Occupational status and disability retirement among employees with diabetes 27 Hora´lek J, Denby B, de Smet PAM, de Leeuw FAAM, Kurfu¨rst P, Swart R, van Noije T. Spatial mapping of air quality for European scale assessment. ETC./ACC Technical paper No 2006/6. Bilthoven: European Topic Centre on Air and Climate Change, 2007. 28 Caetano M, Nunes V, Nunes A. CORINE Land Cover 2006 for Continental Portugal, Relato´rio te´cnico. Instituto Geogra´fico Portugueˆs, 2009. 29 Caetano M, Arau´jo A, Neves A, Pereira M. Accuracy Assessment of the CORINE Land Cover 2006 Map of Continental Portugal, Relato´rio te´cnico. Instituto Geogra´fico Portugueˆs, 2009. 30 GEOSTAT 1km2 population grid [Internet]. GEOSTAT, Eurostat JRC, European Commission. 2006. Available at: http://epp.eurostat.ec.europa.eu/portal/page/ portal/gisco_Geographical_information_maps/popups/references/population_ distribution_demography 27th November 2014.
617
31 Black RJ, Bray F, Ferlay J, Parkin DM. Cancer incidence and mortality in the European Union: cancer registry data and estimates of national incidence for 1990. Eur J Cancer 1997;33:1075–107. 32 Wood S. mgcv: Mixed GAM Computation Vehicle with GCV/AIC/REML Smoothness Estimation. Vienna, Austria: R Foundation for Statistical Computing, 2009. 33 Corvala´n C, Briggs D, Zielhuis G. Decision-Making in Environmental Health—From Evidence to Action. London: E & FN Spon, 2000. 34 Monteiro A, Carvalho V, Oliveira T, Sousa C. Excess mortality and morbidity during the July 2006 heat wave in Porto, Portugal. Int J Biometeorol 2013;57:155–67. 35 Nogueira PJ, Falcao JM, Contreiras MT, et al. Mortality in Portugal associated with the heat wave of August 2003: early estimation of effect, using a rapid method. Euro Surveill 2005;10:150–3.
......................................................................................................... European Journal of Public Health, Vol. 25, No. 4, 617–619 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku240 Advance Access published on 9 February 2015
.........................................................................................................
Short Report
A prospective study of occupational status and disability retirement among employees with diabetes in Denmark Bryan Cleal1, Kjeld Poulsen1, Harald Hannerz2, Lars L. Andersen2 1 Steno Health Promotion Research, Steno Diabetes Center, Gentofte, Denmark 2 The National Research Center for the Working Environment, Copenhagen, Denmark Correspondence: Bryan Cleal, Steno Health Promotion Center, Steno Diabetes Center, Niels Steensens Vej 8, Gentofte DK-2820, Denmark. Tel: + (45) 30 79 79 72, Fax: + (45) 39 68 10 48, e-mail: [email protected]
The aim of this study was to examine the extent and distribution of disability retirement among people with diabetes in the workforce. Using four population registries, the study examined the relative rates of disability retirement among employees in Denmark over a 10-year period. The findings highlight that the risk of disability retirement increases as occupational status decreases. With an ageing workforce and increasing prevalence of diabetes, it is important to target primary, secondary and tertiary prevention to the groups that need it most in attempts to prolong the working lives of individuals.
.........................................................................................................
Introduction ype 1 (T1DM) and type 2 diabetes mellitus (T2DM) have
Tpreviously been shown to have a significant impact on the risk
of disability retirement.1–4 The aim of this study was to estimate the proportion of disability retirements, among employees with diabetes, which could be attributed to occupational status. This perspective was considered important since both incident diabetes5 and disability6 are marked by a social gradient. Obtaining detailed information on the relationship between diabetes, disability retirement and occupational status is, therefore, undertaken with a view to informing efforts to tackle the problem of early retirement7 and, in particular, early retirement among people with diabetes. Utilizing the population registries in Denmark provides strong and comprehensive data upon which these relationships can be delineated and understood.
Methods The study used a dataset generated by combining variables from four national registries—the central person registry (CPR), the Danish National Diabetes Registry (DNDR),8 the employment classification
module (AKM) and the National Registry of Social Transfer Payments (DREAM) in Denmark.9 The CPR contains information on date of birth, gender, geographic residence, death and migrations for every person who is/has been an inhabitant of Denmark at some time since 1968. DNDR does not enable any distinction between T1DM and T2DM. Every resident of Denmark has a unique CPR number which provides the basis for linking individual data between different registries. Occupational classification was derived from the SOCIO variable used by Statistics Denmark. SOCIO follows the categorization applied in the International Standard for the Classification of Occupations (ISCO 88) and, as such, classification will be based on the skills deemed necessary to undertake a specific occupation and not on formal education or income. The study population comprised all employees in Denmark aged 20–59 years old registered in DNDR at baseline (1 January 2001). These people were followed from 1 January 2001 to 31 December 2010. The endpoint was disability retirement sometime during follow-up. All subjects were followed until any of the following events occurred: s/he reached the endpoint, s/he emigrated, s/he opted for early retirement, s/he turned 65 (65 being the official pension age during the study period), s/he died, the study
Downloaded from http://eurpub.oxfordjournals.org/ by guest on June 5, 2016
.........................................................................................................
618
European Journal of Public Health
Comparing professionals with diabetes to those without, we can observe that professionals with diabetes have a 353% greater risk of disability retirement than their counterparts without diabetes. But diabetes and low occupational status also have a clear compound effect, evinced in the result that workers in elementary occupations have a 1173% greater risk for early retirement than professionals without diabetes. When looking exclusively to people with diabetes, the EF was 0.477 (95% CI 0.431–0.521). In practice these findings imply that 47.7% of cases would not have occurred if people with diabetes in all occupational groups had a rate of retirement equivalent to professionals with diabetes.
period ended. Person years at risk (PYRS) are calculated for each individual. With professionals without diabetes as reference, we used Poisson regression to estimate occupational rate ratios (RR) for disability retirement, stratifying by gender, age (10-year age groups) and regional demography. The RRs are presented with 95% confidence intervals. Proc genmod in SAS version 9.3 was used to implement the analysis. The term ‘excess fraction’ (EF) refers to the proportion of the cases of disability retirement that would not have occurred if the retirement rate in each occupational group had been the same as it was among the professionals. For the purposes of this analysis we focussed exclusively on people with diabetes, so it is professionals with diabetes who represent the reference group here. The EF was calculated according to the equation P pi ðRRi 1Þ i P EF ¼ , 1 þ pi ðRRi 1Þ
Discussion
i
where pi is the proportion of the employees that belong to occupational group i while RRi is the rate ratio between group i and the reference group (professionals with diabetes). Monte Carlo simulation was used to calculate a 95% confidence interval for the EF estimate.
Results In total, there were 58 735 people with diabetes aged 20–59 years old living in Denmark at baseline, of which 32 341 were employees. 3331 employees were excluded due to a missing occupational code, meaning we have no valid occupational information about them. The remaining 29 210 (16 855 men and 12 355 women) were included in the analysis. The follow-up yielded 3163 cases of disability retirement in 231 484 PYRS. As highlighted in table 1, both occupational status and diabetes are associated with significantly elevated risk for early retirement.
Table 1 Disability retirement among Danish employees with diabetes at baseline during 10-year follow-up compared with employees who did not have diabetes
Sex Female (Reference) Male Age at entry 20–29 years (Reference) 30–39 years 40–49 years 50–59 years Sociooccupational group—without diabetes Professionals (Reference) Legislators, senior officials and managers Technicians and associate professionals Workers in occupations that require skills at basic level Workers in elementary occupations Socio-occupational group—who develop diabetes Professionals Legislators, senior officials and managers Technicians and associate professionals Workers in occupations that require skills at basic level Workers in elementary occupations Geographic region Northern Denmark Mid-Jutland Southern Denmark Zealand Main Capital Area
Employees
Disability retirement
N
n
960 313 1 019 859
36 535 30 890
1.00 0.75
– (0.74–0.76)
RR
95% CL
440 575 518 444
628 882 824 838
4811 13 052 26 101 23 461
1.00 2.26 5.01 7.14
– (2.19–2.34) (4.91–5.23) (6.92–7.37)
286 55 377 1 005 225
401 823 340 542 856
4724 926 8486 36 040 14 086
1.00 0.93 1.44 2.73 4.65
– (0.87–1.00) (1.39–1.49) (2.65–2.82) (4.50–4.80)
3630 1032 5206 14 632 4710
228 62 382 1653 838
3.53 3.22 4.21 7.10 11.73
(3.09–4.03) (2.50–4.13) (3.79–6.67) (6.72–7.51) (10.90–12.63)
5352 15 476 15 788 20 484 10 325
1.00 1.17 1.27 1.14 1.30
– (1.13–1.21) (1.23–1.31) (1.11–1.18) (1.26–1.34)
176 457 417 625 302
452 438 389 959 934
Downloaded from http://eurpub.oxfordjournals.org/ by guest on June 5, 2016
The prevalence of diabetes among the working population in Denmark is relatively low when compared with prevalence within the population as a whole.8 This can be accounted for by the fact that T2DM prevalence is directly related to age and excluding everyone over 59 years of age at baseline inevitably limits the size of the study population. Nonetheless, the observed cases of disability retirement represent >10% of the study population. Given the individual, social and economic consequences of disability retirement, 10% permanently leaving the labour market over a 10-year period represents a notable level of attrition. In terms of direct causality, work factors alone may account for a proportion of the observed inequalities, but clearly work is not the sole cause of structural inequalities in health. We must also recognize the potential for endogenity in our results, as people who develop T2DM are also vulnerable to other risk factors that could directly or indirectly lead to premature exit from the workforce. Yet while work alone is not the only source of health inequalities it is, nonetheless, one of the social structures in which health inequality is most clearly articulated. As such, it provides an ideal arena to address and tackle health inequalities and our results support the view that health professionals should target specific
Occupational status and disability retirement among employees with diabetes
Key points The study presents comprehensive population data concerning disability retirement among people with diabetes in the workforce. More than 10% of the study population went into early retirement during the 10-year follow-up period. Occupational status and diabetes have a compound impact on the risk of early retirement, with a 1173% risk differential between individuals in the highest occupational group without diabetes and those in the lowest occupational group with diabetes. The results suggest that prolonging the working lives of people with diabetes requires attention, especially in occupations with low occupational status.
References 1
Breton MC, Guenette L, Amiche MA, et al. Burden of diabetes on the ability to work: a systematic review. Diabetes Care 2013;36:740–9.
2
Herquelot E, Gueguen A, Bonenfant S, et al. Impact of diabetes on work cessation: data from the GAZEL cohort study. Diabetes Care 2011;34:1344–9.
3
Von Korff M, Katon W, Lin EH, et al. Work disability among individuals with diabetes. Diabetes Care 2005;28:1326–32.
4
Vijan S, Hayward RA, Langa KM. The impact of diabetes on workforce participation: results from a national household sample. Health Serv Res 2004;39:1653–69.
5
Agardh E, Allebeck P, Hallqvist J, et al. Type 2 diabetes incidence and socio-economic postion: a systematic review and meta-analysis. Int J Epidemiol 2011;40:804–18.
6
Minkler M, Fuller-Thomson E, Guralnik JM. Gradient of disability across the socioeconomic spectrum in the United States. N Engl J Med 2006;355:695–703.
7
Lahelma E, Uusitalo H, Martikainen P. Editorial: longer work careers through tackling socioeconomic inequalities in disability retirement. Eur J Public Health 2012;22:299–300.
8
Carstensen B, Kristensen JK, Marcussen MM, et al. The national diabetes register. Scand J Public Health 2011;39:58–61.
9
Hjollund NH, Breinholt Larsen F, Andersen JH. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a populationbased survey. Scand J Public Health 2007;35:497–502.
Acknowledgements The authors would like to acknowledge the assistance of Jens Worm Begtrup from the National Center for the Working Environment for his assistance in the preparation of the data and to Ingrid Willaing of Steno Diabetes Center for her comments on an earlier draft of the article. The data was presented in poster form at the American Diabetes Association annual conference in June 14–17 2014, held in San Francisco. Conflicts of interest: Bryan Cleal and Kjeld Poulsen are employed by Steno Diabetes Center A/S, a research hospital working in the Danish National Health Service. Steno Diabetes Center receives part of its core funding from unrestricted grants from the Novo Foundation and Novo Nordisk A/S.
10 Imkampe AK, Gulliford M. Increasing socio-economic inequality in type 2 diabetes prevalence—repeated cross-sectional surveys in England 1994–2006. Eur J Public Health 2010;21:484–90.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on June 5, 2016
groups, such as employees with diabetes engaged in occupations which confer low occupational status. The relative risks revealed in our study are especially concerning given that there is evidence to suggest levels of social inequality in prevalent T2DM are on the increase.10 Assuming these trends continue there will, both proportionally and numerically, be more individuals with diabetes with a relatively high risk of disability retirement. Targeting primary, secondary and tertiary prevention to the groups that need it most thus seems a potentially important strategy in attempts to prolong the working lives of individuals. It is a weakness of our data that we are not able to distinguish between T1DM and T2DM. Future work in this area should investigate different paths to disability among people with diabetes with more precision. The dataset is, however, also the strength of this study and using comprehensive population data has allowed us to provide strong evidence for the level of social inequality in disability retirement among people with diabetes. In addition to the patent moral and social arguments for addressing inequality, the data we present here also support the inference of economic ramifications. In countries with an ageing workforce, it is inevitable that we will see increasing numbers of individuals with chronic conditions within the labour force. Raising the retirement age is, thus, an insufficient solution to the economic problems an ageing workforce poses, unless accompanied by strategies to help those most at risk of disability retirement.
619
617
31 Black RJ, Bray F, Ferlay J, Parkin DM. Cancer incidence and mortality in the European Union: cancer registry data and estimates of national incidence for 1990. Eur J Cancer 1997;33:1075–107. 32 Wood S. mgcv: Mixed GAM Computation Vehicle with GCV/AIC/REML Smoothness Estimation. Vienna, Austria: R Foundation for Statistical Computing, 2009. 33 Corvala´n C, Briggs D, Zielhuis G. Decision-Making in Environmental Health—From Evidence to Action. London: E & FN Spon, 2000. 34 Monteiro A, Carvalho V, Oliveira T, Sousa C. Excess mortality and morbidity during the July 2006 heat wave in Porto, Portugal. Int J Biometeorol 2013;57:155–67. 35 Nogueira PJ, Falcao JM, Contreiras MT, et al. Mortality in Portugal associated with the heat wave of August 2003: early estimation of effect, using a rapid method. Euro Surveill 2005;10:150–3.
......................................................................................................... European Journal of Public Health, Vol. 25, No. 4, 617–619 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku240 Advance Access published on 9 February 2015
.........................................................................................................
Short Report
A prospective study of occupational status and disability retirement among employees with diabetes in Denmark Bryan Cleal1, Kjeld Poulsen1, Harald Hannerz2, Lars L. Andersen2 1 Steno Health Promotion Research, Steno Diabetes Center, Gentofte, Denmark 2 The National Research Center for the Working Environment, Copenhagen, Denmark Correspondence: Bryan Cleal, Steno Health Promotion Center, Steno Diabetes Center, Niels Steensens Vej 8, Gentofte DK-2820, Denmark. Tel: + (45) 30 79 79 72, Fax: + (45) 39 68 10 48, e-mail: [email protected]
The aim of this study was to examine the extent and distribution of disability retirement among people with diabetes in the workforce. Using four population registries, the study examined the relative rates of disability retirement among employees in Denmark over a 10-year period. The findings highlight that the risk of disability retirement increases as occupational status decreases. With an ageing workforce and increasing prevalence of diabetes, it is important to target primary, secondary and tertiary prevention to the groups that need it most in attempts to prolong the working lives of individuals.
.........................................................................................................
Introduction ype 1 (T1DM) and type 2 diabetes mellitus (T2DM) have
Tpreviously been shown to have a significant impact on the risk
of disability retirement.1–4 The aim of this study was to estimate the proportion of disability retirements, among employees with diabetes, which could be attributed to occupational status. This perspective was considered important since both incident diabetes5 and disability6 are marked by a social gradient. Obtaining detailed information on the relationship between diabetes, disability retirement and occupational status is, therefore, undertaken with a view to informing efforts to tackle the problem of early retirement7 and, in particular, early retirement among people with diabetes. Utilizing the population registries in Denmark provides strong and comprehensive data upon which these relationships can be delineated and understood.
Methods The study used a dataset generated by combining variables from four national registries—the central person registry (CPR), the Danish National Diabetes Registry (DNDR),8 the employment classification
module (AKM) and the National Registry of Social Transfer Payments (DREAM) in Denmark.9 The CPR contains information on date of birth, gender, geographic residence, death and migrations for every person who is/has been an inhabitant of Denmark at some time since 1968. DNDR does not enable any distinction between T1DM and T2DM. Every resident of Denmark has a unique CPR number which provides the basis for linking individual data between different registries. Occupational classification was derived from the SOCIO variable used by Statistics Denmark. SOCIO follows the categorization applied in the International Standard for the Classification of Occupations (ISCO 88) and, as such, classification will be based on the skills deemed necessary to undertake a specific occupation and not on formal education or income. The study population comprised all employees in Denmark aged 20–59 years old registered in DNDR at baseline (1 January 2001). These people were followed from 1 January 2001 to 31 December 2010. The endpoint was disability retirement sometime during follow-up. All subjects were followed until any of the following events occurred: s/he reached the endpoint, s/he emigrated, s/he opted for early retirement, s/he turned 65 (65 being the official pension age during the study period), s/he died, the study
Downloaded from http://eurpub.oxfordjournals.org/ by guest on June 5, 2016
.........................................................................................................
618
European Journal of Public Health
Comparing professionals with diabetes to those without, we can observe that professionals with diabetes have a 353% greater risk of disability retirement than their counterparts without diabetes. But diabetes and low occupational status also have a clear compound effect, evinced in the result that workers in elementary occupations have a 1173% greater risk for early retirement than professionals without diabetes. When looking exclusively to people with diabetes, the EF was 0.477 (95% CI 0.431–0.521). In practice these findings imply that 47.7% of cases would not have occurred if people with diabetes in all occupational groups had a rate of retirement equivalent to professionals with diabetes.
period ended. Person years at risk (PYRS) are calculated for each individual. With professionals without diabetes as reference, we used Poisson regression to estimate occupational rate ratios (RR) for disability retirement, stratifying by gender, age (10-year age groups) and regional demography. The RRs are presented with 95% confidence intervals. Proc genmod in SAS version 9.3 was used to implement the analysis. The term ‘excess fraction’ (EF) refers to the proportion of the cases of disability retirement that would not have occurred if the retirement rate in each occupational group had been the same as it was among the professionals. For the purposes of this analysis we focussed exclusively on people with diabetes, so it is professionals with diabetes who represent the reference group here. The EF was calculated according to the equation P pi ðRRi 1Þ i P EF ¼ , 1 þ pi ðRRi 1Þ
Discussion
i
where pi is the proportion of the employees that belong to occupational group i while RRi is the rate ratio between group i and the reference group (professionals with diabetes). Monte Carlo simulation was used to calculate a 95% confidence interval for the EF estimate.
Results In total, there were 58 735 people with diabetes aged 20–59 years old living in Denmark at baseline, of which 32 341 were employees. 3331 employees were excluded due to a missing occupational code, meaning we have no valid occupational information about them. The remaining 29 210 (16 855 men and 12 355 women) were included in the analysis. The follow-up yielded 3163 cases of disability retirement in 231 484 PYRS. As highlighted in table 1, both occupational status and diabetes are associated with significantly elevated risk for early retirement.
Table 1 Disability retirement among Danish employees with diabetes at baseline during 10-year follow-up compared with employees who did not have diabetes
Sex Female (Reference) Male Age at entry 20–29 years (Reference) 30–39 years 40–49 years 50–59 years Sociooccupational group—without diabetes Professionals (Reference) Legislators, senior officials and managers Technicians and associate professionals Workers in occupations that require skills at basic level Workers in elementary occupations Socio-occupational group—who develop diabetes Professionals Legislators, senior officials and managers Technicians and associate professionals Workers in occupations that require skills at basic level Workers in elementary occupations Geographic region Northern Denmark Mid-Jutland Southern Denmark Zealand Main Capital Area
Employees
Disability retirement
N
n
960 313 1 019 859
36 535 30 890
1.00 0.75
– (0.74–0.76)
RR
95% CL
440 575 518 444
628 882 824 838
4811 13 052 26 101 23 461
1.00 2.26 5.01 7.14
– (2.19–2.34) (4.91–5.23) (6.92–7.37)
286 55 377 1 005 225
401 823 340 542 856
4724 926 8486 36 040 14 086
1.00 0.93 1.44 2.73 4.65
– (0.87–1.00) (1.39–1.49) (2.65–2.82) (4.50–4.80)
3630 1032 5206 14 632 4710
228 62 382 1653 838
3.53 3.22 4.21 7.10 11.73
(3.09–4.03) (2.50–4.13) (3.79–6.67) (6.72–7.51) (10.90–12.63)
5352 15 476 15 788 20 484 10 325
1.00 1.17 1.27 1.14 1.30
– (1.13–1.21) (1.23–1.31) (1.11–1.18) (1.26–1.34)
176 457 417 625 302
452 438 389 959 934
Downloaded from http://eurpub.oxfordjournals.org/ by guest on June 5, 2016
The prevalence of diabetes among the working population in Denmark is relatively low when compared with prevalence within the population as a whole.8 This can be accounted for by the fact that T2DM prevalence is directly related to age and excluding everyone over 59 years of age at baseline inevitably limits the size of the study population. Nonetheless, the observed cases of disability retirement represent >10% of the study population. Given the individual, social and economic consequences of disability retirement, 10% permanently leaving the labour market over a 10-year period represents a notable level of attrition. In terms of direct causality, work factors alone may account for a proportion of the observed inequalities, but clearly work is not the sole cause of structural inequalities in health. We must also recognize the potential for endogenity in our results, as people who develop T2DM are also vulnerable to other risk factors that could directly or indirectly lead to premature exit from the workforce. Yet while work alone is not the only source of health inequalities it is, nonetheless, one of the social structures in which health inequality is most clearly articulated. As such, it provides an ideal arena to address and tackle health inequalities and our results support the view that health professionals should target specific
Occupational status and disability retirement among employees with diabetes
Key points The study presents comprehensive population data concerning disability retirement among people with diabetes in the workforce. More than 10% of the study population went into early retirement during the 10-year follow-up period. Occupational status and diabetes have a compound impact on the risk of early retirement, with a 1173% risk differential between individuals in the highest occupational group without diabetes and those in the lowest occupational group with diabetes. The results suggest that prolonging the working lives of people with diabetes requires attention, especially in occupations with low occupational status.
References 1
Breton MC, Guenette L, Amiche MA, et al. Burden of diabetes on the ability to work: a systematic review. Diabetes Care 2013;36:740–9.
2
Herquelot E, Gueguen A, Bonenfant S, et al. Impact of diabetes on work cessation: data from the GAZEL cohort study. Diabetes Care 2011;34:1344–9.
3
Von Korff M, Katon W, Lin EH, et al. Work disability among individuals with diabetes. Diabetes Care 2005;28:1326–32.
4
Vijan S, Hayward RA, Langa KM. The impact of diabetes on workforce participation: results from a national household sample. Health Serv Res 2004;39:1653–69.
5
Agardh E, Allebeck P, Hallqvist J, et al. Type 2 diabetes incidence and socio-economic postion: a systematic review and meta-analysis. Int J Epidemiol 2011;40:804–18.
6
Minkler M, Fuller-Thomson E, Guralnik JM. Gradient of disability across the socioeconomic spectrum in the United States. N Engl J Med 2006;355:695–703.
7
Lahelma E, Uusitalo H, Martikainen P. Editorial: longer work careers through tackling socioeconomic inequalities in disability retirement. Eur J Public Health 2012;22:299–300.
8
Carstensen B, Kristensen JK, Marcussen MM, et al. The national diabetes register. Scand J Public Health 2011;39:58–61.
9
Hjollund NH, Breinholt Larsen F, Andersen JH. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a populationbased survey. Scand J Public Health 2007;35:497–502.
Acknowledgements The authors would like to acknowledge the assistance of Jens Worm Begtrup from the National Center for the Working Environment for his assistance in the preparation of the data and to Ingrid Willaing of Steno Diabetes Center for her comments on an earlier draft of the article. The data was presented in poster form at the American Diabetes Association annual conference in June 14–17 2014, held in San Francisco. Conflicts of interest: Bryan Cleal and Kjeld Poulsen are employed by Steno Diabetes Center A/S, a research hospital working in the Danish National Health Service. Steno Diabetes Center receives part of its core funding from unrestricted grants from the Novo Foundation and Novo Nordisk A/S.
10 Imkampe AK, Gulliford M. Increasing socio-economic inequality in type 2 diabetes prevalence—repeated cross-sectional surveys in England 1994–2006. Eur J Public Health 2010;21:484–90.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on June 5, 2016
groups, such as employees with diabetes engaged in occupations which confer low occupational status. The relative risks revealed in our study are especially concerning given that there is evidence to suggest levels of social inequality in prevalent T2DM are on the increase.10 Assuming these trends continue there will, both proportionally and numerically, be more individuals with diabetes with a relatively high risk of disability retirement. Targeting primary, secondary and tertiary prevention to the groups that need it most thus seems a potentially important strategy in attempts to prolong the working lives of individuals. It is a weakness of our data that we are not able to distinguish between T1DM and T2DM. Future work in this area should investigate different paths to disability among people with diabetes with more precision. The dataset is, however, also the strength of this study and using comprehensive population data has allowed us to provide strong evidence for the level of social inequality in disability retirement among people with diabetes. In addition to the patent moral and social arguments for addressing inequality, the data we present here also support the inference of economic ramifications. In countries with an ageing workforce, it is inevitable that we will see increasing numbers of individuals with chronic conditions within the labour force. Raising the retirement age is, thus, an insufficient solution to the economic problems an ageing workforce poses, unless accompanied by strategies to help those most at risk of disability retirement.
619
