New findings on type 2 diabetes in first-generation Chinese migrants settled in Italy: Chinese in Prato (CHIP) cross-sectional survey

A randomized trial to evaluate a complex, co-created, culture-sensitive intervention to promote healthy lifestyles and compliance to therapy in immigrants with type 2 diabetes: A protocol of a multicenter Italian study

INTRODUCTION

The active involvement of end users may overcome socio-economic, cultural and context-related barriers that may reduce health promotion effectiveness in type 2 diabetes control and prevention. The "Cardio-metabolic diseases in immigrants and ethnic minorities: from epidemiology to new prevention strategies" (DIABETHIC) project funded by the European Union through the Italian Ministry of Health includes a multicentre randomised controlled trial (RCT) aimed to assess the effectiveness of a co-created health promotion intervention for immigrants affected by type 2 diabetes. This protocol describes the co-creation process and methodological challenges in evaluating co-created health promotion interventions.

METHODS AND ANALYSIS

Between November 2023 and July 2024, four Italian primary care centres will recruit 200 immigrants with type 2 diabetes that will be randomised to usual health promotion practice or to the experimental health promotion intervention developed through a participatory process. Endpoints are changes in glycated haemoglobin, Body Mass Index, diet, physical activity and therapeutic adherence at 12 months after recruitment. Qualitative research experts supported the participatory process at local and national levels. According to available evidence and recommendations, the participatory process focused on the three pillars of type 2 diabetes control (diet, physical activity, and therapeutic adherence). To co-create the intervention, interviews, focus groups and role-plays were conducted with patients and immigrants, healthcare workers and representatives of social services. Identified barriers were ranked according to priority and actionability. Given different health promotion practice in the four centres, the intervention was standardised by function (dietary counselling, culturally tailored information materials, access to cultural mediation, training in effective and reflective communication, individual and group meetings) rather than by form (operators involved, protocols and timeframes), which was defined locally by feasibility and by contrasting usual health promotion. (Trial registration: ClinicalTrials.gov ID NCT06131411).

Cardiovascular risk and access to primary care: Comparisons among Chinese documented and undocumented immigrants

AIMS

The aim of this study was to examine main risk factors of undocumented Chinese migrants living in Italy when compared with Chinese migrants registered with National Health Service (NHS).

METHODS

A cohort of 3435 Chinese first-generation immigrants living in Prato underwent blood pressure (BP) measurement and blood tests. Hypertension was diagnosed for BP ≥ 140/90 mmHg at 2 visits, and/or antihypertensive drug use; type 2 diabetes (T2DM) for fasting glucose ≥ 126 mg/dL at 2 visits, and/or use of hypoglycemic drugs; hypercholesterolemia (HC) for cholesterol ≥ 240 mg/dL and/or statins use. Subjects diagnosed with hypertension, T2DM, or HC unaware of their condition were considered newly diagnosed. Comparisons were performed using multivariable adjusted logistic regression analysis.

RESULTS

A large proportion of Chinese migrants were undocumented (1766, 51 %); newly diagnoses of risk factors were performed especially among undocumented migrants; registration with NHS was associated with higher level of awareness for hypertension and T2DM and with 6 times higher rate of treatment for T2DM. Only a small minority of subjects with high cholesterol were treated with statins.

CONCLUSIONS

Undocumented immigrants had high prevalence of risk factors with lower levels of awareness than migrants registered with the NHS. Health policies targeting this hard-to-reach population needs to be improved.

Impact of migration on diabetes burden: audit in the metropolitan area of Bologna, Italy

PURPOSE

To investigate the impact of diabetes in immigrants on the Italian healthcare system, as well as their compliance with standard protocols of control and treatment.

METHODS

The prevalence of immigrants with diabetes living in the metropolitan area of Bologna (about 1 million inhabitants) in 2019 was investigated using a database containing all subjects in active follow-up for diabetes, based on antidiabetic drug use, disease-specific copayment exemption, ICD-9 codes, continuous care in diabetes units. Country of origin was derived from fiscal code.

RESULTS

The overall prevalence of diabetes (n = 53,941; 51.8% males, median age 64) was 6.1% in both Italy-born and immigrant cohorts. Immigrant prevalence was 12.4%, moderately higher than that observed in the total population (12.2%). Diabetes risk was increased in the whole immigrant cohort (odds ratio (OR) 1.74; 95% Confidence Interval (CI) 1.69-1.79). Among cases with incident diabetes, the proportion of immigrants (median age, 49 vs. 65 in Italy-born individuals) increased progressively from 11.7% to 26.5% from 2011 to 2019 (males, 8.9-21.0%; females, 14.9-32.8%) in all age groups, particularly in young adults, but also in older subjects. Metabolic control was lower in immigrants, as was adherence to shared diagnostic and therapeutic protocols, without systematic differences in antidiabetic drug use, but much lower use of drugs for comorbid conditions.

CONCLUSIONS

The population with diabetes in the metropolitan area of Bologna is rapidly changing. Quality improvement initiatives are needed to reduce the burden for the universalistic Italian health care system generated by the rapidly-growing high-risk immigrant population.

Prevalence and risk factors contributing to the occurrence of diabetes mellitus in Chinese international migrants: A narrative review

AIMS

This paper reviewed the literature on diabetes prevalence and risk factors associated with diabetes among first-generation Chinese international migrants.

METHODS

MEDLINE, Scopus, Web of Science, CINAHL and Maternity and Infant Care were searched until March 2022, for articles written in English. The quality of the included articles was assessed using the Newcastle-Ottawa Scale.

RESULTS

In total, 17 articles were included (nine for gestational diabetes, six for type 2 diabetes, and none for type 1 diabetes). The average crude prevalence rate for type 2 diabetes and gestational diabetes was 12.1% and 9.3% respectively. Risk factors contributing to the occurrence of type 2 diabetes included older age, sex, family history of type 2 diabetes, higher BMI/waist circumference, longer time since migration, alcohol consumption, smoker, hypertension, and high triglycerides. Risk factors contributing to the occurrence of gestational diabetes included older maternal age, history of gestational diabetes, higher weight/pre-pregnancy BMI, longer time since migration, and Chinese ethnicity.

CONCLUSIONS

We identified a research gap in the diabetes health of Chinese migrants, particularly for type 1 diabetes, highlighting the need for ethnic-specific diabetes research and care, including for subsequent generations of migrants and those living in developing countries.

Body-Size Perception among First-Generation Chinese Migrants in Italy

Body-size perception is an important factor in motivating people to lose weight. Study aim was to explore the perception of body image among first-generation Chinese migrants living in Italy. A sample of 1258 Chinese first-generation immigrants and of 285 native Italians living in Prato, Italy, underwent blood pressure measurements, blood tests (with measurement of glucose, cholesterol, and triglycerides), and anthropometric measurements. Body-size perception was investigated with Pulvers’ figure rating scale using logistic or linear multivariable regression adjusted for age, gender, BMI, education and years spent in Italy. Chinese migrants had lower BMI and discrepancy score (preferred minus current body size) than Italians (p < 0.05 for both). After a logistic regression analysis, the discrepancy score remained lower in the Chinese than in the Italian cohort independently from BMI and other confounders (OR 0.68; 95%CI 0.50 to 0.92). In the Chinese cohort, female gender, BMI and years spent in Italy were positive determinants of discrepancy score (desire to be thinner), while age showed negative impact (p < 0.05 for all). Overweight is an important risk factor for diabetes, a very prevalent condition among first-generation Chinese migrants. The present study offers useful information and suggests the need for prevention programs specifically addressed to men.

Gender differences in acculturation and cardiovascular disease risk-factor changes among Chinese immigrants in Italy: Evidence from a large population-based cohort

Background

In recent decades, the Chinese presence in Southern Europe has grown rapidly but no data is available on the influence that residing in Mediterranean countries has on Chinese immigrants. In this study, we aim to examine the association between acculturation and cardiovascular risk factors among first-generation Chinese immigrants in Italy.

Design

Population-based, cross-sectional study.

Methods

A sample of 2589 Chinese first-generation immigrants (1599 women and 990 men) living in Prato, Italy, underwent blood pressure measurement, blood tests (with measurement of glucose, cholesterol, and triglycerides), and anthropometric measurements. The influence of length of residence (dependent variable) on hypertension, type 2 diabetes, overweight/obesity, and hyperlipidemia (high cholesterol) (independent variables) was investigated with multivariable logistic regression adjusted for age, sex, education and urban/rural home area in China before migration.

Results

Mean age of Chinese participants was 47.2 ± 10.7 years and 61.7% were women. Immigrants residing in Italy for ≥20 years were more likely to be hypertensive [odd ratio (OR) 1.84; 95% confidence interval (CI) 1.33 to 2.59], or diabetic (1.91; 1.26 to 2.86) than those residing in Italy for <10 years. Differently, prevalence of hypercholesterolemia (total cholesterol≥240 mg/dl) was lower in immigrants residing in Italy for ≥20 years than in those with <10 years of residence (0.52; 0.32 to 0.83). The association between indicators of acculturation and cardiovascular risk factors appeared to differ by sex.

Conclusion

Acculturation of Chinese immigrants in Italy was associated with hypertension and type 2 diabetes whereas a favorable effect on hypercholesterolemia was observed.

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies

BACKGROUND AND AIMS

Italy has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy.

METHODS AND RESULTS

A multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013-14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16-2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65-1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk.

CONCLUSION

Adult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.

Blood pressure and fasting glucose changes in male migrants waiting for an asylum decision in Italy. A pilot study

BACKGROUND

The Central Mediterranean route from Libya to Italy has been for years the major port of entry from Africa to Europe. However, information on the early effects of permanence in Italy on cardiovascular risk factors is limited. Therefore, the association between length of stay in Italy and blood pressure or blood glucose was explored in young asylum seekers.

METHODS

Cross-sectional study performed on male asylum seekers (aged 18-40 years), hosted for 0-30 months in Prato, Italy. Blood pressure and blood glucose, measured with validated instruments, were classified according to European Society of Hypertension and American Diabetes Association guidelines respectively. The relationship of quartiles of months of stay in Italy (independent variable) with blood pressure and fasting glucose was investigated with multivariate linear regression adjusted for years of age, world area of origin, education level, travel duration in months, smoking habit, alcohol use, body mass index, triglycerides.

RESULTS

On average, the 217 asylum seekers lived in Italy for 8.4 months (95% CI 7.5-9.3; range 0-30 months). At multivariate adjusted linear regression analysis, quartiles of months in Italy were associated with a forward shift in the blood pressure categories of the European Society of Hypertension (B = 0.396; 95% CI 0.190 to 0.602) and in the categories fasting glucose levels of the American Diabetes Association (B = 0.450; 95% CI 0.023 to 0.876).

CONCLUSIONS

When considering the importance of high blood pressure and type 2 diabetes for ethnic minorities living in Europe, changes of cardiovascular risk factors in the new environment probably need more attention.

Migrant Workers and Physical Health: An Umbrella Review

Migrants are mainly employed in “3D jobs” which are dirty, dangerous, and difficult, are characterized by monotony and intense rhythms, and are found in sectors with higher risks such as construction, heavy industry, and agriculture. The aim of this study is to construct a systematic review in order to identify the main occupational risks and occupational diseases of this category. Research included articles published from 2013 to 2018 on major online databases (PubMed, Cochrane Library, and Scopus), which were obtained using a combination of keywords (migrant workers, expatriates, physical health, diseases, illnesses, travel, travelers, work, and occupational medicine). The online search included 1109 references. We excluded 977 studies because they were unrelated to physical health and another 64 due to duplication. There were 68 articles which were analyzed, including six reviews and 62 original articles. The main risks which emerged are developing infectious diseases, metabolic cardiovascular diseases and manifesting a lower quality of life, in particular due to difficulties in accessing local health services. It will be crucial to implement the role of occupational medicine in order to introduce multilevel interventions designed to prevent work-related injuries and illnesses, and to promote healthier working environments.

Daily urinary sodium and potassium excretion in Chinese first-generation migrants in Italy

BACKGROUND

China has one of the highest salt intake levels in the world, and Chinese people form one of the largest foreign-born communities now living in Europe. The present study was performed to assess 24-hour urinary sodium and potassium excretion in Chinese migrants in Italy and to explore possible associations with hypertension, hypertension awareness, and length of residence in Italy.

METHODS

A cross-sectional evaluation was conducted on 319 first-generation Chinese migrants (154 women and 165 men) aged 18-70 years. Subjects were asked to do a 24-hour urine collection and the relationships of urinary sodium and potassium and arterial blood pressure, hypertension (BP ≥ 140/90 mmHg or anti-hypertensive drug use), hypertension awareness, and years of residence in Italy were investigated with linear or logistic regression analysis.

RESULTS

Sodium excretion was 145.2 mmol/day (95%CI 138.0-152.3) in men, and 134.7 (95%CI 127.6-141.8) in women corresponding to a dietary salt intake of 9.4 g/day (95%CI 9.0-9.9) and 8.8 (95%CI 8.3-9.2) respectively. Potassium excretion was 35.1 mmol/day (95%CI 33.6-36.5), with no significant difference by gender. At multivariable adjusted linear regression analysis body mass index, low education level, and hypertension were positive predictors of sodium urinary excretion; gender (women), and body mass index were positive predictors of potassium excretion. Sodium and potassium excretion were unaffected by hypertension awareness or years of residence in Italy.

CONCLUSIONS

Sodium excretion in Chinese workers is higher than recommended and in line with high salt intake in Italy. Potassium consumption remains low.

Ethnic inequalities in acute myocardial infarction hospitalization rates among young and middle-aged adults in Northern Italy: high risk for South Asians

The knowledge of ethnic-specific health needs is now essential to design effective health services and population-based prevention strategies. However, data on migrant populations living in Southern Europe are limited. The study is designed to investigate ethnic inequalities in hospitalization for acute myocardial infarction (AMI) in the Veneto region (Italy). Hospital admissions for AMI in Veneto for the whole resident population aged 20-59 years during 2008-2013 were studied. Age and gender-specific AMI hospitalization rates for immigrant groups (classified by country of origin according to the United Nations geoscheme) and Italians were calculated. The indirect standardization method was used to estimate standardized hospitalization ratios (SHR) for each immigrant group, with rates of Italian residents as a reference. Overall, 8200 AMI events were retrieved, 648 among immigrants. The highest risk of AMI is seen in South Asians males (SHR 4.2, 95% CI 3.6-4.9) and females (SHR 2.5, 95% CI 1.4-4.5). AMI rates in South Asian males sharply increase in the 30-39 years age class. Other immigrant subgroups (Eastern Europe, North Africa, Sub-Saharan Africa, other Asian countries, Central-South America, high-income countries) displayed age- and gender-adjusted hospitalization rates similar to the native population. Present findings stress the urgent need for implementation of ethnic-specific health policies in Italy. The awareness about the high cardiovascular risk in subjects from South Asia must be increased among general practitioners and immigrant communities.

Diverging patterns of cardiovascular diseases across immigrant groups in Northern Italy

BACKGROUND

Only fragmentary data are available on the burden of non-communicable diseases among immigrants in Europe, mostly limited to mortality by cause. Aim of the study is to investigate the prevalence of cardiovascular diseases across different immigrant groups in the Veneto Region (North-Eastern Italy).

METHODS

The resident population aged 20-59 was classified according to country of citizenship. The Adjusted Clinical Groups System was adopted to identify selected cardiovascular conditions by linkage of Hospital Discharge Records, Emergency Room visits, Chronic disease registry for copayment exemptions, the Home care database, and drugs reimbursed by the Regional Health Service. Age standardized prevalence rates were compared across population groups, and rate ratios (RR) with 95% confidence intervals (CI) were computed taking the Italian population as reference.

RESULTS

The prevalence of diabetes was higher across all immigrant groups compared to Italians. Specific risk patterns could be identified associated to different ethnicities: South Asian immigrants were at very high risk of diabetes, dyslipidemia, and ischemic heart disease (males RR 2.3, CI 1.9-2.8; females RR 2.0, CI 1.2-3.5). Immigrants from Africa were affected by high rates of hypertension, cerebrovascular diseases, and heart failure, with a more pronounced unfavorable profile among females (hypertension RR 3.0, CI 2.6-3.3; cerebrovascular diseases RR 1.7, CI 1.1-2.7).

CONCLUSIONS

Wide differences in the prevalence of cardiovascular diseases could be detected across immigrant groups. These findings represent a first step towards systematic chronic disease surveillance by ethnicity, a fundamental tool for shaping culturally-tailored prevention strategies.

Prevalence, Awareness, Treatment, and Control of Hypertension among Chinese First-Generation Migrants and Italians in Prato, Italy: The CHIP Study

Data on health needs of Chinese living in the South of Europe are lacking. To compare prevalence, awareness, treatment, control, and risk factors for hypertension between Chinese migrants and Italian adults, a sample of 1200 first-generation Chinese migrants and 291 native Italians aged 35–59 years living in Prato (Italy) was recruited in a community-based participatory cross-sectional survey. Primary outcome measure was hypertension, diagnosed for blood pressure values ≥ 140/90 mmHg or current use of antihypertensive medications. Associations with exposures (including age, gender, body mass index, waist, education level, total cholesterol, and triglycerides) were examined using logistic regression. When compared with Italians, Chinese had higher hypertension prevalence (27.2% versus 21.3%, p < 0.01), with comparable levels of awareness (57.4% and 48.4%) but lower treatment rates (70.6% and 90.0%, resp.). In both ethnic groups age and parental history of hypertension were predictors of awareness and treatment, body mass index being predictor of hypertension diagnosis. In Chinese participants, where the optimum cut-off point for body mass index was ≥23.9 kg/m², the sensibility and specificity prediction for hypertension were 61.7% and 59.8%, respectively (area under the ROC curve = 0.629). Implementation of specific, culturally adapted health programs for the Chinese community is now needed.