0.71)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eModel 1: Non-adjusted\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eModel 2: Adjusted for Age and Sex\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eModel 3: Model 2\u0026thinsp;+\u0026thinsp;Income Status, Smoking, Drinking, Regular exercise, DYS, HP, BMI, eGFR\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eModel 4: Model 3\u0026thinsp;+\u0026thinsp;DM Duration\u0026thinsp;\u0026ge;\u0026thinsp;5 yrs, Number of oral antidiabetic drugs, Insulin, Fasting glucose\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn model 4, \u003cb\u003ewhich incorporated full adjustments for clinical and behavioral covariates, the hazard ratio for Q4 was 0.672 (95% CI: 0.636\u0026ndash;0.71), indicating a statistically significant lower amputation risk compared to Q1.\u003c/b\u003e This trend emphasizes the protective effect of higher income levels on diabetic limb preservation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStratified Analysis: Age, Sex, and Diabetes Duration\u003c/h2\u003e\u003cp\u003eIn subgroup analyses, the protective association between higher income and limb preservation was most pronounced among individuals aged\u0026thinsp;\u0026lt;\u0026thinsp;65 years (p for interaction\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.) The IR in Q4 for individuals younger than 65 years was 0.31 per 1,000 person-years compared to 0.57 in Q1 (HR: 0.586; 95% CI: 0.543\u0026ndash;0.632). Among individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years, the protective effect was weaker (Q4 HR: 0.787; 95% CI: 0.725\u0026ndash;0.854).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHazard Ratio for Risk of Amputation in Diabetic Foot according to Age, Sex, Diabetes Duration, and Number of Oral Antidiabetic Drugs, Insulin use, and CKD Stratified by Income Quartile\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubgroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eIncome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEvent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDuration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eIR per 1,000\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eModel 4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep for inter\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e377134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2693813.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e370859\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1299\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2681374.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.909 (0.844, 0.978)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e468885\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3402450.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.737 (0.685, 0.793)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e537473\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3877794.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.586 (0.543, 0.632)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e164043\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e883\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1082119.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e118365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e657\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e778839.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.996 (0.9, 1.102)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e186604\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1243274.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.948 (0.866, 1.037)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e357222\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1623\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2379992.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.787 (0.725, 0.854)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, Male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e297930\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1844\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2054929.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.4667\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e295704\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1498\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2075668.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.923 (0.862, 0.988)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e407841\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1784\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2866556.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.797 (0.747, 0.851)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e546866\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3785738.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.663 (0.622, 0.706)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, Female\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e243247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e575\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1721003.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e193520\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e458\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1384545.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.018 (0.9, 1.151)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e247648\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e552\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1779167.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.875 (0.778, 0.983)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e347829\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e707\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2472048.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.702 (0.629, 0.784)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDM Duration\u0026thinsp;\u0026lt;\u0026thinsp;5 yrs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e348112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e766\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2493443.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.5293\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e330249\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e642\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2391384.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.911 (0.821, 1.012)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e430803\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e708\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3126077.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.768 (0.693, 0.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e538811\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e772\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3865017.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.664 (0.601, 0.734)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDM Duration\u0026thinsp;\u0026ge;\u0026thinsp;5 yrs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e193065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1653\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1282489.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e158975\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1068829.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.96 (0.893, 1.032)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e224686\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1628\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1519646.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.837 (0.782, 0.897)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e355884\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2392769.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.676 (0.634, 0.722)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNo oral antidiabetic drug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e230866\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e616\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1676599.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.3574\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e229572\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e511\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1682035.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.891 (0.792, 1.002)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e291388\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e585\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2139686.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.792 (0.707, 0.887)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e343266\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e661\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2488245.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.695 (0.623, 0.776)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOne oral antidiabetic drug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84386\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e354\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e573955.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e482766.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.964 (0.823, 1.129)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e373\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e691275.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.89 (0.77, 1.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e158445\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e514\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1089721.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.75 (0.655, 0.859)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTwo oral antidiabetic drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e144041\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e759\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e976426.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e121077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e596\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e830951.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.935 (0.84, 1.041)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e169973\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e705\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1173075.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.782 (0.706, 0.866)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e256884\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e886\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1758037.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.631 (0.573, 0.696)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMore than three oral antidiabetic drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81884\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e690\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e548951.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e575\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e464460.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.995 (0.891, 1.112)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e673\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e641687.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.834 (0.75, 0.928)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e136100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e780\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e921782.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.658 (0.594, 0.729)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eInsulin (-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e493320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1581\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3468454.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.3717\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e449684\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1299\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3203058.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.947 (0.88, 1.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e600946\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1523\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4287218.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.808 (0.753, 0.867)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e813886\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1790\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5732309.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.652 (0.609, 0.698)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eInsulin (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47857\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e838\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e307478.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39540\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e657\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e257154.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.938 (0.847, 1.039)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54543\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e813\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e358505.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.828 (0.752, 0.912)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80809\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e525477.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.709 (0.647, 0.777)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCKD (-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e479111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1758\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3369149.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.7118\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e440636\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1449\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3137160.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.937 (0.874, 1.005)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e585987\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1688\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4179423.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.803 (0.751, 0.858)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e779734\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1950\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5493518.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.662 (0.62, 0.706)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCKD (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e661\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e406783.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48588\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e507\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e323052.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.951 (0.847, 1.067)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69502\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e648\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e466301.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.847 (0.76, 0.944)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e114961\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e891\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e764268.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.704 (0.637, 0.779)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn contrast, the differences in amputation risk associated with income were not statistically significant for other subgroups. These include sex (p for interaction\u0026thinsp;=\u0026thinsp;0.4667), diabetes duration (p for interaction\u0026thinsp;=\u0026thinsp;0.5293), use of oral medications (p for interaction\u0026thinsp;=\u0026thinsp;0.3574), insulin use (p for interaction\u0026thinsp;=\u0026thinsp;0.3717), and chronic kidney disease (CKD) status (p for interaction\u0026thinsp;=\u0026thinsp;0.7118).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eCumulative Incidence of Amputation by Income Group\u003c/h2\u003e\u003cp\u003e\u003cb\u003eThe Kaplan\u0026ndash;Meier\u003c/b\u003e plot (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.) \u003cb\u003ea persistently lower cumulative incidence of LEA among higher-income groups over the 10-year follow-up, supporting the inverse association observed in hazard models\u003c/b\u003e. Q1 consistently showed the highest occurrence rate across all time points, emphasizing the persistent impact of low socioeconomic status on poor outcomes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eInterpretation\u003c/h2\u003e\u003cp\u003eOur findings indicate a clear socioeconomic gradient in diabetic limb preservation, with higher-income groups experiencing significantly fewer amputations. This association is particularly dramatic among younger individuals and those with longer diabetes duration. The results suggest that targeted interventions to improve access to care and resources among lower-income groups substantially reduce amputation rates and enhances quality of life in diabetic populations.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis nationwide population-based study \u003cb\u003edemonstrated an observed association\u003c/b\u003e between income inequality and disparities in diabetic limb preservation, with higher income levels correlating with better limb preservation outcomes. This \u003cb\u003eobserved trend appeared more\u003c/b\u003e pronounced among individuals younger than 65 years, \u003cb\u003esuggesting a possible\u003c/b\u003e increased vulnerability of younger, lower-income diabetic patients to limb loss. These findings \u003cb\u003esuggest a potential association\u003c/b\u003e between socioeconomic factors and \u003cb\u003ediabetic limb outcomes, as demonstrated by differences in adjusted hazard ratios across income groups\u003c/b\u003e. (23\u0026ndash;25)\u003c/p\u003e\u003cp\u003eThe inverse relationship between income levels and diabetic limb amputation rates observed in our study aligns with previous research on health disparities in diabetes care. (13, 26, 27) However, the magnitude of this disparity, especially among younger patients, adds a new dimension to our understanding. (14, 28, 29) This age-specific effect suggests that the impact of socioeconomic factors on health outcomes may be more profound during the working years, potentially due to competing priorities between work and health management. (30, 31)\u003c/p\u003e\u003cp\u003eThese disparities may have several causes. Lower-income individuals often face barriers to preventive care, including limited transportation options, inability to take time off work, and lack of health insurance or high out-of-pocket costs. (2, 32, 33) These factors can lead to delayed diagnoses and suboptimal management of diabetes and its complications. (34, 35) Additionally, lower health literacy and reduced access to diabetes education programs may contribute to poorer self-management practices among lower-income groups. (36, 37) The socioeconomic gradient in health behaviors is another crucial factor. (9, 19) Lower-income individuals may have limited access to healthy food options, safe environments for physical activity, and resources for stress management. These are all critical components of diabetes management. (10, 38, 39) The cumulative effect of these disadvantages over time may explain the more pronounced disparities observed in younger age groups. (40, 41)\u003c/p\u003e\u003cp\u003eThis study\u0026rsquo;s findings have significant clinical implications. These results highlight the need for targeted interventions and intensified care for lower-income diabetic patients, particularly those younger than 65 years. (7, 42) Clinicians should be aware of the heightened risk in this population and should perform more frequent follow-ups, comprehensive foot examinations, and earlier interventions to prevent complications. (43\u0026ndash;45)\u003c/p\u003e\u003cp\u003eDiabetic foot ulcers and their progression to amputation carry a significant risk of mortality, primarily due to complications such as infections, tissue necrosis, and cardiovascular disease. (46) Five-year mortality rates for patients with diabetic ulcers range between 42\u0026ndash;44%, and this risk increases to 68\u0026ndash;79% following LEA. (22, 47, 48) The high mortality after amputation reflects not only the physical burden of losing a limb, but also the systemic health decline associated with severe diabetes-related complications. (49) Patients with amputations frequently experience worsening cardiovascular conditions, infections, and other metabolic complications, further contributing to high mortality rates. (50, 51)\u003c/p\u003e\u003cp\u003eThese high mortality rates for patients with diabetic ulcers escalate significantly following LEA, underscoring the urgency of prevention and early intervention. (52, 53) From a policy perspective, our results stress the need for systemic changes to address health inequalities. (48, 54, 55) Proposed initiatives include expanding access to affordable healthcare, implementing community-based diabetes prevention programs in low-income areas, and developing policies to improve the social determinants of health. (52, 53, 55, 56) Addressing both socioeconomic barriers and clinical management is essential to reduce LEA and associated mortality rates. Effective policies that improve healthcare access such as subsidized diabetic care and preventive services can mitigate complications and lower mortality rates among vulnerable populations. Integrating regular screenings, patient education, and community-based interventions can further enhance outcomes for socioeconomically disadvantaged groups, and addressing disparities in healthcare access is crucial not only for improving survival rates, but also for advancing overall health equity.\u003c/p\u003e\u003cp\u003eThe pronounced disparities in amputation risk among patients younger than 65 years reflect the profound impact of socioeconomic barriers on health outcomes during working-age years. (57, 58) In this age group, physical function is essential not only for individual well-being, but also for workforce participation and national productivity. (59) The higher amputation rates observed among low-income individuals in this demographic group suggest that economic barriers impede access to preventive care and timely treatment. This results in more severe complications such as infections, tissue necrosis, and LEA. (60, 61) As these younger patients are typically active in the workforce, the rise in disability from diabetic complications can lead to a decline in national productivity and increase in healthcare costs. Socioeconomic inequality is exacerbated by limiting career progression opportunities and income stability. (47, 49)\u003c/p\u003e\u003cp\u003eTo address these disparities and improve outcomes, it is essential to strengthen workplace health programs and national screening efforts. (62) Enhanced participation in regular health examinations and national diabetes screening programs will assist in detection of early signs of diabetic foot complications in younger populations. (63) Expanding access to preventive services through workplace wellness programs that offer routine foot screenings and education can promote early intervention, especially for workers in high-risk or physically demanding jobs. (64, 65) National health policies should prioritize preventive interventions in younger patients. Reducing amputations in this age group has long-term benefits for both individual health and national productivity. (50) By minimizing disabilities, these policies will not only reduce healthcare costs, but also preserve workforce capacity, thereby promoting economic sustainability. (48, 51)\u003c/p\u003e\u003cp\u003eWorkplace wellness programs and policies supporting diabetes management for working-age adults could be particularly beneficial. (56, 66) The success of such programs is evident in studies showing reduced rates of hospitalization, lengths of hospital stay, and lower extremity amputations after implementation. (67, 68)\u003c/p\u003e\u003cp\u003eThe relationship between income and chronic disease management has been extensively studied in various healthcare systems worldwide. In the United States, a market-based system, research consistently shows that low-income individuals experience poorer health outcomes due to limited access to preventive care, fragmented insurance coverage, and high out-of-pocket costs. (3, 69) These economic barriers are linked to delayed diagnoses, poor disease management, and increased complications, particularly for chronic conditions like diabetes. (70, 71)\u003c/p\u003e\u003cp\u003eIn contrast, South Korea offers universal health coverage through the National Health Insurance Service (NHIS). However, our study reveals persistent income-related disparities in amputation risks, particularly among younger individuals and those with long-standing diabetes. This suggests that, while basic healthcare services are accessible to all, non-medical barriers such as financial stress, time constraints, and knowledge gaps continue to impact health outcomes. (72, 73) Another key difference lies in workplace dynamics and access to employer-based health programs. In South Korea, younger individuals in low-income groups are often engaged in physically demanding jobs with limited flexibility that may hinder their ability to seek timely medical care. (74) This differs from the United States context in which healthcare access is often tied to employment benefits, but coverage remains uneven across socioeconomic groups. (75) Moreover, cultural factors in Korea, such as a lack of emphasis on preventive care among younger adults, may further exacerbate the disparities in diabetic outcomes observed in this study. (76\u0026ndash;78)\u003c/p\u003e\u003cp\u003eEuropean countries present a third model. These countries have varying degrees of universal healthcare and social support systems. For instance, the United Kingdom's National Health Service (NHS) provides comprehensive coverage; but socioeconomic disparities in diabetic outcomes persist, albeit to a lesser extent than in more market-driven systems. (79, 80) Sweden, with its strong emphasis on equity in healthcare, has shown smaller income-related disparities in diabetes management, Sweden still faces challenges in reaching certain vulnerable populations. (81, 82) These findings across different healthcare systems suggest that structural interventions beyond universal coverage are necessary to address socioeconomic disparities in diabetic care globally. (20, 83) Policies that target both financial and non-financial barriers are critical to closing the gap. For all countries, regardless of healthcare system structure, strengthening workplace health programs, ensuring flexible healthcare access for working-age adults, and providing targeted health education would mitigate the impact of income disparities, especially in younger populations at higher risk of complications. (19, 84) Additionally, community-based screening programs and subsidized preventive care for low-income patients would be universally beneficial in reducing diabetic complications and associated healthcare costs. (10)\u003c/p\u003e\u003cp\u003eThe strengths of our study lie in its nationwide scope and the novel insights gained from age-stratified analyses. (67, 68, 85) However, we acknowledge several limitations. First, our dataset lacked detailed clinical information that could have provided better insights into the progression of diabetic foot complications. (85, 86) The use of administrative claims data from the NHIS inherently restricts access to detailed clinical variables such as ulcer severity, wound classification, vascular imaging, or ambulatory function. These unmeasured variables may have influenced the outcomes but could not be controlled in our models. Second, income level was approximated using health insurance premium quartiles, which may not fully reflect individual socioeconomic status, particularly for dependents or non-wage earners. Third, residual confounding cannot be ruled out due to the absence of certain behavioral or contextual factors\u0026mdash;such as education level, health literacy, healthcare-seeking behaviors, and quality of diabetic foot care\u0026mdash;all of which may contribute to disparities in outcomes. Fourth, due to the retrospective observational design, the results demonstrate associations rather than causal relationships. (2, 87) Fifth, generalizability to populations outside Korea may be limited due to healthcare system differences. These factors may have introduced bias or affected the robustness of our findings, warranting caution in the interpretation of results.\u003c/p\u003e\u003cp\u003eFuture research should focus on longitudinal studies to better understand the temporal relationship among income, age, and diabetic limb preservation. (43, 88) Intervention studies targeting low-income, younger diabetic patients are needed to evaluate the effectiveness of tailored prevention strategies. (89, 90) Furthermore, investigating the interactions between income and other socioeconomic factors, such as education level and occupation type, could provide a more comprehensive understanding of health disparities in diabetes care. (91, 92)\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides empirical evidence on the impact of income inequality on healthcare equity and diabetic limb preservation rates. Income inequality \u003cb\u003ewas observed to be\u003c/b\u003e strongly associated with disparities in diabetic foot outcomes, with higher income linked amputation to improved limb preservation, especially among younger individuals. \u003cb\u003eThese findings suggest a need for\u003c/b\u003e targeted interventions to improve healthcare access for low-income patients, emphasizing the importance of workplace and national screening programs, leveraging digital health technologies, and expanding insurance coverage to address these disparities. These interventions \u003cb\u003emay help\u003c/b\u003e improve patients\u0026rsquo; quality of life and reduce amputation rates and \u003cb\u003ecould contribute to alleviating\u003c/b\u003e the individual and societal burden associated with diabetic foot complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflicts of interest\u003c/h2\u003e\u003cp\u003eNone to declare.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eORCID\u003c/h2\u003e\u003cp\u003eYoon Jae Lee \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-8376-9135\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-8376-9135\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eKyung-Do Han \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-6096-1263\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-6096-1263\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eJun Hyeok Kim \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0003-4657-2090\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0003-4657-2090\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLee was responsible for drafting the manuscript. Han contributed by organizing the dataset and conducting statistical analyses. Kim conceived the study, acquired funding, and supervised the completion of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgment\u003c/h2\u003e\u003cp\u003eThis research was supported by a grant from the Institute of Clinical Medicine Research in Yeouido St. Mary\u0026rsquo;s Hospital, The Catholic University of Korea and the Catholic Medical Center Research Foundation made in the program year of 2025.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analyzed during the current study were obtained from the Korean National Health Insurance Service (NHIS) under institutional data use agreements. Due to strict privacy and regulatory restrictions, the raw data cannot be shared publicly or deposited in a repository. However, the aggregated data that support the findings of this study are fully presented in the tables within the manuscript. Additional summary information may be available from the corresponding author upon reasonable request and with NHIS approval.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSaeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9(th) edition. Diabetes Res Clin Pract. 2019;157:107843. Epub 20190910. doi: 10.1016/j.diabres.2019.107843. PubMed PMID: 31518657.\u003c/li\u003e\n\u003cli\u003eArmstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med. 2017;376(24):2367-75. doi: 10.1056/NEJMra1615439. PubMed PMID: 28614678.\u003c/li\u003e\n\u003cli\u003eWalker RJ, Smalls BL, Campbell JA, Strom Williams JL, Egede LE. Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review. Endocrine. 2014;47(1):29-48. Epub 20140215. doi: 10.1007/s12020-014-0195-0. PubMed PMID: 24532079; PubMed Central PMCID: PMC7029167.\u003c/li\u003e\n\u003cli\u003eSecrest AM, Costacou T, Gutelius B, Miller RG, Songer TJ, Orchard TJ. Associations between socioeconomic status and major complications in type 1 diabetes: the Pittsburgh epidemiology of diabetes complication (EDC) Study. Ann Epidemiol. 2011;21(5):374-81. doi: 10.1016/j.annepidem.2011.02.007. PubMed PMID: 21458731; PubMed Central PMCID: PMC3079455.\u003c/li\u003e\n\u003cli\u003eStevens CD, Schriger DL, Raffetto B, Davis AC, Zingmond D, Roby DH. Geographic clustering of diabetic lower-extremity amputations in low-income regions of California. Health Aff (Millwood). 2014;33(8):1383-90. doi: 10.1377/hlthaff.2014.0148. PubMed PMID: 25092840; PubMed Central PMCID: PMC4242846.\u003c/li\u003e\n\u003cli\u003eMargolis DJ, Hoffstad O, Nafash J, Leonard CE, Freeman CP, Hennessy S, et al. Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes. Diabetes Care. 2011;34(11):2363-7. Epub 20110920. doi: 10.2337/dc11-0807. PubMed PMID: 21933906; PubMed Central PMCID: PMC3198303.\u003c/li\u003e\n\u003cli\u003eLavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288-93. doi: 10.2337/dc05-2425. PubMed PMID: 16732010.\u003c/li\u003e\n\u003cli\u003eBoulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-24. doi: 10.1016/S0140-6736(05)67698-2. PubMed PMID: 16291066.\u003c/li\u003e\n\u003cli\u003eKerr M, Rayman G, Jeffcoate WJ. Cost of diabetic foot disease to the National Health Service in England. Diabet Med. 2014;31(12):1498-504. Epub 20140801. doi: 10.1111/dme.12545. PubMed PMID: 24984759.\u003c/li\u003e\n\u003cli\u003eLazzarini PA, Hurn SE, Fernando ME, Jen SD, Kuys SS, Kamp MC, et al. Prevalence of foot disease and risk factors in general inpatient populations: a systematic review and meta-analysis. BMJ Open. 2015;5(11):e008544. Epub 20151123. doi: 10.1136/bmjopen-2015-008544. PubMed PMID: 26597864; PubMed Central PMCID: PMC4663442.\u003c/li\u003e\n\u003cli\u003eKominski GF, ProQuest, Kominski GF. Changing the U.S. health care system : key issues in health services policy and management. Fourth edition. ed. San Francisco: Jossey-Bass Wairīpaburisshingujapan; 2014.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"12\"\u003e\n\u003cli\u003ePeek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev. 2007;64(5 Suppl):101S-56S. doi: 10.1177/1077558707305409. PubMed PMID: 17881626; PubMed Central PMCID: PMC2367214.\u003c/li\u003e\n\u003cli\u003eHolman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia. 2012;55(7):1919-25. Epub 20120308. doi: 10.1007/s00125-012-2468-6. PubMed PMID: 22398645.\u003c/li\u003e\n\u003cli\u003eWrobel JS, Mayfield JA, Reiber GE. Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population. Diabetes Care. 2001;24(5):860-4. doi: 10.2337/diacare.24.5.860. PubMed PMID: 11347744.\u003c/li\u003e\n\u003cli\u003eHill J, Nielsen M, Fox MH. Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill. Perm J. 2013;17(2):67-72. doi: 10.7812/TPP/12-099. PubMed PMID: 23704847; PubMed Central PMCID: PMC3662286.\u003c/li\u003e\n\u003cli\u003eMarmot M, Allen J, Bell R, Bloomer E, Goldblatt P, Consortium for the European Review of Social Determinants of H, et al. WHO European review of social determinants of health and the health divide. Lancet. 2012;380(9846):1011-29. Epub 20120908. doi: 10.1016/S0140-6736(12)61228-8. PubMed PMID: 22964159.\u003c/li\u003e\n\u003cli\u003eAdler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood). 2002;21(2):60-76. doi: 10.1377/hlthaff.21.2.60. PubMed PMID: 11900187.\u003c/li\u003e\n\u003cli\u003eMarmot M, Friel S, Bell R, Houweling TA, Taylor S, Commission on Social Determinants of H. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-9. doi: 10.1016/S0140-6736(08)61690-6. PubMed PMID: 18994664.\u003c/li\u003e\n\u003cli\u003ePaisey RB, Abbott A, Levenson R, Harrington A, Browne D, Moore J, et al. Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England. Diabet Med. 2018;35(1):53-62. Epub 20171011. doi: 10.1111/dme.13512. PubMed PMID: 29023974; PubMed Central PMCID: PMC5765400.\u003c/li\u003e\n\u003cli\u003eJeffcoate WJ, Vileikyte L, Boyko EJ, Armstrong DG, Boulton AJM. Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. Diabetes Care. 2018;41(4):645-52. doi: 10.2337/dc17-1836. PubMed PMID: 29559450.\u003c/li\u003e\n\u003cli\u003eBaek JH, Park YM, Han KD, Moon MK, Choi JH, Ko SH. Comparison of Operational Definition of Type 2 Diabetes Mellitus Based on Data from Korean National Health Insurance Service and Korea National Health and Nutrition Examination Survey. Diabetes Metab J. 2023;47(2):201-10. Epub 20230208. doi: 10.4093/dmj.2022.0375. PubMed PMID: 36750233; PubMed Central PMCID: PMC10040628.\u003c/li\u003e\n\u003cli\u003eLee YJ, Han KD, Kim JH. Association among Current Smoking, Alcohol Consumption, Regular Exercise, and Lower Extremity Amputation in Patients with Diabetic Foot: Nationwide Population-Based Study. Endocrinol Metab (Seoul). 2022;37(5):770-80. Epub 20221012. doi: 10.3803/EnM.2022.1519. PubMed PMID: 36222086; PubMed Central PMCID: PMC9633221.\u003c/li\u003e\n\u003cli\u003eZhang P, Lu J, Jing Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017;49(2):106-16.\u003c/li\u003e\n\u003cli\u003eMonteiro-Soares M, Boyko EJ, Ribeiro I. Predictive factors for diabetic foot ulceration: a systematic review. Diabetes Metab Res Rev. 2012;28(7):574-600.\u003c/li\u003e\n\u003cli\u003eStevens CD, Schriger DL, Raffetto B. Geographic clustering of diabetic lower-extremity amputations in low-income regions of California. Health Aff (Millwood). 2014;33(8):1383-90.\u003c/li\u003e\n\u003cli\u003eMargolis DJ, Hoffstad O, Nafash J. Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes. Diabetes Care. 2011;34(11):2363-7.\u003c/li\u003e\n\u003cli\u003eNather A, Bee CS, Huak CY. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications. 2008;22(2):77-82.\u003c/li\u003e\n\u003cli\u003eGregg EW, Li Y, Wang J. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med. 2014;370(16):1514-23.\u003c/li\u003e\n\u003cli\u003eGeiss LS, Li Y, Hora I. Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care. 2019;42(1):50-4.\u003c/li\u003e\n\u003cli\u003eNarres M, Kvitkina T, Claessen H. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoS One. 2017;12(8):e0182081.\u003c/li\u003e\n\u003cli\u003eJeffcoate WJ, Vileikyte L, Boyko EJ. Current challenges and opportunities in the prevention and management of diabetic foot ulcers. Diabetes Care. 2018;41(4):645-52.\u003c/li\u003e\n\u003cli\u003eBoyko EJ, Seelig AD, Ahroni JH. Limb- and person-level risk factors for lower-limb amputation in the prospective Seattle Diabetic Foot Study. Diabetes Care. 2018;41(4):891-8.\u003c/li\u003e\n\u003cli\u003ePrompers L, Huijberts M, Apelqvist J. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50(1):18-25.\u003c/li\u003e\n\u003cli\u003eBoulton AJ, Vileikyte L, Ragnarson-Tennvall G. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-24.\u003c/li\u003e\n\u003cli\u003eLavery LA, Armstrong DG, Wunderlich RP. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288-93.\u003c/li\u003e\n\u003cli\u003eHicks CW, Selvarajah S, Mathioudakis N. Trends and determinants of costs associated with the inpatient care of diabetic foot ulcers. J Vasc Surg. 2014;60(5):1247-54.e2.\u003c/li\u003e\n\u003cli\u003eSkrepnek GH, Mills JL, Sr., Lavery LA. Health care service and outcomes among an estimated 6.7 million ambulatory care diabetic foot cases in the U.S. Diabetes Care. 2017;40(7):936-42.\u003c/li\u003e\n\u003cli\u003eLazzarini PA, Hurn SE, Kuys SS. Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study. BMJ Open. 2016;6(6):e010811.\u003c/li\u003e\n\u003cli\u003eJeffcoate WJ, Chipchase SY, Ince P. Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. Diabetes Care. 2006;29(8):1784-91.\u003c/li\u003e\n\u003cli\u003ePrompers L, Schaper N, Apelqvist J. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008;51(5):747-54.\u003c/li\u003e\n\u003cli\u003eReiber GE, Vileikyte L, Boyko EJ. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999;22(1):157-62.\u003c/li\u003e\n\u003cli\u003eBoyko EJ, Ahroni JH, Stensel V. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care. 1999;22(7):1036-42.\u003c/li\u003e\n\u003cli\u003eLazzarini PA, Pacella RE, Armstrong DG. Diabetes-related lower-extremity complications are a leading cause of the global burden of disability. Diabet Med. 2018;35(9):1297-9.\u003c/li\u003e\n\u003cli\u003eBoulton AJM. The pathway to foot ulceration in diabetes. Med Clin North Am. 2013;97(5):775-90.\u003c/li\u003e\n\u003cli\u003eApelqvist J, Larsson J, Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med. 1993;233(6):485-91.\u003c/li\u003e\n\u003cli\u003eArmstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic Foot Ulcers: A Review. JAMA. 2023;330(1):62-75.\u003c/li\u003e\n\u003cli\u003eJupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J. 2016;13(5):892-903.\u003c/li\u003e\n\u003cli\u003eMoulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26(2):491-4.\u003c/li\u003e\n\u003cli\u003eChammas NK, Hill RL, Edmonds ME. Increased mortality in diabetic foot ulcer patients: the significance of ulcer type. J Diabetes Res. 2016;2016:2879809.\u003c/li\u003e\n\u003cli\u003eHoffmann M, Kujath P, Flemming A, Pro\u0026szlig; M, Begum N, Zimmermann M. Survival of diabetes patients with major amputation is comparable to malignant disease. Diab Vasc Dis Res. 2015;12(4):265-71.\u003c/li\u003e\n\u003cli\u003eMorbach S, Furchert H, Gr\u0026ouml;blinghoff U, Hoffmeier H, Kersten K, Klauke GT. Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care. 2012;35(10):2021-7.\u003c/li\u003e\n\u003cli\u003eMargolis DJ, Malay DS, Hoffstad OJ. Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: Data Points #2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011.\u003c/li\u003e\n\u003cli\u003ePrompers L, Huijberts M, Schaper N. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia. 2008;51(10):1826-34.\u003c/li\u003e\n\u003cli\u003eBrownrigg JR, Davey J, Holt PJ. The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis. Diabetologia. 2012;55(11):2906-12.\u003c/li\u003e\n\u003cli\u003eKerr M. Foot care for people with diabetes: the economic case for change. 2012.\u003c/li\u003e\n\u003cli\u003eArmstrong DG, Wrobel J, Robbins JM. Guest Editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286-7.\u003c/li\u003e\n\u003cli\u003eHolman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia. 2012;55(7):1919-25.\u003c/li\u003e\n\u003cli\u003eFakorede FA, Fakorede A, Hennebry TA. Reducing Disparities in Diabetic Amputations. NIDDK [Internet]. 2021.\u003c/li\u003e\n\u003cli\u003eArmstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13:16.\u003c/li\u003e\n\u003cli\u003eBali V, Yermilov I, Koyama A, Legorreta AP. Secondary prevention of diabetes through workplace health screening. Occup Med (Lond). 2018;68(9):610-6.\u003c/li\u003e\n\u003cli\u003eRagnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis. 2004;39 Suppl 2:S132-S9.\u003c/li\u003e\n\u003cli\u003eHafez D, Fedewa A, Moran M, O'Brien M, Ackermann R, Kullgren JT. Workplace Interventions to Prevent Type 2 Diabetes Mellitus: a Narrative Review. Curr Diab Rep. 2017;17(12):121.\u003c/li\u003e\n\u003cli\u003ePu J, Chewning B, Johnson HM, Vanness DJ, Young HN, Kreling DH. Health Behavior Change After Blood Pressure Feedback. PLoS One. 2015;10(10):e0139644.\u003c/li\u003e\n\u003cli\u003eBrown SA, Garc\u0026iacute;a AA, Zu\u0026ntilde;iga JA, Lewis KA. Effectiveness of workplace diabetes prevention programs: A systematic review of the evidence. Patient Educ Couns. 2018;101(6):1036-50.\u003c/li\u003e\n\u003cli\u003eConn VS, Hafdahl AR, Mehr DR, LeMaster JW, Brown SA, Nielsen PJ. Metabolic effects of interventions to increase exercise in adults with type 2 diabetes. Diabetologia. 2007;50(5):913-21.\u003c/li\u003e\n\u003cli\u003eBarshes NR, Sigireddi M, Wrobel JS. The system of care for the diabetic foot: objectives, outcomes, and opportunities. Diabet Foot Ankle. 2013;4.\u003c/li\u003e\n\u003cli\u003eLipsky BA, Berendt AR, Cornia PB. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e73.\u003c/li\u003e\n\u003cli\u003eHinchliffe RJ, Brownrigg JR, Andros G. Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. Diabetes Metab Res Rev. 2016;32 Suppl 1:136-44.\u003c/li\u003e\n\u003cli\u003eSecrest AM, Costacou T, Gutelius B, Miller RG, Songer TJ, Orchard TJ. Associations between socioeconomic status and major complications in type 1 diabetes: the Pittsburgh epidemiology of diabetes complication (EDC) Study. Ann Epidemiol. 2011;21(5):374-81.\u003c/li\u003e\n\u003cli\u003eBrown AF, Ettner SL, Piette J, Weinberger M, Gregg E, Shapiro MF. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev. 2004;26:63-77.\u003c/li\u003e\n\u003cli\u003eBooth GL, Hux JE. Relationship between avoidable hospitalizations for diabetes mellitus and income level. Arch Intern Med. 2003;163(1):101-6.\u003c/li\u003e\n\u003cli\u003eKim D, Kang S, Kim J, Kim H, Min H, Lee H. Socioeconomic status and the prevalence of type 2 diabetes in South Korean adults: a population-based cross-sectional study. J Epidemiol. 2020;30(12):550-8.\u003c/li\u003e\n\u003cli\u003eHa R, Kim D, Choi J, Jung-Choi K. A national pilot program for chronic diseases and health inequalities in South Korea. BMC Public Health. 2021;21(1):1142.\u003c/li\u003e\n\u003cli\u003eKim D. Socioeconomic status and the prevalence of type 2 diabetes in South Korean adults: a population-based cross-sectional study. J Epidemiol. 2020;30(12):550-8.\u003c/li\u003e\n\u003cli\u003eWalker RJ. Understanding the influence of psychological and socioeconomic factors on diabetes self-care using structured equation modeling. Patient Educ Couns. 2015;98(1):34-40.\u003c/li\u003e\n\u003cli\u003eCho NH. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018;138:271-81.\u003c/li\u003e\n\u003cli\u003eKang H. Diabetes management and self-care education for hospitalized patients with diabetes in Korea. Diabetes Metab J. 2018;42(5):425-36.\u003c/li\u003e\n\u003cli\u003eKim KS. Management of type 2 diabetes mellitus in older adults. Diabetes Metab J. 2012;36(5):336-44.\u003c/li\u003e\n\u003cli\u003eGrintsova O, Maier W, Mielck A. Inequalities in health care among patients with type 2 diabetes by individual socio-economic status (SES) and regional deprivation: a systematic literature review. Int J Equity Health. 2014;13:43.\u003c/li\u003e\n\u003cli\u003eHippisley-Cox J, O'Hanlon S, Coupland C. Association of deprivation, ethnicity, and sex with quality indicators for diabetes: population based survey of 53,000 patients in primary care. BMJ. 2004;329(7477):1267-9.\u003c/li\u003e\n\u003cli\u003eAgardh E, Allebeck P, Hallqvist J, Moradi T, Sidorchuk A. Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. Int J Epidemiol. 2011;40(3):804-18.\u003c/li\u003e\n\u003cli\u003eRawshani A, Svensson AM, Rosengren A, Eliasson B, Gudbj\u0026ouml;rnsdottir S. Impact of socioeconomic status on cardiovascular disease and mortality in 24,947 individuals with type 1 diabetes. Diabetes Care. 2015;38(8):1518-27.\u003c/li\u003e\n\u003cli\u003eMarmot M, Friel S, Bell R, Houweling TA, Taylor S, Commission on Social Determinants of H. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-9.\u003c/li\u003e\n\u003cli\u003ePatout CA, Jr., Birke JA, Horswell R, Williams D, Cerise FP. Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Diabetes Care. 2000;23(9):1339-42.\u003c/li\u003e\n\u003cli\u003eHingorani A, LaMuraglia GM, Henke P. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016;63 Suppl 2:3S-21S.\u003c/li\u003e\n\u003cli\u003eSchaper NC, Van Netten JJ, Apelqvist J. Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes Metab Res Rev. 2016;32 Suppl 1:7-15.\u003c/li\u003e\n\u003cli\u003eJeffcoate WJ, Bus SA, Game FL. Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: required details and markers of good quality. Lancet Diabetes Endocrinol. 2016;4(9):781-93.\u003c/li\u003e\n\u003cli\u003eBoulton AJM, Armstrong DG, Kirsner RS. Diagnosis and Management of Diabetic Foot Complications. Arlington (VA): American Diabetes Association; 2018.\u003c/li\u003e\n\u003cli\u003eRayman G, Vas PR, Baker N. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011;34(7):1517-8.\u003c/li\u003e\n\u003cli\u003eLavery LA, Higgins KR, Lanctot DR. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007;30(1):14-20.\u003c/li\u003e\n\u003cli\u003eBus SA, Lavery LA, Monteiro-Soares M. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36 Suppl 1:e3269.\u003c/li\u003e\n\u003cli\u003eArmstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998;21(5):855-60.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"income inequality, diabetic foot, lower extremity amputation, type 2 diabetes, socioeconomic disparities, preventive care","lastPublishedDoi":"10.21203/rs.3.rs-6794725/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6794725/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIncome inequality has a profound impact on health outcomes by limiting access to preventive care, early diagnosis, and effective treatment with chronic conditions such as diabetes. Our aim was to investigate the impact of income inequality on diabetic foot amputation rates, focusing on disparities in outcomes among income levels.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study used data from the Korean National Health Insurance Service database that tracked 2,580,585 diabetic patients from 2009 to 2019. Participants were categorized into income quartiles (Q1\u0026ndash;Q4) with Q1 being the lowest-income group. The primary outcome was the first occurrence of diabetes-related lower extremity amputation (LEA).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eLEA performance rates were inversely related to income, with Q1 having the highest rate (0.64 per 1,000 person-years) and Q4 the lowest (0.45 per 1,000 person-years). Adjusted models revealed a protective effect of higher income on LEA. The difference \u003cb\u003eappeared to be more\u003c/b\u003e pronounced in individuals younger than 65 years, \u003cb\u003ebased on stratified analysis\u003c/b\u003e.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIncome inequality is strongly associated with disparities in diabetic foot outcomes, with higher income linked to improved limb preservation, especially among younger individuals. These findings underscore the importance of targeted interventions to mitigate structural inequities, reduce the socioeconomic burden of diabetes, and enhance quality of life in vulnerable populations.\u003c/p\u003e","manuscriptTitle":"Footing the Bill: Income Inequality and Disparities in Diabetic Limb Preservation in a Nationwide Population-Based Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 13:12:35","doi":"10.21203/rs.3.rs-6794725/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-27T04:53:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T17:13:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-21T14:07:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-19T02:24:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231452752079745615654868781577148467893","date":"2025-07-14T14:01:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109261312126907689117543113420262251579","date":"2025-07-14T10:35:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273438877760326504730263807503697542586","date":"2025-07-14T09:09:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54154377746631634354961827544685322702","date":"2025-07-14T08:40:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T08:21:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-14T08:02:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-17T09:01:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-04T13:28:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-06-04T13:24:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c8a25a1-6bf6-444d-b091-6e4bce0a7a55","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":51528996,"name":"Health sciences/Diseases/Endocrine system and metabolic diseases/Diabetes/Diabetes complications"},{"id":51528997,"name":"Health sciences/Health care/Health care economics"},{"id":51528998,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-12-15T16:05:00+00:00","versionOfRecord":{"articleIdentity":"rs-6794725","link":"https://doi.org/10.1038/s41598-025-27511-x","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-12-12 15:59:03","publishedOnDateReadable":"December 12th, 2025"},"versionCreatedAt":"2025-07-18 13:12:35","video":"","vorDoi":"10.1038/s41598-025-27511-x","vorDoiUrl":"https://doi.org/10.1038/s41598-025-27511-x","workflowStages":[]},"version":"v1","identity":"rs-6794725","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6794725","identity":"rs-6794725","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}