Journal of Racial and Ethnic Health Disparities

https://doi.org/10.1007/s40615-018-0477-y

HRQOL in Diverse Ethnic Groups with Diabetes: Findings

from the 2014 BRFSS
Kelley Newlin Lew 1 & Julie Wagner 2 & Omar Braizat 1

Received: 19 June 2017 / Revised: 16 September 2017 / Accepted: 27 February 2018

# W. Montague Cobb-NMA Health Institute 2018

Abstract
Objective The study’s objective is to examine differences in mental and physical health-related quality of life (HRQOL) in non-
Hispanic Whites, non-Hispanic Blacks, and Hispanics adults with diabetes.
Design A secondary analysis of 2014 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted. A total of 26
states participated in the 2014 BRFSS core and optional diabetes models (n = 17,923). HRQOL was measured by the number of
mentally and physically unhealthy days during the past month, respectively. A series of regression models were developed to assess
differences in HRQOL without and with inclusion of demographic (age, marital status, income, gender, and education) and
diabetes-related (depression, sleep time, insulin use, complications, age of diabetes diagnosis, BMI, smoking, and exercise) factors.
Results In the fully adjusted models (inclusion of demographic and diabetes-related factors), non-Hispanic Whites had more
mentally (β = 0.88, p = 0.03) and physically (β = 1.35, p = 0.01) unhealthy days per month compared to Hispanics. Non-Hispanic
Blacks (β = 1.42, p < 0.0001) also had more mentally unhealthy days per month in relation to Hispanics when adjusting for
demographic and diabetes-related factors. Depression emerged as a potent predictor of mentally (β = 8.60; p < 0.0001) and
physically (β = 4.43; p < 0.0001) unhealthy days in the multivariate models.
Conclusion Non-Hispanic Black and White adults with diabetes may be more vulnerable to poor HRQOL compared to their
Hispanic counterparts. Increased, widened application of diabetes interventions targeting depression appears warranted to im-
prove HRQOL outcomes.

Keywords Health-related quality of life . Diabetes . Ethnic minorities

Ethnic minorities are disproportionately burdened by diabetes
and its secondary complications. Among United States (US)
adults,Hispanics(12.8%)andnon-HispanicBlacks(13.2%)have
higher rates of diabetes relative to non-Hispanic Whites (7.6%)
[1]. Whereas diabetes treatment aims to optimize diabetes clinical
outcomes, such as prevention or amelioration of secondary com-
plications, an associated aim is quality of life (QOL) [2].
Compelling evidence suggests that QOL uniquely contributes
to mortality, independent of duration of diabetes, smoking status,
glycemic control, and diabetes-related complications [3, 4].
Among those burdened by diabetes, addressing QOL may im-
prove the subjective experience of living with this progressive,
chronic disease while also reducing risk for pre-mature mortality.
* Kelley Newlin Lew
kelley.newlin_lew@uconn.edu
1
University of Connecticut, Storrs, CT, USA
2
University of Connecticut Health Center, Farmington, CT, USA
QOL is a multidimensional construct that captures an indi-
vidual’s subjective perception of physical, emotional, and so-
cial well-being. This global construct also captures specific
subdomains, such as health, with attention, for example, to
both subjective mental and physical health-related (HR)QOL
[5].
Although US health policy has focused on eliminat-
ing health disparities over the last two decades, it re-
mains uncertain which ethnic groups with diabetes are
disproportionately burdened by poor health-related qual-
ity of life (HRQOL). To more fully understand and,
thereby, contribute to elimination of HRQOL disparities
in diverse diabetes populations, additional research is
warranted. Thus, the purpose of this study is to examine
differences in mental and physical HRQOL in non-
Hispanic Whites, non-Hispanic Blacks, and Hispanics
with consideration of demographic and diabetes-related
(depression, sleep time, insulin use, complications, age
of diabetes diagnosis, body mass index [BMI], smoking,
and exercise) factors.

Literature Review
HRQOL
A growing number of studies have examined levels of HRQOL
across ethnically diverse US diabetes populations with varied
findings reported [6–11]. Analysis of 2001–2010 National
Health and Nutrition Examination Survey (NHANES) data
(n = 2594), for example, revealed that Hispanics with diabetes
had more optimal mental and physical HRQOL compared to
their non-Hispanic White counterparts. Differences in mental or
physical HRQOL between non-Hispanic Whites and Blacks
were not observed [8]. Another study, sampling older adults
with diabetes (N = 6096), reported both Hispanics and Blacks
had more optimal physical, but not mental, HRQOL in relation
to Whites [9]. Additional research (n = 21,504) suggests that
Hispanics may have better HRQOL compared to Blacks and
Whites [6]. Yet, the Diabetes Attitudes, Wishes, and Needs
study (n = 1055) found that Hispanics with diabetes had poorer
QOL in relation to African Americans but not Whites [11].
Mixed findings across the literature may reflect varied mea-
surement of HRQOL, sampling frames, and adjustments for
covariates. Across the literature, salient covariates—such as
depression, sleep patterns or quality, insulin use, age of diabe-
tes diagnosis, diabetes-related complications, BMI, smoking,
and exercise—are not consistently included in the analyses in
examining differences in HRQOL across diverse ethnic
groups [6–10]. Inadequate selection of important background
variables affecting the dependent variables, such as mental
and physical HRQOL, may lead to omitted variable bias. In
multivariate modeling, adequate inclusion of background var-
iables is critical in order to adjust for differences in the sample
population and allow for more precise comparisons across
groups, thereby enhancing validity of the study findings.
Depression and HRQOL
Depression is a well-established co-morbidity of diabetes.
Depression is a chronic disease characterized by symptoms that
may include poor mood, loss of interests or pleasure, sleep distur-
bance, and appetite changes [12]. Among Hispanics, Blacks, and
Whites with diabetes, data tend to suggest that depression preva-
lence is fairly comparable and often estimated at ~ 30% across
groups [13–16]. A body of research suggests that depression is a
strong predictor of HRQOL in populations with diabetes. A sys-
tematic review (N = 14) reported depressive symptoms dimin-
ished HRQOL, particularly its mental health dimension, across
both global and disease-specific measures [17].
Sleep and HRQOL
Among people with diabetes, sleep patterns or quality may be
disrupted by inadequate sleep (< 7 h per night), insomnia,
J. Racial and Ethnic Health Disparities
nocturia, obstructive sleep apnea (OSA), and restless leg syn-
drome (RLS), which, in turn, may diminish HRQOL.
Analysis of 2005–2008 NHANES data revealed that adults
with diabetes were at higher risk for sleep problems (particu-
larly nocturia, inadequate sleep, OSA, and symptoms of RLS),
relative to the general population, after adjustment for condi-
tions contributing to poor sleep [18]. Additional research sug-
gests that poor sleep quality or problems are related to decre-
ments in mental and physical HRQOL in diabetes populations
[19, 20]. The relationship of OSA and RLS to HRQOL in
diabetes populations is understudied. However, related re-
search suggests that both conditions may compromise
HRQOL [21, 22].
Insulin Therapy and HRQOL
Insulin therapy, for some with diabetes, may be demanding in
terms of daily self-management and elicit fear, secondary to
risk for hypoglycemia, and thereby potentially affect HRQOL
[23–25]. Research results are mixed in terms of the relation-
ship of insulin therapy to HRQOL. Analysis of Behavioral
Risk Factor Surveillance System (BRFSS) data revealed,
among older adults with diabetes, that mental and physical
HRQOL were reduced for those treated with insulin compared
to those not treated with insulin in the adjusted models [26].
Findings from the Diabetes Control and Complications Trial
(DCCT), however, indicate that intensive multiple daily injec-
tion therapy is not associated with decrements in HRQOL in
patients with type 1 diabetes (T1D) [27]. Yet, among those
with type 2 diabetes (T2D), a number of reports suggest insu-
lin therapy may contribute to poor HRQOL [28–30].
Diabetes-Related Complications and HRQOL
Diabetes-related complications include nephropathy, retinop-
athy with or without visual impairment, stroke, and myocar-
dial infarction, among others. Research findings suggest that
diabetes-related complications contribute to reduced HRQOL
[30–33]. For example, analyzing a longitudinal data set repre-
sentative of diabetes patients from 20 countries in Australasia,
Asia, Europe, and North America, the relationship of HRQOL
to diabetes-related complications was assessed on four occa-
sions over a 5-year period. Findings revealed that the presence
of having any diabetes-related complication (e.g., stroke,
myocardial infarction, ischemic heart disease, renal failure,
and blindness) significantly reduced HRQOL scores while
adjusting for baseline age, sex, and economic region [32].
BMI and HRQOL
BMI is a metric based on height and weight that may be used
to assess weight categories for both adult men and women.
Standard weight categories are underweight (BMI < 18.5),
J. Racial and Ethnic Health Disparities
normal or healthy weight (BMI = 18.5–24.9), overweight
(BMI = 25.0–29.9, and obese (BMI ≥30). It is well established
that, among populations with diabetes, an elevated BMI, indic-
ative of overweight or obesity, may contribute to poor HRQOL
[8, 28, 30, 34, 35]. For example, in the Canadian Community
Health Survey Cycle 1.1 (n = 5497), determinants of HRQOL
in adults with T2D were examined with multivariate analyses.
Results revealed obesity provided significant explanatory pow-
er in predicting HRQOL [30]. Analyzing 2001–2010
NHANES data (n = 2594) to investigate predictors of
HRQOL in diverse ethnic groups with diabetes, another study
reported that an increased BMI negatively predicted physical
HRQOL. Among non-Hispanic Whites, being overweight
contributed to more limited activity days while being obese
predicted more frequent physically unhealthy days for non-
Hispanic Blacks [8].
Smoking and HRQOL
In diabetes populations, several studies report that smoking is
related to poorer HRQOL [8, 2834, 35]. In addition to in-
creased BMI, the 2001–2010 NHANES study also reported
current smoking status was a significant predictor of poorer
mental and physical HRQOL for non-Hispanic Whites and
Blacks, but not Hispanics, with diabetes [8]. Similarly, the
Alberta Longitudinal Exercise and Diabetes Research
Advancement study reported being a non-smoker predicted
more optimal HRQOL in adults with T1D (N = 490) and
T2D (N = 1147), respectively [34, 35].
Exercise and HRQOL
A positive relationship between exercise and HRQOL in pop-
ulations with diabetes is well documented [28, 30, 36–41]. For
example, a study (n = 173), ancillary to the Health Benefits of
Aerobic and Resistance Training in individuals with type 2
Diabetes (HART-D), investigated the effect of aerobic
training, resistance training, or a combination of resis-
tance and aerobic training, versus a non-exercise control
group, on HRQOL [36]. Improvements in physical
HRQOL were observed in all treatment conditions in
relation to the non-exercise control group. Another clin-
ical trial (N = 43) similarly reported a combined aerobic-
resistance exercise intervention improved HRQOL, both
mental and physical, compared to the non-exercise con-
trol group [38].
The present study, informed by this body of research, ex-
amines levels of mental and physical HRQOL across diverse
US diabetes populations with consideration of demographic
(age, marital status, income, gender, and education) and
diabetes-related (depression, sleep time, insulin use, compli-
cations, age of diabetes diagnosis, BMI, smoking, and
exercise) factors. In so doing, the following research questions
are posed:
1. Across Hispanic, non-Hispanic Black, and non-Hispanic
White populations with diabetes, are there significant dif-
ferences in mental and physical HRQOL?
2. Across Hispanic, non-Hispanic Black, and non-Hispanic
White populations with diabetes, are there significant dif-
ferences in mental and physical HRQOL following ad-
justments for demographics?
3. Across Hispanic, non-Hispanic Black, and non-Hispanic
White populations with diabetes, are there significant dif-
ferences in mental and physical HRQOL following ad-
justments for demographics and diabetes-related factors?
Methods
Study Design and Data Source
A secondary quantitative analysis of cross-sectional
2014 BRFSS data was conducted. The BRFSS is an ongoing,
annual surveillance system designed to measure behavioral risk
factors for the non-institutionalized adult population residing in
the USA and participating territories (District of Columbia,
Puerto Rico, and Guam), referred to as states in this document
consistent with BRFSS terminology. Administered and sup-
ported by the Centers for Disease Control (CDC), the BRFSS
consists of a (1) core component (administered across all states)
and (2) optional modules (administered selectively across
states) (see the BMeasures^ section) [42].
Sample
The BRFSS is a state-based system of telephone surveys
(landline and cellular) that selects adults aged ≥ 18 years with
random dialing procedures. In conducting the BRFSS landline
telephone survey, data were collected from a randomly select-
ed adult in a household. In conducting the cellular telephone
version of the BRFSS questionnaire, data were collected from
adults with a cellular telephone and residing in a private res-
idence or college housing [42].
The BRFSS provides no direct method of accounting for
non-telephone coverage. Therefore, the BRFSS uses a weight-
ed method, iterative proportional fitting (or raking). Raking
allows for the incorporation of cellular telephone survey data.
Raking adjusts the data to ensure that underrepresented groups
are more accurately represented in the final data set with re-
duction of error within estimates [42].
In our secondary analysis, landline or cellular participants
from those states administering the BRFSS’ optional diabetes
module (see the BMeasures^ section) were included. In 2014,

a total of 26 states collected optional diabetes module data:
Alaska, Arizona, Connecticut, Delaware, District of Columbia,
Florida, Georgia, Guam, Indiana, Iowa, Louisiana, Maine,
Mississippi, Nebraska, New Jersey, New Mexico, North
Dakota, Ohio, Puerto Rico, South Carolina, South Dakota,
Tennessee, Texas, Virginia, West Virginia, and Wyoming [43].
Measures
The BRFSS core component is a standard set of questions
administered to participants across all states in English and
Spanish, accordingly. Core content includes demographics
and items addressing HRQOL, specific health conditions (e.-
g., diabetes, blindness, stroke, heart attack, kidney disease,
and depression), and health behaviors (e.g., smoking and ex-
ercise). Additionally, the core content assesses BMI, age of
diabetes diagnosis, and hours of sleep in a 24-h period. The
optional diabetes module includes items assessing insulin use
and diabetes eye disease or retinopathy [44].
In the present study, the following BRFSS demographic
variables were included: age, marital status, annual income,
gender, education, and ethnicity. Age was assessed ordinally
using the BRFSS calculated variable for a six-level imputed
age category (age 18–24 years, age 25–34 years, age 35–
44 years, age 45–54 years, age 55–64 years, age ≥65 years).
Marital status was assessed nominally (married; divorced,
widowed, or separated; never married; or member of
an unmarried couple). Annual income was assessed
ordinally: < $25,000, $25,000 to $34,999, $35,000 to
$49,999, $50,000 to $74,999, and ≥$75,000. Gender was
assessed dichotomously (male or female). Education was
assessed ordinally (never attended school or only attended
kindergarten, grades 1–8 [elementary school], grades 9–11
[some high school], grade 12 or GED [high school graduate],
college 1–3 years [some college or technical school],
college ≥ 4 years [college graduate]). Ethnicity was
assessed nominally using the BRFSS calculated variable
for racial/ethnic categories with specific capture of
White only, non-Hispanic; Black only, non-Hispanic;
and Hispanic only [44, 45].
HRQOL was measured continuously, in terms of the fre-
quency of suboptimal physical or mental health days over the
past month, respectively. In terms of physical health, respon-
dents were asked: BNow thinking about your physical health,
which includes physical illness and injury, for how many days
during the past 30 days was your physical health not
good?^ With respect to mental health, respondents were
asked: BNow thinking about your mental health, which
includes stress, depression, and problems with emotions,
for how many days during the past 30 days was your
mental health not good?^ [44].
Diabetes-related factors included health conditions, which
were measured dichotomously. Health conditions were
J. Racial and Ethnic Health Disparities
assessed with the following items: (1) Bever told you have
diabetes?^, (2) Bare you blind or do you have serious difficulty
seeing, even when wearing glasses?^, (3) B ever told you that
diabetes has affected your eyes or that you had retinopathy?^,
(4)Bever told you had angina or coronary heart disease?^, (5)
Bever told you had a stroke?^, (6) Bever told you had a heart
attack, also called a myocardial infarction?^, (7) Bever told
you have kidney disease?^ (do not include kidney stones,
bladder infection or incontinence), and (8) Bever told you have
depressive disorder, including depression, major depression,
dysthymia, or minor depression?^ [44] We created a comor-
bidities variable reflecting the presence or absence of the fol-
lowing: (1) blindness or difficulty seeing, (2) diabetes
eye disease or retinopathy, (3) angina or coronary heart
disease, (4) heart attack, (5) stroke, (6) kidney disease,
and (7) depression to assist in describing our sample in
the bivariate analyses.
Other diabetes-related factors included age of diabetes diag-
nosis (measured continuously), insulin use (measured dichoto-
mously), and hours of sleep in a 24-h period (measured contin-
uously). Additionally, BMI was assessed with an ordinal calcu-
lated variable coded to reflect overweight (BMI = 25.0–29.9),
obesity (BMI ≥ 30), or not (BMI < 25.0) based on partici-
pant self-report of height and weight. Smoking status was
measured dichotomously with the BRFSS calculated var-
iable assessing the presence or absence of current ciga-
rette smoking. Exercise was likewise assessed dichoto-
mously with the following item: BDuring the past month,
other than your regular job, did you participate in any
physical activities or exercises such as running, calisthen-
ics, golf, gardening, or walking for exercise?^ [44, 45].
Data Analysis
SAS version 9.4 was used to analyze all data with the CDC
weighting two-part weight methodology (design weight and
raking) to adjust for non-coverage and non-response in admin-
istering the BRFSS, thereby forcing the total number of cases
to equal population estimates for each geographic region.
CDC weighting helps to adjust for assumption violations
when deviations from assumptions are large enough to affect
the results. Use of the two-part weight methodology is neces-
sary to make generalizations from the sampled population to
the general population [42, 43, 46].
All analyses were conducted using SAS SURVEY proce-
dures. To describe the sample, we calculated percentages,
standard errors, and 95% confidence intervals with computa-
tion of Rao-Scott chi-square test statistics for dichotomous
and ordinal level variables across ethnic groups. We computed
means and standard errors across ethnic groups for continuous
variables. Additionally, we assessed HRQOL by comorbidi-
ties. To answer research question no. 1, simple linear regres-
sion models assessed differences in HRQOL, both physical
J. Racial and Ethnic Health Disparities
and mental HRQOL, respectively, with non-Hispanic Whites
and Hispanics as the referent groups in separate models. To
answer research question no. 2, demographic factors (age,
marital status, income, gender, and education) were added into
the regression equations simultaneously. For research ques-
tion no. 3, diabetes-related factors (depression, sleep time,
insulin use, complications, age of diabetes diagnosis, BMI,
smoking, and exercise) were next added into the multiple re-
gression equations simultaneously.
Results
The sample (N = 17,923) was composed largely of non-
Hispanic Whites (73.9%), followed by non-Hispanic
Blacks (13.9%), and then Hispanics (12.2%). In terms
of age, most non-Hispanic Whites (72.8%) and, to a less-
er degree, non-Hispanic Blacks (63.5%) and Hispanics
(62.3%) were ≥ 55 years of age. A majority of non-
Hispanic Whites (88.3%), and fewer non-Hispanic
Blacks (79.3%) and Hispanics (59.0%), completed high
school or more. With respect to income, a majority of
Hispanics (64.8%) and non-Hispanic Blacks (50.8%)
had an annual income of < $25,000 (see Table 1).
With respect to diabetes-related factors, non-Hispanic
Whites (26.8%) and Hispanics (26.3%) more frequently re-
ported depression compared to non-Hispanic Blacks (20.5%).
Age of diabetes diagnosis was lower for Hispanics (M = 45.9,
SE = 0.69) and non-Hispanic Blacks (M = 45.8, SE = 0.51)
compared to non-Hispanic Whites (M = 50.3, SE = 0.26). In
terms of heart disease and heart attack, non-Hispanic Whites
(16.3, 15.4%) had the highest rates, followed by non-Hispanic
Blacks (12.1, 10.7%) and Hispanics (10.5, 10.1%). Rates of
self-reported stroke were highest among non-Hispanic Blacks
(10.4%) compared to non-Hispanic Whites (8.5%) and
Hispanics (6.5%). Differences in diabetes eye disease and
blindness were observed with non-Hispanic Blacks (23.0,
12.4%) and Hispanics (20.6, 13.2%) reporting higher rates
in relation to non-Hispanic Whites (16.5, 9.1%), respectively.
Non-Hispanic Blacks (18.6%) more frequently reported cur-
rent smoking compared to non-Hispanic Whites (15.2%) and
Hispanics (13.2%) (see Table 2).
In assessing levels of HRQOL, we observed that non-
Hispanic Blacks, on average, had more suboptimal mental
(M = 5.3, SE = 0.41) and physical (M = 8.4; SE = 0.46)
HRQOL days per month compared to non-Hispanic Whites
(M = 4.6, SE = 0.16; M = 7.8, SE = 0.19) and Hispanics (M =
4.4, SE = 0.37; M = 7.9, SE = 0.50), respectively (see Table 2).
With all ethnic groups combined, results showed that those with
one or more comorbidities had, on average, 7.0 (SE = 0.15)
mentally and 10.8 (SE = 0.24) physically poor HRQOL days
per month. In contrast, participants without comorbidities
tended to have 1.8 (SE = 0.22) mentally and 4.5 (SE = 0.22)
physically suboptimal HRQOL days per month.
Simple linear regression models revealed that the frequency
of poor mental HRQOL days did not significantly differ across
ethnic groups with Hispanics and non-Hispanic Whites as ref-
erent categories, respectively. However, adjusting for demo-
graphics (age, marital status, income, gender, and education),
non-Hispanic Whites had 1.54 (p < 0.0001) and non-Hispanic
Blacks had 1.02 (p = 0.04) more poor mental HRQOL days per
month, on average, compared to Hispanics. Adjusting for de-
mographics and diabetes-related factors (depression, sleep time,
insulin use, complications, age of diabetes diagnosis, BMI,
smoking, and exercise) in the fully adjusted model, these rela-
tionships persisted. Non-Hispanic Whites, on average, had 0.88
(p = 0.03) more days of poor mental HRQOL days per month in
relation to Hispanics. Likewise, non-Hispanic Blacks tended to
have 1.42 (p < 0.01) more days of poor mental HRQOL per
month compared to their Hispanic counterparts. Depression
emerged as the most potent predictor of mental HRQOL (β =
8.60, SE = 0.40, p < 0.0001) (see Table 3).
In terms of poor physical HRQOL days, simple linear re-
gression models revealed no significant differences across eth-
nic groups. Yet, adjusting for demographics, non-Hispanic
Whites (2.04 days, p < 0.0001) tended to have more subopti-
mal physical HRQOL days per month than Hispanics . This
relationship remained in the fully adjusted model, controlling
for demographics and diabetes-related factors. Specifically,
non-Hispanic Whites had, on average, 1.35 more days of poor
physical HRQOL per month compared to Hispanics
(p = 0.01). No significant differences in physical HRQOL
were observed between non-Hispanic Blacks and Hispanics.
Yet, non-Hispanic Blacks (-1.23 days, p = 0.004) had fewer
poor physical health days, relative to their White peers, when
adjusting for demographics only. As with mental HRQOL,
depression provided substantial explanatory power for physi-
cal HRQOL (β = 4.43, SE = 0.40, p < 0.0001) (see Table 4).
Discussion
This is the first study (N = 17,923), to our knowledge, that has
examined differences in mental and physical HRQOL across
diverse ethnic groups with diabetes while considering both
demographic (age, marital status, income, gender, and educa-
tion) and several salient diabetes-related (depression, sleep
time, insulin use, complications, age of diabetes diagnosis,
BMI, smoking, and exercise) factors using a largely nationally
representative sample of adults with diabetes. Our multivariate
modeling included critical demographic and diabetes-related
factors to adjust for differences in the sample population, and
thereby, allow for increased precision in comparing groups to
enhance the validity of our findings.
 J. Racial and Ethnic Health Disparities

Table 1 Weighted demographic characteristics by ethnic group

Ethnic group Non-Hispanic Whites Non-Hispanic Blacks Hispanics

n = 13,239 n = 2494 n = 2190
Demographic factors % (SE) % (SE) % (SE) p value
95% CI 95% CI 95% CI

Female 45.6 (0.88) 58.3 (2.10) 48.35 (2.37) < 0.0001

43.88–47.32 54.17–62.42 43.71–53.00
Age < 0.0001
18–24 years 1.0 (0.20) 1.0 (0.44) 0.5 (0.23)
0.50–1.30 0.13–1.84 0.06–0.94
25–34 years 2.6 (0.32) 3.1 (0.63) 5.0 (1.09)
1.93–3.18 1.84–4.33 2.83–7.12
35–44 years 7.1 (0.53) 10.9 (1.35) 10.7 (1.47)
6.03–8.10 8.26–13.56 7.84–13.59
45–54 years 16.7 (0.73) 21.5 (1.69) 21.5(1.80)
15.23–18.11 18.19–24.82 17.96–25.03
55–64 years 28.3 (0.83) 34.2 (2.18) 30.3 (2.32)
26.67–29.91 29.96–38.49 25.78–34.90
≥65 years 44.5 (0.81) 29.3 (1.86) 32.0 (2.12)
42.88–46.16 25.64–32.94 27.81–36.13
Education < 0.0001
≤ Kindergarten 0.2 (0.11) <0.1 (0.05) 2.8 (0.74)
0.00–0.41 0.00–0.15 1.40–4.30
Grades 1–8 2.3 (0.21) 4.4 (0.68) 20.7 (1.60)
1.84–2.68 3.04–5.73 17.57–23.86
Grades 9–11 9.2 (0.53) 16.3 (1.72) 17.4 (1.96)
8.21–10.30 12.92–19.67 13.60–21.27
Grade 12 or GED 32.9 (0.78) 34.6 (2.25) 27.9 (2.23)
31.39–34.45 30.19–39.03 23.52–32.28
College (1–3 years) or technical school 34.8 (0.88) 27.6 (1.74) 18.9 (2.00)
33.10–36.56 24.19–31.02 15.01–22.86
College graduate ( ≥4 years) 20.6 (0.68) 17.1 (1.38) 12.2 (1.32)
19.23–21.90 14.36–19.75 9.58–14.74
Marital status < 0.0001
Married 60.9 (0.83) 43.2 (2.11) 56.3 (2.33)
59.29–62.53 39.0–47.30 51.78–60.92
Divorced/separated/widowed 28.9 (0.71) 38.5 (2.21) 29.5 (2.01)
27.54–30.31 34.13–42.78 25.56–33.45
Never married 8.2 (0.49) 17.4 (1.55) 9.1 (1.75)
7.28–9.21 14.32–20.39 5.65–12.51
Member of unmarried couple 1.9 (0.37) 1.0 (0.29) 5.1 (0.95)
1.20–2.64 0.44–1.58 3.19–6.93
Annual income < 0.0001
< $25,000 33.6 (0.80) 50.8 (2.12) 64.8 (2.44)
32.06–35.19 46.67–54.97 60.01–69.56
$25,000–$34,999 12.0 (0.50) 13.7 (1.39) 11.2 (1.77)
11.00–12.95 10.98–16.44 7.78–14.73
$35,000–$49,999 15.9 (0.62) 10.8 (1.0) 7.8 (1.19)
14.69–17.14 8.81–12.72 5.52–10.18
$50,000–$74,999 15.9 (0.73) 11.2 (1.23) 7.0 (1.03)
14.42–17.29 8.82–13.64 5.01–9.07
≥ $75,000 22.6 (0.76) 13.5 (1.50) 9.1 (1.90)
21.13–24.13 10.54–16.40 5.34–12.80

Note: CI confidence interval; p values based on the x2 test

J. Racial and Ethnic Health Disparities

Table 2 Weighted diabetes-related factors and HRQOL by ethnic group

Ethnic group Non-Hispanic Whites Non-Hispanic Blacks Hispanics

n = 13,239 n = 2494 n = 2190
% (SE) % (SE) % (SE) p value
95% CI 95% CI 95% CI

Diabetes-related factors
Insulin use 31.0 (0.86) 38.8 (2.21) 32.3 (2.28) 0.004
29.31–32.67 34.51–43.15 27.79–36.75
Age diabetes diagnosis, years (M), range 1–96 50.3 (0.26) 45.8 (0.51) 45.9 (0.69) < 0.0001
49.77–50.80 44.76–46.76 44.58–47.29
Nightly sleep time, hours (M), range 1–22 7.0 (0.03) 7.0 (0.11) 6.9 (0.06) < 0.0001
6.99–7.10 6.77–7.19 6.82–7.07
Depressiona 26.8 (0.71) 20.5 (1.73) 26.3 (2.16) 0.01
25.38–28.18 17.14–23.94 22.06–30.52
Diabetes eye diseasea 16.5 (0.66) 23.0 (1.65) 20.6 (1.73) < 0.001
15.25–17.85 19.76–26.24 17.21–23.98
Blindnessa 9.1 (0.46) 12.4 (1.36) 13.2 (1.20) 0.001
8.18–9.99 9.74–15.06 10.82–15.54
Chronic kidney diseasea 8.4 (0.38) 8.7 (1.08) 9.9 (1.88) 0.62
7.67–9.18 6.62–10.85 6.24–13.60
Heart diseasea 16.3 (0.70) 12.1 (1.56) 10.5 (1.43) < 0.01
14.90–17.65 9.07–15.21 7.66–13.25
Strokea 8.5 (0.47) 10.4 (1.10) 6.5 (1.11) 0.04
7.54–9.40 8.24–12.55 4.37–8.72
Heart attacka 15.4 (0.69) 10.7 (1.07) 10.1 (1.22) < 0.0001
14.09–16.80 8.55–12.77 7.67–12.45
Comorbiditya 56.3 (0.89) 52.5 (2.20) 54.0 (2.36) 0.27
54.53–58.01 48.24–56.85 49.39–58.65
Obesitya 54.6 (0.89) 57.9 (2.13) 51.4 (2.36) 0.09
52.85–56.33 53.74–62.10 46.74–56.00
Smokinga 15.2 (0.66) 18.6 (1.60) 13.2 (1.72) 0.05
13.89–16.48 15.43–21.71 9.81–16.56
Exercisea 63.2 (0.87) 60.9 (2.25) 57.3 (2.37) 0.06
61.50–64.89 56.55–65.36 52.69–61.98
HRQOL
Poor physical health, days per month (M) range 0–30 7.8 (0.19) 8.4 (0.46) 7.9 (0.50) < 0.0001
7.48–8.22 7.51–9.32 6.97–8.94
Poor mental health, days per month (M), range 0–30 4.6 (0.16) 5.3 (0.41) 4.4 (0.37) < 0.0001
4.25–4.89 4.49–6.08 3.71–5.17

Note: CI confidence interval; p values based on the x2 test

NA not available
a
Presence of disease state or behavior

With respect to research question no. 1, no significant dif-
ferences in the number of poor mental and physical HRQOL
days per month, across ethnic groups, were observed in the
unadjusted models. In terms of research question no. 2, find-
ings revealed that (1) non-Hispanic Whites and Blacks had
more poor mental HRQOL days per month in relation to
Hispanics; (2) non-Hispanic Whites had a greater number of
poor physical HRQOL days per month compared to
Hispanics; and (3) non-Hispanic Blacks had fewer poor phys-
ical HRQOL days per month compared to non-Hispanic
Whites when adjusting for demographic factors. When
holding demographic and diabetes-related factors constant
for research question no. 3, results showed that (1) non-
Hispanic Whites and Blacks had more poor mental HRQOL
days per month compared to Hispanics and (2) non-Hispanic
Whites had more poor physical HRQOL days per month in
relation to Hispanics.
Overall, our results reveal that non-Hispanic Blacks and
Whites have increased burden of poor HRQOL compared to
Hispanics. To date, differences in mental HRQOL between
Blacks and Hispanics remain understudied. In terms of mental
HRQOL, one study, sampling patients seeking care in general
 J. Racial and Ethnic Health Disparities

Table 3 Simple and multiple

linear regression models Intercept Unadjusted Demographics Adjusted Fully Adjusted
predicting poor mental Model Model Model
health days R2 R2 R2
β (SE) p β (SE) p β (SE) p

Ethnic group < 0.001 0.07 0.28

Non-Hispanic White (Hispanic referent) − 0.03 (0.38) 1.54 (0.40) < 0.0001 0.88 (0.40) 0.03
0.94
Non-Hispanic Blacks (Hispanic referent) 0.63 (0.50) 1.02 (0.50) 0.04 1.42 (0.51) < 0.01
0.21
Non-Hispanic Blacks (Non-Hispanic 0.66 (0.40) − 0.52 (0.42) 0.21 0.54 (0.38) 0.15
White referent) 0.10
Demographics
Age − 1.43 (0.14) < 0.0001 − 0.87 (0.17)
< 0.0001
Income − 1.03 (0.11) < 0.0001 − 0.45 (0.10)
< 0.0001
Education − 0.20 (0.13) 0.12 − 0.04 (0.12) 0.72
Gendera 0.98 (0.26) < 0.001 0.23 (0.25) 0.34
Marital status 0.21 (0.21) 0.33 0.13 (0.18) 0.48
Diabetes-related factors
Insulin useb − 0.09 (0.28) 0.76
Age diabetes diagnosis < 0.01 (0.01) 0.94
Nightly sleep time − 0.25 (0.12) .04
Depressionb 8.60 (0.40)
< 0.0001
Diabetes eye diseaseb 0.60 (0.38) 0.12
Blindnessb 2.22 (0.45)
< 0.0001
Chronic kidney diseaseb 0.09 (0.49) 0.86
Heart diseaseb 0.85 (0.39) 0.03
Strokeb 0.07 (0.46) 0.87
Heart attackb 0.52 (0.39) 0.18
BMI 0.43 (0.12)
< 0.001
Exerciseb − 1.31 (0.26)
< 0.0001
Current smokerb − 0.96 (0.23)
< 0.0001
a
Males as reference group
b
Absence of disease state or behavior as reference group

medical settings, suggested that Blacks have comparable
levels of emotional well-being but marginally poorer role
limits due to emotional health in relation to Hispanics [6]. In
terms of mental and physical HRQOL, prior studies, consis-
tent with our findings, report differences between Whites and
Hispanics with diabetes. Similar to our findings, analysis of
2001–2010 NHANES data (n = 2594) revealed that Hispanics
had more optimal mental and physical HRQOL after adjust-
ments for age, sex, education, family poverty-income ratio,
BMI, smoking status, insurance coverage, diabetes duration,
and marital status [8]. Likewise, another study, sampling older
adults with diabetes (N = 6096) reported that Hispanics with
diabetes had more optimal physical HRQOL than their Whites
counterparts while holding demographics, health behaviors
(e.g., smoking and exercise), diabetes complications, and de-
pression, among other factors constant [9].
More optimal HRQOL among Hispanics, compared to
Blacks and Whites, may reflect increased social support.
Investigating the determinants of HRQOL in diverse ethnic
groups with diabetes, Zang and colleagues reported that,
among Hispanics, social support (specifically, being married
or living with a partner) was related to more optimal mental
and physical HRQOL [8]. Additional research suggests
Hispanics, but not Blacks, with diabetes benefit from social
support in the setting of stress with maintenance of stable
mental HRQOL across levels [47]. Additional research is
J. Racial and Ethnic Health Disparities

Table 4 Simple and multiple

linear regression models Intercept Unadjusted Demographics-adjusted Fully adjusted
predicting poor physical model model model
health days R2 R2 R2
β (SE) p β (SE) p β (SE) p

Ethnic group < 0.001 0.07 0.20

Non-Hispanic Whites (Hispanics referent) − 0.15 (0.51) 2.04 (0.52) < 0.0001 1.35 (0.53) 0.01
0.78
Non-Hispanic Blacks (Hispanics referent) 0.30 (0.61) 0.81 (0.60) 0.18 1.11 (0.65) 0.85
0.61
Non-Hispanic Blacks (non-Hispanic − 0.16 (0.41) − 1.23 (0.42) 0.004 − 0.23 (0.46) 0.61
Whites referent) 0.70
Demographics
Age − 0.28 (0.14) 0.05 − 0.13 (0.21) 0.52
Income − 1.78 (0.12) < 0.0001 − 1.05 (0.12)
< 0.0001
Education − 0.48 (0.16) 0.003 − 0.30 (0.15) 0.05
Gendera 0.20 (0.31) 0.53 − 0.10 (0.34) 0.77
Marital status − 0.23 (0.23) 0.33 − 0.42 (0.25) 0.08
Diabetes-related factors
Insulin useb 2.20 (0.42)
< 0.0001
Age diabetes diagnosis < 0.01 (0.01) 0.74
Nightly sleep time − 0.34 (0.11)
0.001
Depressionb 4.43 (0.40)
< 0.0001
Diabetes eye diseaseb 1.22 (0.47) < 0.01
Blindnessb 3.00 (0.57)
< 0.0001
Chronic kidney diseaseb 2.53 (0.61)
< 0.0001
Heart diseaseb 2.78 (0.49)
< 0.0001
Strokeb 1.93 (0.62) < 0.01
Heart attackb 0.51 (0.53) 0.33
BMI 0.60 (0.16)
< 0.001
Exerciseb − 3.38 (0.36)
< 0.0001
Current smokerb − 0.62 (0.25) 0.01
a
Males as reference group
b
Absence of disease state or behavior as reference group

needed to better understand why Hispanics with diabetes,
compared to their non-Hispanic Black and White counter-
parts, may have more optimal HRQOL in living with a
chronic, progressive disease.
Further, we identified depression, consistent with previous
research, as a potent predictor of HRQOL, especially mental
HRQOL [17]. Depression is a potentially modifiable predictor
of HRQOL through both screening and treatment. However,
in disadvantaged groups, rates of depression screening may be
suboptimal [48, 49]. Interdisciplinary team interventions im-
prove rates of depression screening and treatment while
culturally sensitive diabetes self-management interventions
improve levels of depression and HRQOL [50, 51].
Increased, widened application of such interventions appears
warranted to improve HRQOL outcomes, a primary goal of
diabetes care and education [2].
The present study uniquely examined differences in mental
and physical HRQOL while holding demographic (age, mar-
ital status, income, gender, and education) and diabetes-
related (depression, sleep time, insulin use, diabetes-related
complications, age of diabetes diagnosis, BMI, smoking,
and exercise) factors constant. Yet, despite inclusion of

multiple demographic and diabetes-related factors, as in-
formed by the literature, the fully adjusted models for mental
and physical HRQOL only accounted for about 30 and 20%,
respectively, of the variance in HRQOL. This indicates that
additional salient background factors contribute to HRQOL in
diverse populations with diabetes.
Unexamined in the present study, research suggests that race
or ethnic related variables may significantly contribute to
HRQOL in diverse ethnic groups, particularly Blacks. With
respect to mental HRQOL, Blacks have significantly higher
race-related stress and ethnic identity, relative to other groups,
with findings indicating that ethnic identity and cultural racism
may account for 16% of the total variance in HRQOL [52]. In
older Blacks, institutional racism has exclusively explained
18% of the total variance in mental HRQOL [53].
Also, among Whites with or without diabetes, research
indicates perceived discrimination is negatively related to
HRQOL [54, 55]. Further, among Blacks and Hispanics,
higher levels of perceived discrimination and racial disadvan-
tage are associated with decrements in HRQOL, [55, 56]. In
Hispanics, racial discrimination appears to effect mental
and physical HRQOL through anxiety symptoms although
additional factors may be operative [57].
Although largely unexamined in the diabetes literature, be-
ginning research suggests that symptom severity, in the setting
of diabetes complications, may adversely affect HRQOL [58,
59]. Among Hispanics and Blacks with gastroparesis, for ex-
ample, greater symptom severity predicted poorer HRQOL
[59].
Limitations
The present study has a number of limitations. We examined
non-Hispanic Blacks and Hispanics as homogenous sub-
groups, respectively, despite their ethnic heterogeneity.
HRQOL was studied cross-sectionally, not longitudinally. A
longitudinal investigation would allow examination of chang-
es in HRQOL over time, and thereby, more validly assess
differences across ethnic groups. In the present study,
operationalization of HRQOL was limited to number of poor
mental or physical days over the past month, which did not
capture the complexity of the concept under study. Lastly,
measures of discrimination, race, or ethnic-related concepts
were not included in the analyses.
Conclusion
Using a largely national representative sample of adults with
diabetes, the present study observed that non-Hispanic Black
and White adults with diabetes, relative to their Hispanic
counterparts, are disproportionately burdened by poorer
HRQOL. Depression was found to be a potent predictor of
J. Racial and Ethnic Health Disparities
both mental and physical HRQOL. To advance understanding
of differences in HRQOL across ethnic groups, future studies
may use path analysis to disentangle the effects of salient
background factors. Inclusion of race or ethnic related vari-
ables appears particularly warranted in future HRQOL analy-
ses as does symptom severity. With diabetes health disparities
persisting, especially burdening economically disadvantaged
and diverse ethnic groups, additional research is needed to
improve HRQOL outcomes in accordance with clinical guide-
lines [2].
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