Associations of disability with incidence of heart disease in people with diabetes

Associations of disability with incidence of heart disease in people with diabetes | 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 Associations of disability with incidence of heart disease in people with diabetes Kyusung Kim, Hwa-Young Lee, Dong Wook Shin, Kyung‑Do Han, Jin Hyung Jung, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4302371/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract This study investigated associations of disability, including its severity and type, with incidence of heart disease in people with diabetes. Korean National Health Insurance data from 2009 to 2019 were used. This study sampled 50% of people with disability registered in 2009 and 2010 and matched them 1:1 by sex and age to obtain a control group. A longitudinal analysis was conducted to examine the incidence of heart disease by disability, including its severity and type, in 17,338 diabetics from 2010 to 2019. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals. Hazard ratio of disability for the incidence of heart disease in those with diabetes was statistically significantly increased in all adjusted models. By disability severity, it was higher in both mild and severe groups than in the non-disabled group. It was much higher in the severe group. By disability type, the hazard ratio for the incidence of heart disease was significantly increased in those with mobility, communication disability, and those classified as others, but not in those with a mental disability. In conclusion, disability was associated with an increased risk of developing heart disease among people with diabetes. Health sciences/Risk factors Health sciences/Health care/Public health/Epidemiology Disability Diabetes Heart Disease Korean National Health Insurance data Epidemiology Figures Figure 1 Introduction Diabetes is a disease that affects approximately 422 million people worldwide, and is responsible for 1.5 million deaths a year 1 . Diabetes is a major risk factor for heart disease. It is known that the risk of cardiovascular disease in people with diabetes is 2 to 6 times higher than in those without diabetes 2 , 3 . Cardiovascular disease is a major cause of death in people with diabetes 4 , 5 . People with disability also suffer from diabetes. For those with chronic diseases such as diabetes and hypertension, morbidity is higher in people with disabilities than in people without disability 6 , 7 . A plausible explanation for the vulnerability of people with disabilities to chronic diseases is that they have limited access to primary care medical services, including chronic disease management 8 . Poor quality of diabetes care for people with developmental disabilities 9 , inadequate disease management skills, and lifestyle issues such as poor diet high in fat, salt, and sugar for people with intellectual disabilities might also explain for the vulnerability 10 . On the other hand, underlying diabetes can also increase the risk of physical disability 11 . Leaving aside the possibility of causality in both directions 11 , 12 , it is generally reasonable to assume that there is an association between disability and diabetes and that many people with disabilities are highly likely to have diabetes. Managing complications in diabetes is important. It is generally accepted that for every percentage point reduction in glycemic hemoglobin (HbA1c) level in people with diabetes, the risk of microvascular complications is reduced by 40% and that control of blood pressure can reduce the risk of cardiovascular disease by 33–50% and the risk of microvascular complications by about 33% 13 . Although diabetes-related complications are decreasing, data are limited to certain populations, such as some high-income countries 14 . The number of people with undiagnosed diabetes has been estimated to be around 30% 15 . This means that the management of diabetes complications in vulnerable populations is still very important. Although the association between disability and diabetes has been dealt with in several previous studies 10 – 12 , there are few studies on ongoing comorbidities or complications in people with disabilities who are suffering from diabetes or in diabetic patients using disability as a variable. Furthermore, very few previous studies have examined how heart disease rates differ in people with diabetes who are disabled compared to people without disabilities, especially how they vary by the type and severity of disability. Therefore, this study aimed to investigate associations of disability, including its type and its severity, with the incidence of heart disease in people with diabetes. Through a 9-year longitudinal observational study comparing people with and without disabilities in the diabetes population, this study sought to understand whether people with disability might be more vulnerable to developing complications such as heart disease than people without disabilities and what factors might contribute to this vulnerability to provide evidence to inform healthcare delivery for people with chronic conditions. Results Distribution of socio-demographic characteristics of people with new-onset diabetes by disability, its severity, and its type Tables 1 and 2 show socio-demographic characteristics of study participants (people with new-onset diabetes matched 1:1 for people with and without disabilities) according to disability, its type (Table 1), and its severity (Table 2). Of 36,063 people with new-onset diabetes in this study, the mean age at baseline was 63.58 years (SD: 11.53) for those without disability and 61.63 years (SD: 12.25) for those with disability. By the severity of disability, the mean age was 62.69 years (SD: 11.68) for the mild group and 60.02 years (SD: 12.9) for the severe group. By the type of disability, mean ages for those with mobility, communication disability, mental disability, and other disabilities were 63.58 (SD: 11.53), 61.54 (SD: 11.48), 65.35 (SD: 12.22), 50.06 (SD: 10.27) and 60.48 (SD: 12.91) years, respectively, with those having mental disabilities being younger. According to the distribution of income based on national health insurance premiums, the proportion of medical aid was higher in the severe disability group (32.68%) and the mental disability group (70.21%). In terms of regional distribution, people with disability living in rural areas had a significantly higher proportion than those living in urban areas. Development of heart disease by disability, its severity, and its type in people with diabetes Table 3 shows hazard ratios of disability, its type, and its severity for the incidence of heart disease in people with diabetes. In all adjusted models, disability was significantly associated with the incidence of heart diseases in people with diabetes. HRs (95% CIs) were as follows: 1.373 (1.29–1.462) in the unadjusted model, 1.445 (1.355–1.541) in Model 1 adjusted for sex, age, income, and region, 1.442 (1.352–1.538) in Model 2 adjusted for sex, age, income, region, and medication possession ratio. When analyzed by disability severity, the incidence of heart disease was significantly higher in both mild and severe disability groups. HR (95% CIs) was 1.385 (1.291–1.487) for those with mild disability and 1.574 (1.443-1.718) for those with severe disability in model 2 with all covariates adjusted. Both mild and severe disability increased the incidence of heart disease in diabetic patients, with slightly higher HRs for those with severe disability. By disability type, there was a statistically significant increase in the incidence of heart disease for all types except mental disability. HRs (95% CIs) were 1.430 (1.329-1.538) in mobility disability, 1.253 (1.132-1.387) in communication disability, and 1.875 (1.679-2.093) in other disability in model 2. However, for mental disability, HRs (95% CIs) were 1.254 (0.992-1.585) without showing statistical significance. Subgroup analysis of disability and incidence of heart disease in people with diabetes by socio-demographic characteristics and medication possession ratio In subgroup analyses by sex, age, income, region, and medication possession ratio 16 (MPR), difference in heart disease incidence between non-disabled and people with disability tended to be greater in men than in women, in younger age groups, in higher income groups, and in the group with MPR ≤ 80% . The difference was statistically significant in the group with MPR ≤ 80% compared to the group with MPR > 80% MPR (Table 4). Discussion In our study, disability was associated with an increased risk of heart disease in people with diabetes. The more severe the disability, the higher the risk. By the type of disability, mobility, and communication disability, but not mental disability, significantly increased the incidence of heart disease in people with diabetes. Disability increased the risk of heart disease in people with diabetes even after adjusting for socio-demographic and healthcare-related factors. In subgroup analysis, the difference in heart disease incidence between people with and without disability tended to be greater in men than in women, those with a younger age, those with a higher income, and those with a lower MPR. The ‘Framingham Disability Study’ 17 has identified a relationship between disability and risk factors for cardiovascular disease in people without a diagnosis of cardiovascular disease. Disability was associated with several cardiovascular risk factors, including hypertension, diabetes, body mass index, and smoking in different ways depending on sex and age. Although that study had a different population and used risk factors for heart disease as the outcome variable rather than heart disease itself, its results were somewhat consistent with ours. A previous study has also shown that disability can predict the development of cardiovascular disease in a population aged 55 years and more 18 . Another study has reported increased prevalence of hypertension and ischemic heart disease in traumatic spinal cord injured patients compared with their controls and increased prevalence of diabetes and ischemic heart disease in amputees 19 . Disability progression in patients with multiple sclerosis is also associated with cardiovascular disease comorbidities 20 . However, to the best of our knowledge, few studies have comprehensively examined associations between different types of disability and heart disease per se, especially in populations at risk of cardiovascular disease such as people with diabetes. While much of the research to date has focused on the association between disability itself and risk factors for heart disease, it is important to note that disability can also lead to heart disease in a population with risk factors such as diabetes. The reason why we focused on a population with risk factors for cardiovascular disease was to see if disability might have an impact not only on risk factors themselves, but also on progressing to heart disease. Given the bidirectional association between disability and diabetes in previous studies 11 , 12 , preventing risk factors in people with disabilities is insufficient to prevent cardiovascular disease in people with disabilities. Furthermore, there is an association between disability and heart disease in people with diabetes even after adjusting for treatment-related variables, suggesting that additional interventions beyond risk factor prevention are needed. The mechanisms by which disability increases the incidence of cardiovascular events in people with diabetes need to be interpreted differently depending on the type and severity of disability. In the present study, mobility disability, communication disability, and disabilities classified as others, including mental retardation and developmental disability, significantly increased the incidence of heart disease. However, mental disability did not significantly increase the incidence of heart disease. We used the classification of the Korean Disability Welfare Act to define mental disability, which included bipolar affective disorder, schizophrenia, schizoaffective disorder, recurrent depressive disorder, obsessive-compulsive disorder that would not improve with continued treatment, temperamental mental disorder due to neurological damage to the brain, Tourette's disorder, and narcolepsy. We speculate that the reason why certain disabilities could lead to the development of cardiovascular disease in diabetes is due to differences in insulin resistance or reduced muscle mass due to low levels of physical activity. Main mechanisms by which cardiovascular disease develops in diabetes are atherosclerosis and vascular inflammatory response 4 , 21 – 24 . Given that insulin resistance may contribute to cardiovascular disease 25 , 26 and that studies have linked low muscle mass in diabetes with inflammatory responses and various forms of atherosclerosis 27 – 29 , it is possible that certain disabilities might have negatively impact obesity, overall muscle mass, and/or insulin resistance in people with diabetes. Mobility disability, communication disability, and those classified as others in our study are often associated with a high likelihood of being unable to perform basic activities of daily living independently 30 , 31 . Mental disability, on the other hand, is not expected to cause problems with activities of daily living per se, but only difficulties with complex social activities. Control of mental symptoms by medication is expected to allow a variety of physical activities. However, in our study, there were no specific measurements of variables that could prove our speculations, such as level of daily activities or muscle mass for each disorder. Further research into the mechanisms of physical pathology is therefore needed. Based on subgroup analyses, it is likely that male, younger, and higher-income people without disability are more proactive in managing complications of diabetes and therefore have lower heart disease incidence, whereas people with disability in the same conditions have poorer diabetes control than people without disability. This suggests that younger, higher-income people with disability need more supportive policies to prevent them from having poorer diabetes control than people with other conditions. The difference in heart disease rate between people with and without disability was particularly large in the group with poor MPR, suggesting a great need for support for people with disability having poor diabetes control due to poor access to healthcare. This suggests that supportive policies are needed to reduce the gap in heart disease rate between people with and without diabetes by ensuring no gaps in ongoing care and treatment in healthcare facilities. Our study has several strengths. First, we used nationwide data to analyze a 1:1 matched sample of people with and without disability. Second, the incidence of outcomes was examined by disability severity and type, suggesting that prevention and management of heart disease in people with diabetes should be approached differently according to disability severity and its type. Third, it was noteworthy that disability was associated with an increased incidence of heart disease in diabetes even in subgroup analyses after adjusting for access to or quality of care, such as income, region, and MPR. This means that the association between disability and heart disease in diabetes is not determined by access to care alone. The severity and type of disability itself might have effects. However, this only suggests that other mechanisms are at work even after adjusting for access to care. The importance of these factors should not be underestimated. As noted in the explanation for subgroup analyses, our findings did not contradict this. The study has the following limitations. First, although a follow-up period of nine years is not typically short in studies, there might not have been enough time between the diagnosis of diabetes and the development of heart disease. However, this should be considered in the context of the risk of underestimating the incidence of heart disease. It might be a minor limitation to results of this study suggesting an increased risk. Second, this study did not look at various factors that could influence the development of heart disease, such as detailed health status and behaviors. However, the fact that the risk of heart disease did not vary significantly with medication adherence, such as MPR, suggested that the type and severity of disability could increase the risk of heart disease in people with diabetes, without confounding by healthcare access. Further research is needed to identify specific mediating or moderating factors between the severity and type of disability and the incidence of heart disease in high-risk populations such as people with diabetes. We found that disability status and severity per se could increase the risk of heart disease in people with diabetes even after adjusting for socio-demographic or healthcare access factors and that different types of disability might have different effects on the risk. Therefore, disability should be carefully considered as an important factor contributing to cardiovascular disease in high-risk groups such as people with diabetes. Policy discussions should focus on solutions to improve existing health conditions or health behaviors associated with disability itself, such as obesity and physical activity, beyond simply improving access to health care. In addition, more intensive policy support might be needed for groups with a high incidence of heart disease by disability, such as males, those with young age, and those with relatively high-income levels. Future research is needed to identify specific mediators or modifiers between disability and cardiovascular disease in high-risk groups. In conclusion, disability was associated with an increased incidence of heart disease in people with diabetes. The incidence of heart disease was increased with increasing severity of disability. By the type of disability, the incidence of heart disease was increased in those with mobility, communication disability, and other disabilities. However, the increase in mental disability was not statistically significant. This was true even after adjusting for health care access variables such as income, region, and medication possession ratio. To prevent heart disease in people with disability and diabetes, policy interventions should be targeted according to the severity and type of disability. Methods Study design and data source Socio-demographic distribution was examined by disability, its type, and its severity in people with new-onset diabetes at baseline. A longitudinal analysis was performed to examine the incidence of heart disease by disability, its type, and its severity from 2010 to 2019. The Korean National Health Insurance data from 2009 to 2019 were used. We sampled 50% of people with disabilities registered in 2009–2010 and added a 1:1 matched control group based on sex and age for a total number of 2,495,186 people. Exclusion criteria were: those with age < 20 years; those with missing variables for sex, age, income, and region; those with death in 2010; those having no diabetes in 2010; and those who had diabetes in 2009 for the distribution study. We also excluded those who had heart disease, kidney disease, or stroke in 2010 and those who were not prescribed any medications for the longitudinal study (Fig. 1 ). After excluding those who met our exclusion criteria, 36,063 participants with new-onset diabetes in 2010 were selected for the distribution study and 17,338 final participants were used for the longitudinal study. To determine the incidence of heart disease by disability, its severity, and its type in those with newly diagnosed diabetes, hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for covariates were calculated. Adjusting covariates were sex, age, income, and region in Model 1. MPR was additionally adjusted in Model 2. Subgroup analyses were also performed for the incidence of heart disease by disability based on each covariate: sex, age, income, region, and MPR within the disabled group. Measurement of variables Disability status was measured by cumulative disability registrations from 2019 to 2010 in the Korean National Health Insurance data. The type and severity of disability were based on the criteria of the Korean Disability Welfare Act 32 . Types of disability were grouped and categorized as follows: mobility (physical), communication (visual, hearing, speech, facial), mental disability (e.g., bipolar affective disorder, schizophrenia, etc.) and others (brain lesions, intellectual, autism, kidney, heart, respiratory, liver, ostomy-urostomy, epilepsy). Severity of disability was categorized as mild for grades 4–6 and severe for grades 1–3 on the disability scale. Diabetes mellitus (DM) was defined as those having International Statistical Classification of Diseases and Related Health Problems (ICD) codes I10-13 and I15 with medication. Heart disease was defined as those having ICD codes I20-25, I46, I48, and I50 with two or more days of hospitalization. Kidney disease was defined as those with ICD codes N17, N18, and N19 with two or more hospital days. Stroke was defined as those having ICD codes I60-67, I69, and G45 with two or more hospital days. Covariates included sex, age, income, region, and MPR. Income was categorized as medical aid, low, mid-low, mid-high, and high based on the national health insurance premium rate bands. Region was divided into urban and rural. MPR was divided into ≤ 80% or > 80% per year. Statistical analysis The distribution of socio-demographic characteristics by disability in people with new-onset diabetes was described using the chi-squared test for nominal variables and analysis of variance (ANOVA) for continuous variables. Cox proportional hazards models were used to calculate HRs and 95% CIs in a longitudinal analysis of the incidence of heart disease by disability in people with diabetes. All statistical analyses were performed using SAS statistical package version 9.4 (SAS Institute Inc., Cary, NC, USA). Two-tailed p -values < 0.05 were considered statistically significant. Declarations Ethics This study adhered to the Declaration of Helsinki. The study was reviewed and approved by the Institutional Review Board of Samsung Medical Center (IRB number: SMC 2022-03-060), and waived the requirement to obtain any informed consent because anonymized and de-identified information in compliance with the confidentiality guidelines was used for analyses. The Deliberative Committee of the National Health Insurance Service approved the conditional use of the database for this study. Data availability statement The datasets generated and/or analyzed during the current study are available in the Korean National Health Insurance Sharing Service database repository, (https://nhiss.nhis.or.kr). The datasets used and/or analyzed during the current study available from the NHIS on reasonable request. Author contributions Conceptualization: K.K., D.W.S., H.L., and J.P., Data curation and formal analysis: K.H., and J.H.J., Methodology: K.H., K.K., and J.P., Supervision: J.P., Writing-original draft: K.K., Writing-review & editing: All authors. Funding This research was supported by a grant (grant number: HI20C1073) from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI) funded by the Ministry of Health & Welfare, Republic of Korea. Competing interests The authors have no competing interests to disclose. References Roglic, G. WHO Global report on diabetes: A summary. International Journal of Noncommunicable Diseases 1 , 3-8 (2016). Ko, S.-H. et al. Past and current status of adult type 2 diabetes mellitus management in Korea: a National Health Insurance Service database analysis. 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Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Dec, 2024 Reviews received at journal 06 Dec, 2024 Reviewers agreed at journal 26 Nov, 2024 Reviewers agreed at journal 18 Oct, 2024 Reviews received at journal 19 Jun, 2024 Reviewers agreed at journal 19 Jun, 2024 Reviewers invited by journal 10 May, 2024 Editor assigned by journal 09 May, 2024 Editor invited by journal 29 Apr, 2024 Submission checks completed at journal 29 Apr, 2024 First submitted to journal 21 Apr, 2024 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. 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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-4302371","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":297905877,"identity":"67a4c06d-e78e-4b17-a966-32461bea1882","order_by":0,"name":"Kyusung Kim","email":"","orcid":"","institution":"Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kyusung","middleName":"","lastName":"Kim","suffix":""},{"id":297905878,"identity":"01a28be7-d979-4360-9dba-8261eb7e7f25","order_by":1,"name":"Hwa-Young Lee","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Hwa-Young","middleName":"","lastName":"Lee","suffix":""},{"id":297905879,"identity":"239462d5-e34d-42c3-b223-4fe22c91273f","order_by":2,"name":"Dong Wook Shin","email":"","orcid":"","institution":"Samsung Medical Center, Sungkyunkwan University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Dong","middleName":"Wook","lastName":"Shin","suffix":""},{"id":297905880,"identity":"6425c960-64c8-4f2a-818b-6ac6c25ecad5","order_by":3,"name":"Kyung‑Do Han","email":"","orcid":"","institution":"Soongsil University","correspondingAuthor":false,"prefix":"","firstName":"Kyung‑Do","middleName":"","lastName":"Han","suffix":""},{"id":297905881,"identity":"d0b1b1fe-e3a6-4c85-a9d2-b036aa1417a1","order_by":4,"name":"Jin Hyung Jung","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"Hyung","lastName":"Jung","suffix":""},{"id":297905882,"identity":"c2afd071-b862-46c7-9e6c-a59de5930fa5","order_by":5,"name":"Jae-hyun Park","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYFCCAwzMIIqNmbHB4AOIwU6sFj725obCGWC9RNgDViPHc7zhMw+ciweYMx5++Liw7XAem0Ri42abX9vk+ZgZGD98zMGtxbLhmLHxzLbDxUAtzca5fbcN25gZmCVnbsOtxeDAATNp3rbDiW0SiW3GuT23GYFa2Jh58Wo5/v03VEv7b8ue2/ZEaDljxgzWwnOwwZjhx+1EglosG84US/OcS09sY29sMOxtuJ3cxszYjNcv5hLHN37mKbNOnN/M/sDgx5/btvPbmw9++IjPYRIHGBgY2aA8xjYw2YBbPUgLP0j+D4z7B7fKUTAKRsEoGLkAAAi5VlYtWh8HAAAAAElFTkSuQmCC","orcid":"","institution":"Sungkyunkwan University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Jae-hyun","middleName":"","lastName":"Park","suffix":""}],"badges":[],"createdAt":"2024-04-22 00:59:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4302371/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4302371/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55799649,"identity":"a02ed28e-3066-42b3-99a3-96b469dfabb3","added_by":"auto","created_at":"2024-05-03 12:16:15","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80528,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart showing the select of study participants.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4302371/v1/1aea2769d749c0653ae6d4ef.jpg"},{"id":55799695,"identity":"cec01c5f-c84b-45a1-b4e8-f6967fa26026","added_by":"auto","created_at":"2024-05-03 12:16:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":399436,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4302371/v1/e4482f7f-6784-4d22-9df0-24a70f4191a1.pdf"},{"id":55799650,"identity":"a40fa0c9-5738-415f-9a99-939f053d6aec","added_by":"auto","created_at":"2024-05-03 12:16:15","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":41531,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4302371/v1/9212d0d84ddd777f9a32f3d3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations of disability with incidence of heart disease in people with diabetes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes is a disease that affects approximately 422\u0026nbsp;million people worldwide, and is responsible for 1.5\u0026nbsp;million deaths a year \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Diabetes is a major risk factor for heart disease. It is known that the risk of cardiovascular disease in people with diabetes is 2 to 6 times higher than in those without diabetes \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Cardiovascular disease is a major cause of death in people with diabetes \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePeople with disability also suffer from diabetes. For those with chronic diseases such as diabetes and hypertension, morbidity is higher in people with disabilities than in people without disability \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. A plausible explanation for the vulnerability of people with disabilities to chronic diseases is that they have limited access to primary care medical services, including chronic disease management \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Poor quality of diabetes care for people with developmental disabilities \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, inadequate disease management skills, and lifestyle issues such as poor diet high in fat, salt, and sugar for people with intellectual disabilities might also explain for the vulnerability \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. On the other hand, underlying diabetes can also increase the risk of physical disability \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Leaving aside the possibility of causality in both directions \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, it is generally reasonable to assume that there is an association between disability and diabetes and that many people with disabilities are highly likely to have diabetes.\u003c/p\u003e \u003cp\u003eManaging complications in diabetes is important. It is generally accepted that for every percentage point reduction in glycemic hemoglobin (HbA1c) level in people with diabetes, the risk of microvascular complications is reduced by 40% and that control of blood pressure can reduce the risk of cardiovascular disease by 33\u0026ndash;50% and the risk of microvascular complications by about 33% \u003csup\u003e13\u003c/sup\u003e. Although diabetes-related complications are decreasing, data are limited to certain populations, such as some high-income countries \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The number of people with undiagnosed diabetes has been estimated to be around 30% \u003csup\u003e15\u003c/sup\u003e. This means that the management of diabetes complications in vulnerable populations is still very important.\u003c/p\u003e \u003cp\u003eAlthough the association between disability and diabetes has been dealt with in several previous studies \u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, there are few studies on ongoing comorbidities or complications in people with disabilities who are suffering from diabetes or in diabetic patients using disability as a variable. Furthermore, very few previous studies have examined how heart disease rates differ in people with diabetes who are disabled compared to people without disabilities, especially how they vary by the type and severity of disability.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to investigate associations of disability, including its type and its severity, with the incidence of heart disease in people with diabetes. Through a 9-year longitudinal observational study comparing people with and without disabilities in the diabetes population, this study sought to understand whether people with disability might be more vulnerable to developing complications such as heart disease than people without disabilities and what factors might contribute to this vulnerability to provide evidence to inform healthcare delivery for people with chronic conditions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eDistribution of socio-demographic characteristics of people with new-onset diabetes by disability, its severity, and its type\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTables 1 and 2 show socio-demographic characteristics of study participants (people with new-onset diabetes matched 1:1 for people with and without disabilities) according to disability, its type (Table 1), and its severity (Table 2). Of 36,063 people with new-onset diabetes in this study, the mean age at baseline was 63.58 years (SD: 11.53) for those without disability and 61.63 years (SD: 12.25) for those with disability. By the severity of disability, the mean age was 62.69 years (SD: 11.68) for the mild group and 60.02 years (SD: 12.9) for the severe group. By the type of disability, mean ages for those with mobility, communication disability, mental disability, and other disabilities were 63.58 (SD: 11.53), 61.54 (SD: 11.48), 65.35 (SD: 12.22), 50.06 (SD: 10.27) and 60.48 (SD: 12.91) years, respectively, with those having mental disabilities being younger. According to the distribution of income based on national health insurance premiums, the proportion of medical aid was higher in the severe disability group (32.68%) and the mental disability group (70.21%). In terms of regional distribution, people with disability living in rural areas had a significantly higher proportion than those living in urban areas.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDevelopment of heart disease by disability, its severity, and its type in people with diabetes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 shows hazard ratios of disability, its type, and its severity for the incidence of heart disease in people with diabetes. In all adjusted models, disability was significantly associated with the incidence of heart diseases in people with diabetes. HRs (95% CIs) were as follows: 1.373 (1.29\u0026ndash;1.462) in the unadjusted model, 1.445 (1.355\u0026ndash;1.541) in Model 1 adjusted for sex, age, income, and region, 1.442 (1.352\u0026ndash;1.538) in Model 2 adjusted for sex, age, income, region, and medication possession ratio.\u003c/p\u003e\n\u003cp\u003eWhen analyzed by disability severity, the incidence of heart disease was significantly higher in both mild and severe disability groups. HR (95% CIs) was 1.385 (1.291\u0026ndash;1.487) for those with mild disability and 1.574 (1.443-1.718) for those with severe disability in model 2 with all covariates adjusted. Both mild and severe disability increased the incidence of heart disease in diabetic patients, with slightly higher HRs for those with severe disability.\u003c/p\u003e\n\u003cp\u003eBy disability type, there was a statistically significant increase in the incidence of heart disease for all types except mental disability. HRs (95% CIs) were 1.430 (1.329-1.538) in mobility disability, 1.253 (1.132-1.387) in communication disability, and 1.875 (1.679-2.093) in other disability in model 2. However, for mental disability, HRs (95% CIs) were 1.254 (0.992-1.585) without showing statistical significance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSubgroup analysis of disability and incidence of heart disease in people with diabetes by socio-demographic characteristics and medication possession ratio\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn subgroup analyses by sex, age, income, region, and medication possession ratio\u0026nbsp;\u003csup\u003e16\u003c/sup\u003e (MPR), difference in heart disease incidence between non-disabled and people with disability tended to be greater in men than in women, in younger age groups, in higher income groups, and in the group with MPR \u0026le; 80% . The difference was statistically significant in the group with MPR \u0026le; 80% compared to the group with MPR \u0026gt; 80% MPR (Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, disability was associated with an increased risk of heart disease in people with diabetes. The more severe the disability, the higher the risk. By the type of disability, mobility, and communication disability, but not mental disability, significantly increased the incidence of heart disease in people with diabetes. Disability increased the risk of heart disease in people with diabetes even after adjusting for socio-demographic and healthcare-related factors. In subgroup analysis, the difference in heart disease incidence between people with and without disability tended to be greater in men than in women, those with a younger age, those with a higher income, and those with a lower MPR.\u003c/p\u003e \u003cp\u003eThe ‘Framingham Disability Study’ \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e has identified a relationship between disability and risk factors for cardiovascular disease in people without a diagnosis of cardiovascular disease. Disability was associated with several cardiovascular risk factors, including hypertension, diabetes, body mass index, and smoking in different ways depending on sex and age. Although that study had a different population and used risk factors for heart disease as the outcome variable rather than heart disease itself, its results were somewhat consistent with ours. A previous study has also shown that disability can predict the development of cardiovascular disease in a population aged 55 years and more \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Another study has reported increased prevalence of hypertension and ischemic heart disease in traumatic spinal cord injured patients compared with their controls and increased prevalence of diabetes and ischemic heart disease in amputees \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Disability progression in patients with multiple sclerosis is also associated with cardiovascular disease comorbidities \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. However, to the best of our knowledge, few studies have comprehensively examined associations between different types of disability and heart disease per se, especially in populations at risk of cardiovascular disease such as people with diabetes.\u003c/p\u003e \u003cp\u003eWhile much of the research to date has focused on the association between disability itself and risk factors for heart disease, it is important to note that disability can also lead to heart disease in a population with risk factors such as diabetes. The reason why we focused on a population with risk factors for cardiovascular disease was to see if disability might have an impact not only on risk factors themselves, but also on progressing to heart disease. Given the bidirectional association between disability and diabetes in previous studies \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, preventing risk factors in people with disabilities is insufficient to prevent cardiovascular disease in people with disabilities. Furthermore, there is an association between disability and heart disease in people with diabetes even after adjusting for treatment-related variables, suggesting that additional interventions beyond risk factor prevention are needed.\u003c/p\u003e \u003cp\u003eThe mechanisms by which disability increases the incidence of cardiovascular events in people with diabetes need to be interpreted differently depending on the type and severity of disability. In the present study, mobility disability, communication disability, and disabilities classified as others, including mental retardation and developmental disability, significantly increased the incidence of heart disease. However, mental disability did not significantly increase the incidence of heart disease. We used the classification of the Korean Disability Welfare Act to define mental disability, which included bipolar affective disorder, schizophrenia, schizoaffective disorder, recurrent depressive disorder, obsessive-compulsive disorder that would not improve with continued treatment, temperamental mental disorder due to neurological damage to the brain, Tourette's disorder, and narcolepsy.\u003c/p\u003e \u003cp\u003eWe speculate that the reason why certain disabilities could lead to the development of cardiovascular disease in diabetes is due to differences in insulin resistance or reduced muscle mass due to low levels of physical activity. Main mechanisms by which cardiovascular disease develops in diabetes are atherosclerosis and vascular inflammatory response \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e–\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Given that insulin resistance may contribute to cardiovascular disease \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e and that studies have linked low muscle mass in diabetes with inflammatory responses and various forms of atherosclerosis \u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e–\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, it is possible that certain disabilities might have negatively impact obesity, overall muscle mass, and/or insulin resistance in people with diabetes. Mobility disability, communication disability, and those classified as others in our study are often associated with a high likelihood of being unable to perform basic activities of daily living independently \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Mental disability, on the other hand, is not expected to cause problems with activities of daily living per se, but only difficulties with complex social activities. Control of mental symptoms by medication is expected to allow a variety of physical activities. However, in our study, there were no specific measurements of variables that could prove our speculations, such as level of daily activities or muscle mass for each disorder. Further research into the mechanisms of physical pathology is therefore needed.\u003c/p\u003e \u003cp\u003eBased on subgroup analyses, it is likely that male, younger, and higher-income people without disability are more proactive in managing complications of diabetes and therefore have lower heart disease incidence, whereas people with disability in the same conditions have poorer diabetes control than people without disability. This suggests that younger, higher-income people with disability need more supportive policies to prevent them from having poorer diabetes control than people with other conditions. The difference in heart disease rate between people with and without disability was particularly large in the group with poor MPR, suggesting a great need for support for people with disability having poor diabetes control due to poor access to healthcare. This suggests that supportive policies are needed to reduce the gap in heart disease rate between people with and without diabetes by ensuring no gaps in ongoing care and treatment in healthcare facilities.\u003c/p\u003e \u003cp\u003eOur study has several strengths. First, we used nationwide data to analyze a 1:1 matched sample of people with and without disability. Second, the incidence of outcomes was examined by disability severity and type, suggesting that prevention and management of heart disease in people with diabetes should be approached differently according to disability severity and its type. Third, it was noteworthy that disability was associated with an increased incidence of heart disease in diabetes even in subgroup analyses after adjusting for access to or quality of care, such as income, region, and MPR. This means that the association between disability and heart disease in diabetes is not determined by access to care alone. The severity and type of disability itself might have effects. However, this only suggests that other mechanisms are at work even after adjusting for access to care. The importance of these factors should not be underestimated. As noted in the explanation for subgroup analyses, our findings did not contradict this.\u003c/p\u003e \u003cp\u003eThe study has the following limitations. First, although a follow-up period of nine years is not typically short in studies, there might not have been enough time between the diagnosis of diabetes and the development of heart disease. However, this should be considered in the context of the risk of underestimating the incidence of heart disease. It might be a minor limitation to results of this study suggesting an increased risk. Second, this study did not look at various factors that could influence the development of heart disease, such as detailed health status and behaviors. However, the fact that the risk of heart disease did not vary significantly with medication adherence, such as MPR, suggested that the type and severity of disability could increase the risk of heart disease in people with diabetes, without confounding by healthcare access. Further research is needed to identify specific mediating or moderating factors between the severity and type of disability and the incidence of heart disease in high-risk populations such as people with diabetes.\u003c/p\u003e \u003cp\u003eWe found that disability status and severity per se could increase the risk of heart disease in people with diabetes even after adjusting for socio-demographic or healthcare access factors and that different types of disability might have different effects on the risk. Therefore, disability should be carefully considered as an important factor contributing to cardiovascular disease in high-risk groups such as people with diabetes. Policy discussions should focus on solutions to improve existing health conditions or health behaviors associated with disability itself, such as obesity and physical activity, beyond simply improving access to health care. In addition, more intensive policy support might be needed for groups with a high incidence of heart disease by disability, such as males, those with young age, and those with relatively high-income levels. Future research is needed to identify specific mediators or modifiers between disability and cardiovascular disease in high-risk groups.\u003c/p\u003e \u003cp\u003eIn conclusion, disability was associated with an increased incidence of heart disease in people with diabetes. The incidence of heart disease was increased with increasing severity of disability. By the type of disability, the incidence of heart disease was increased in those with mobility, communication disability, and other disabilities. However, the increase in mental disability was not statistically significant. This was true even after adjusting for health care access variables such as income, region, and medication possession ratio. To prevent heart disease in people with disability and diabetes, policy interventions should be targeted according to the severity and type of disability.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\n "},{"header":"Methods","content":"\u003ch2\u003eStudy design and data source\u003c/h2\u003e\u003cp\u003eSocio-demographic distribution was examined by disability, its type, and its severity in people with new-onset diabetes at baseline. A longitudinal analysis was performed to examine the incidence of heart disease by disability, its type, and its severity from 2010 to 2019. The Korean National Health Insurance data from 2009 to 2019 were used. We sampled 50% of people with disabilities registered in 2009–2010 and added a 1:1 matched control group based on sex and age for a total number of 2,495,186 people. Exclusion criteria were: those with age \u0026lt; 20 years; those with missing variables for sex, age, income, and region; those with death in 2010; those having no diabetes in 2010; and those who had diabetes in 2009 for the distribution study. We also excluded those who had heart disease, kidney disease, or stroke in 2010 and those who were not prescribed any medications for the longitudinal study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After excluding those who met our exclusion criteria, 36,063 participants with new-onset diabetes in 2010 were selected for the distribution study and 17,338 final participants were used for the longitudinal study. To determine the incidence of heart disease by disability, its severity, and its type in those with newly diagnosed diabetes, hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for covariates were calculated. Adjusting covariates were sex, age, income, and region in Model 1. MPR was additionally adjusted in Model 2. Subgroup analyses were also performed for the incidence of heart disease by disability based on each covariate: sex, age, income, region, and MPR within the disabled group.\u003c/p\u003e\u003ch3\u003eMeasurement of variables\u003c/h3\u003e\u003cp\u003eDisability status was measured by cumulative disability registrations from 2019 to 2010 in the Korean National Health Insurance data. The type and severity of disability were based on the criteria of the Korean Disability Welfare Act \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Types of disability were grouped and categorized as follows: mobility (physical), communication (visual, hearing, speech, facial), mental disability (e.g., bipolar affective disorder, schizophrenia, etc.) and others (brain lesions, intellectual, autism, kidney, heart, respiratory, liver, ostomy-urostomy, epilepsy). Severity of disability was categorized as mild for grades 4–6 and severe for grades 1–3 on the disability scale.\u003c/p\u003e\u003cp\u003eDiabetes mellitus (DM) was defined as those having International Statistical Classification of Diseases and Related Health Problems (ICD) codes I10-13 and I15 with medication. Heart disease was defined as those having ICD codes I20-25, I46, I48, and I50 with two or more days of hospitalization. Kidney disease was defined as those with ICD codes N17, N18, and N19 with two or more hospital days. Stroke was defined as those having ICD codes I60-67, I69, and G45 with two or more hospital days.\u003c/p\u003e\u003cp\u003eCovariates included sex, age, income, region, and MPR. Income was categorized as medical aid, low, mid-low, mid-high, and high based on the national health insurance premium rate bands. Region was divided into urban and rural. MPR was divided into ≤ 80% or \u0026gt; 80% per year.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe distribution of socio-demographic characteristics by disability in people with new-onset diabetes was described using the chi-squared test for nominal variables and analysis of variance (ANOVA) for continuous variables. Cox proportional hazards models were used to calculate HRs and 95% CIs in a longitudinal analysis of the incidence of heart disease by disability in people with diabetes. All statistical analyses were performed using SAS statistical package version 9.4 (SAS Institute Inc., Cary, NC, USA). Two-tailed \u003cem\u003ep\u003c/em\u003e-values \u0026lt; 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Declaration of Helsinki. The study was reviewed and approved by the Institutional Review Board of Samsung Medical Center (IRB number: SMC 2022-03-060), and waived the requirement to obtain any informed consent because anonymized and de-identified information in compliance with the confidentiality guidelines was used for analyses. The Deliberative Committee of the National Health Insurance Service approved the conditional use of the database for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available in the Korean National Health Insurance Sharing Service database repository, (https://nhiss.nhis.or.kr). The datasets used and/or analyzed during the current study available from the NHIS on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: K.K., D.W.S., H.L., and J.P., Data curation and formal analysis: K.H., and J.H.J., Methodology: K.H., K.K., and J.P., Supervision: J.P., Writing-original draft: K.K., Writing-review \u0026amp; editing: All authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by a grant (grant number: HI20C1073) from the Korea Health Technology R\u0026amp;D Project through the Korea Health Industry Development Institute (KHIDI) funded by the Ministry of Health \u0026amp; Welfare, Republic of Korea.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRoglic, G. 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H.\u003cem\u003e et al.\u003c/em\u003e Low muscle mass is associated with carotid atherosclerosis in patients with type 2 diabetes. \u003cem\u003eAtherosclerosis\u003c/em\u003e \u003cstrong\u003e305\u003c/strong\u003e, 19-25 (2020).\u003c/li\u003e\n\u003cli\u003eXu, Y.\u003cem\u003e et al.\u003c/em\u003e Association of high muscle Mass with Carotid atherosclerosis: a community-based Population Cohort Study. \u003cem\u003eThe journal of nutrition, health \u0026amp; aging\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 1087-1093 (2022).\u003c/li\u003e\n\u003cli\u003eYoon, S.-K., Kim, H.-N. \u0026amp; Song, S.-W. Associations of skeletal muscle mass with atherosclerosis and inflammatory markers in Korean adults. \u003cem\u003eArchives of gerontology and geriatrics\u003c/em\u003e \u003cstrong\u003e90\u003c/strong\u003e, 104163 (2020).\u003c/li\u003e\n\u003cli\u003eLiou, T.-H., Pi-Sunyer, F. X. \u0026amp; Laferrere, B. Physical disability and obesity. \u003cem\u003eNutrition reviews\u003c/em\u003e \u003cstrong\u003e63\u003c/strong\u003e, 321-331 (2005).\u003c/li\u003e\n\u003cli\u003eRimmer, J. H. \u0026amp; Yamaki, K. Obesity and intellectual disability. \u003cem\u003eMental retardation and developmental disabilities research reviews\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e, 22-27 (2006).\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eDisabled Welfare Act\u003c/em\u003e, \u0026lt;https://www.law.go.kr/LSW/lsInfoP.do?efYd=20221222\u0026amp;lsiSeq=238111#0000\u0026gt;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\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":"Disability, Diabetes, Heart Disease, Korean National Health Insurance data, Epidemiology","lastPublishedDoi":"10.21203/rs.3.rs-4302371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4302371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"This study investigated associations of disability, including its severity and type, with incidence of heart disease in people with diabetes. Korean National Health Insurance data from 2009 to 2019 were used. This study sampled 50% of people with disability registered in 2009 and 2010 and matched them 1:1 by sex and age to obtain a control group. A longitudinal analysis was conducted to examine the incidence of heart disease by disability, including its severity and type, in 17,338 diabetics from 2010 to 2019. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals. Hazard ratio of disability for the incidence of heart disease in those with diabetes was statistically significantly increased in all adjusted models. By disability severity, it was higher in both mild and severe groups than in the non-disabled group. It was much higher in the severe group. By disability type, the hazard ratio for the incidence of heart disease was significantly increased in those with mobility, communication disability, and those classified as others, but not in those with a mental disability. In conclusion, disability was associated with an increased risk of developing heart disease among people with diabetes.","manuscriptTitle":"Associations of disability with incidence of heart disease in people with diabetes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-03 12:16:10","doi":"10.21203/rs.3.rs-4302371/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-09T08:06:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-06T16:15:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263155799732124391069572867095241835651","date":"2024-11-26T10:47:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87592158132914619537996044895967941293","date":"2024-10-18T06:43:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-19T17:15:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113047509936707862520822568937512376264","date":"2024-06-19T13:09:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-10T13:55:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-09T14:21:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-29T06:31:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-29T06:27:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-04-22T00:58:10+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":"3c07995f-ec59-4648-b437-6b0b37789cdd","owner":[],"postedDate":"May 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":31424103,"name":"Health sciences/Risk factors"},{"id":31424104,"name":"Health sciences/Health care/Public health/Epidemiology"}],"tags":[],"updatedAt":"2026-04-22T07:27:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-03 12:16:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4302371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4302371","identity":"rs-4302371","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}