Socioeconomic conditions and type 1 diabetes in childhood in North Rhine-Westphalia, Germany

The impact of social deprivation on development and progression of diabetic kidney disease

Introduction

Diabetes is one of the leading causes of chronic kidney disease. Social deprivation is recognised as a risk factor for complications of diabetes, including diabetic kidney disease. The effect of deprivation on rate of decline in renal function has not been explored in the Irish Health System to date. The objective of this study is to explore the association between social deprivation and the development/progression of diabetic kidney disease in a cohort of adults living with diabetes in Ireland.

Methods

This is a retrospective cohort study using an existing dataset of people living with diabetes who attended the diabetes centre at University Hospital Galway from 2012 to 2016. The variables included in this dataset include demographic variables, type and duration of diabetes, clinical variables such as medication use, blood pressure and BMI and laboratory data including creatinine, urine albumin to creatinine to ratio, haemoglobin A1c and lipids. This dataset will be updated with laboratory data until January 2023. Individual's addresses will be used to calculate deprivation indices using the Pobal Haase Pratschke (HP) deprivation index. Rate of renal function decline will be calculated using linear mixed-effect models. The relationship between deprivation and renal function will be assessed using linear regression (absolute and relative rate of renal function decline based on eGFR) and logistic regression models (rapid vs. non-rapid decline).

Social deprivation and diabetic kidney disease: A European view

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

Parental socio-economic position and the risk of type 1 diabetes in children and young adults in Denmark: A nation-wide register-based study

AIM

Diabetes mellitus type 1 is one of the most common serious chronic diseases in childhood and the incidence is increasing. Insight into risk factors may inform our etiologic understanding of the disease and subsequent prevention. Any socio-economic gradient in disease risk indicates a potential for prevention, since this points towards socially patterned environmental risk factors. The aim of this study was to investigate the association between measures of parental socio-economic position and the onset of type 1 diabetes in offspring based on individual data in the entire Danish population.

METHODS

In a study population of all children born in Denmark between 1 January 1987 and 31 December 2010, we examined the association between parental socio-economic position and the risk of type 1 diabetes up to the age of 25 years. The risk of type 1 diabetes was estimated according to maternal education, paternal education and household income using Cox proportional hazards regression, with adjustments for the a priori selected confounding variables: year of birth, maternal age at birth and parental type 1 diabetes.

RESULTS

In the study population of 1,433,584 children, a total of 4610 developed type 1 diabetes. We found no clear pattern in type 1 diabetes risk according to parental educational attainment or parental household income.

CONCLUSIONS

In this large population covering study of the risk of type 1 diabetes according to individual-level parental socio-economic position, we found no strong indication of a socially patterned disease risk.

Is Population Density Associated with Non-Communicable Disease in Western Developed Countries? A Systematic Review

Over the last three decades, researchers have investigated population density and health outcomes at differing scale. There has not been a systematic review conducted in order to synthesise this evidence. Following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines, we systematically reviewed quantitative evidence published since 1990 on population density and non-communicable disease (NCD) within Westernised countries. Fifty-four studies met the inclusion criteria and were evaluated utilising a quality assessment tool for ecological studies. High population density appears to be associated with higher mortality rates of a range of cancers, cardiovascular disease and COPD, and a higher incidence of a range of cancers, asthma and club foot. In contrast, diabetes incidence was found to be associated with low population density. High and low population density are therefore risk markers for a range of NCDs, indicating that there are unidentified factors and mechanisms underlying aetiology. On closer examination, our synthesis revealed important and complex relationships between population density, the built environment, the nature of greenspace and man-made exposures. In light of increasing rates of morbidity and mortality, future research is required to investigate these associations in order to establish causative agents for each NCD.

Association between sepsis incidence and regional socioeconomic deprivation and health care capacity in Germany - an ecological study

Background

Sepsis is a substantial health care burden. Data on regional variation in sepsis incidence in Germany and any possible associations with regional socioeconomic deprivation and health care capacity is lacking.

Methods

Ecological study based on the nationwide hospital Diagnosis-related Groups (DRG) statistics data of 2016. We identified sepsis by ICD-10-codes and calculated crude and age-standardized incidence proportions in the 401 administrative German districts. Associations between socioeconomic and health care capacity indicators and crude and age-adjusted sepsis incidence were investigated by simple and multiple negative binomial (NB) regressions.

Results

In 2016, sepsis incidence was 178 per 100,000 inhabitants and varied 10-fold between districts. We found that the rate of students leaving school without certificate was significantly associated with crude and age-standardized explicit sepsis incidence in the simple and multiple NB regressions. While we observed no evidence for an association to the capacity of hospital beds and general practitioners, the distance to the nearest pharmacy was associated with crude- and age-standardized sepsis incidence. In the multiple regression analyses, an increase of the mean distance + 1000 m was associated with an expected increase by 21.6 [95% CI, 10.1, 33.0] (p < 0.001), and 11.1 [95% CI, 1.0, 21.2]/100,000 population (p = .026) after adjusting for age differences between districts.

Conclusions

Residence in districts with lower socioeconomic status (e.g., less education) and further distance to pharmacies are both associated with an increased sepsis incidence. This warrants further research with individual-level patient data to better model and understand such dependencies and to ultimately design public health interventions to address the burden of sepsis in Germany.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11629-4.

Impact of deprivation on glycaemic control in youth with type 1 diabetes in the southwestern region of France

OBJECTIVES

The objective of this multicenter cross-sectional study was to determine predictors of poor glycaemic control in children with type 1 diabetes mellitus (T1DM), particularly with respect to socioeconomic status (SES).

METHODS

Our study population consisted of 1154 children who attended T1DM follow-up consultation with a pediatric diabetes specialist. Clinical and demographic data were retrieved retrospectively from patients' records. Individual deprivation was defined by an EPICES (Evaluation of the Deprivation and Inequalities of Health in Healthcare Centers) score ≥ 30. Patients were assigned to quintiles of the European Deprivation Index (EDI) based on their area deprivation scores. We used multivariable linear regression models to detect potential associations between glycaemic control and indicators of low SES.

RESULTS

In total, 33% (n = 376) of patients had an EPICES score ≥ 30 and 23% (n = 268) were in the 5th EDI quintile. Multivariable linear regression analysis showed that poor glycaemic control was associated with both individual (β 0.38; 95%CI 0.26-0.5; p < 0.001) and area deprivation (β 0.26; 95%CI 0.08-0.43; p = 0.004). Demographic factors, body mass index (BMI) and insulin regimen were also independently associated with poor glycaemic control (p < 0.001). Interestingly, access to diabetes technologies was not related to SES or either glycaemic control.

CONCLUSION

Low SES is associated with a higher risk of poor glycaemic control, independently of insulin regimen. BMI, age at the time of consultation, duration of diabetes, and insulin regimen. Also have an impact on HbA1c. These parameters need to be considered when developing novel treatment strategies for children with T1DM to better target at-risk patients.

Associations of area deprivation and urban/rural traits with the incidence of type 1 diabetes: analysis at the municipality level in North Rhine-Westphalia, Germany

AIM

To analyse the associations of area deprivation and urban/rural traits with the incidence of type 1 diabetes in the German federal state of North Rhine-Westphalia.

METHODS

Data of incident type 1 diabetes cases in children and adolescents aged <20 years between 2007 and 2014 were extracted from a population-based diabetes register. Population data, indicators of area deprivation and urban/rural traits at the municipality level (396 entities) were obtained from official statistics. Area deprivation was assessed in five groups based on quintiles of an index of multiple deprivation and its seven deprivation domains. Poisson regression accounting for spatial dependence was applied to investigate associations of area deprivation and urban/rural traits with type 1 diabetes incidence.

RESULTS

Between 2007 and 2014, 6143 incident cases were reported (99% completeness); the crude incidence was 22.3 cases per 100 000 person-years. The incidence decreased with increasing employment and environmental deprivation (relative risk of the most vs. the least deprived municipalities: 0.905 [95% CI: 0.813, 1.007] and 0.839 [0.752, 0.937], respectively) but was not associated with the composite deprivation index. The incidence was higher in more peripheral, rural, smaller and less densely populated municipalities, and the strongest association was estimated for the location trait (relative risk of peripheral/very peripheral compared with very central location: 1.231 [1.044, 1.452]).

CONCLUSIONS

The results suggest that the type 1 diabetes risk is higher in more remote, more rural, less densely populated and less deprived areas. Urban/rural traits were stronger predictors of type 1 diabetes risk than area deprivation indicators.

Incidence of type 1 diabetes by socio-demographic characteristics among South Australian children: Whole-of-population study

AIM

To describe and compare the incidence of type 1 diabetes (T1D) in South Australia by individual and area-level socio-economic characteristics among children aged ≤11 years.

METHODS

This is a whole-of-population, data linkage study (n = 231 685) conducted in South Australia, and included children born from 2002 to 2013, hospitalisation followed from 2002 to 2014. The study used de-identified, linked administrative hospitalisation, birth and perinatal data from the South Australian Early Childhood Data Project. Incidence was calculated by identifying T1D cases from T1D-related hospitalisations using International Classification of Disease, 10th Revision, Australian Modification diagnosis codes (E10, E101-E109).

RESULTS

Overall, 333 children aged ≤11 years (173 boys) were identified as having T1D. The T1D incidence rate was 23.0 per 100 000 person-years (95% confidence interval (CI): 20.7-25.7), with no sex difference. T1D incidence was higher among children whose mothers were Caucasian, private patients and whose parents were employed. For example, T1D incidence was 26.0 per 100 000 (95% CI: 22.8-29.5) among children with both parents employed, compared to 20.0 per 100 000 (95% CI: 12.3-30.6) among children with both parents unemployed. There was no clear gradient in the association between area-level socio-economic position and T1D, with highest incidence for the fourth quintile (26.5 per 100 000 (95% CI: 20.9-33.1)). The most advantaged area (19.4 per 100 000 (95% CI: 13.8-26.5)) had lower incidence than the most disadvantaged area (23.5 per 100 000 (95% CI: 18.9-28.9)).

CONCLUSION

T1D incidence rates differed depending on the measures of socio-economic characteristics. Individual-level indicators showed higher incidence among more advantaged children; however, there was no clear area-level socio-economic patterning of T1D.

Correlating the global increase in type 1 diabetes incidence across age groups with national economic prosperity: A systematic review

BACKGROUND

The global epidemiology of type 1 diabetes (T1D) is not yet well known, as no precise data are available from many countries. T1D is, however, characterized by an important variation in incidences among countries and a dramatic increase of these incidences during the last decades, predominantly in younger children. In the United States and Europe, the increase has been associated with the gross domestic product (GDP) per capita. In our previous systematic review, geographical variation of incidence was correlated with socio-economic factors.

AIM

To investigate variation in the incidence of T1D in age categories and search to what extent these variations correlated with the GDP per capita.

METHODS

A systematic review was performed to retrieve information about the global incidence of T1D among those younger than 14 years of age. The study was carried out according to the PRISMA recommendations. For the analysis, the incidence was organized in the periods: 1975-1999 and 2000-2017. We searched the incidence of T1D in the age-groups 0-4, 5-9 and 10-14. We compared the incidences in countries for which information was available for the two periods. We obtained the GDP from the World Bank. We analysed the relationship between the incidence of T1D with the GDP in countries reporting data at the national level.

RESULTS

We retrieved information for 84 out of 194 countries around the world. We found a wide geographic variation in the incidence of T1D and a worldwide increase during the two periods. The largest contribution to this increase was observed in the youngest group of children with T1D, with a relative increase of almost double when comparing the two periods (P value = 2.5 × e^-5). Twenty-six countries had information on the incidence of T1D at the national level for the two periods. There was a positive correlation between GDP and the incidence of T1D in both periods (Spearman correlation = 0.52 from 1975-1999 and Spearman correlation = 0.53 from 2000-2017).

CONCLUSION

The incidence increase was higher in the youngest group (0-4 years of age), and the highest incidences of T1D were found in wealthier countries.

Association of Socio-Environmental Determinants with Diabetes Prevalence in the Athens Metropolitan Area, Greece: A Spatial Analysis

OBJECTIVES

The aim of this study was to investigate the spatial variation of diabetes in relation to the geographical variability of socio-environmental characteristics in the urban districts of Athens.

METHODS

A sample of 2,445 individuals from the greater area of Athens was randomly enrolled in the ATTICA study between 2001 and 2002. Diabetes was defined according to American Diabetes Association criteria. Geographical and statistical analyses were applied to examine the relationship between diabetes prevalence and factors related to education, economic status, population density, immigrant status, and availability of urban green areas. Diabetes prevalence and socio-environmental factor mapping was based on the Geographic Information Systems (GIS) technology. Variograms and spatial quasi-Poisson regression analysis evaluated the associations of diabetes with the socio-environmental variables at the municipal level.

RESULTS

According to the geographical analysis and mapping, the highest proportions of people with diabetes were found in the West sector and in one district of the East and South sector each. Regression analysis revealed that the proportion of inhabitants with higher education is negatively correlated with diabetes prevalence in the regional areas of Athens.

CONCLUSIONS

The study revealed that socio-environmental status in residential areas, especially educational and economic levels, is correlated with diabetes prevalence at the aggregate level. These correlations may reflect socio-economic segregation patterns at the district level, and different prevalence rates of diabetes among individuals with higher income and educational levels.

Epidemiological pattern of newly diagnosed children with type 1 diabetes mellitus, Taif, Saudi Arabia

Introduction and Aim. Type-1-diabetes mellitus (T1DM) is the most commonly diagnosed type of DM in children and adolescents. We aim to identify the epidemiological profile, risk factors, clinical features, and factors related to delayed diagnosis or mismanagement in children with newly diagnosed T1DM in Taif, Saudi Arabia. Patients and Methods. Ninety-nine newly diagnosed patients were included in the study along with 110 healthy controls. Patients were classified into 3 groups (I: >2 years, II: 2–>6 years, and III: 6–12 years). Both patients and controls were tested for C-peptide, TSH, and autoantibodies associated with DM and those attacking the thyroid gland. Results. Diabetic ketoacidosis was present in 79.8%. Delayed and missed diagnoses were recorded in 45.5%, with significant correlation to age and district of origin. Severity at presentation showed significant correlation with age and cow's milk feeding. Group I, those with misdiagnosis or positive DM related autoantibodies, had more severe presentations. The correlation of C-peptide and TSH levels in patients and controls was significant for C-peptide and nonsignificant for TSH. Conclusion. Misdiagnosis and mismanagement are common and account for more severe presentation, especially in young children >2 years. Early introduction of cow's milk appears to be a risk factor for the development of T1DM.

Family psychological stress early in life and development of type 1 diabetes: the ABIS prospective study

AIMS

This study investigated whether psychological stress in the family during the child's first year of life are associated with the risk of childhood type 1 diabetes (T1D). According to the beta-cell stress hypothesis all factors that increase the need for, or the resistance to, insulin may be regarded as risk factors for T1D.

METHODS

Among 8921 children from the general population with questionnaire data from one parent at child's birth and at 1 year of age, 42 cases of T1D were identified up to 11-13 years of age. Additionally 15 cases with multiple diabetes-related autoantibodies were detected in a sub-sample of 2649 children.

RESULTS

Cox regression analyses showed no significant associations between serious life events (hazard ratio 0.7 for yes vs. no [95% CI 0.2-1.9], p=0.47), parenting stress (0.9 per scale score [0.5-1.7], p=0.79), or parental dissatisfaction (0.6 per scale score [0.3-1.2], p=0.13) during the first year of life and later diagnosis of T1D, after controlling for socioeconomic, demographic, and diabetes-related factors. Inclusion of children with multiple autoantibodies did not alter the results.

CONCLUSIONS

No association between psychological stress early in life and development of T1D could be confirmed.

Early life socioeconomic indicators and risk of type 1 diabetes in children and young adults

OBJECTIVE

To examine the potential role of 2 early-life socioeconomic indicators, parental education, and crowding index, on risk of type 1 diabetes (T1DM) in patients up to age 29 years to test heterogeneity by age at onset according to the hygiene hypothesis.

STUDY DESIGN

The study base was 330 950 individuals born from 1967 to 2006 who resided in the city of Turin at any time between 1984 and 2007. Data on their early life socioeconomic position were derived from the Turin Longitudinal Study; 414 incident cases of T1DM up to age 29 years were derived from the Turin T1DM registry.

RESULTS

Socioeconomic indicators had opposing effects on risk of T1DM in different age at onset subgroups. In a Poisson regression model that included both socioeconomic indicators, there was a 3-fold greater risk of T1DM (relative risk 2.91, 95% CI 0.99-8.56) in children age 0-3 years at diagnosis living in crowded houses. In the 4- to 14-year subgroup, a low parental educational level had a protective effect (relative risk 0.50, 95% CI 0.29-0.84), and the effect of crowding nearly disappeared. In the 15- to 29-year subgroup, neither crowding nor parental educational level was clearly associated with the incidence of T1DM.

CONCLUSIONS

We provide evidence of heterogeneity by age at onset of the association between early-life socioeconomic indicators and the risk of T1DM. This finding is consistent with the hypothesis that infectious agents in the perinatal period may increase the risk, whereas in the following years they may become protective factors (hygiene hypothesis).

Markedly reduced rate of diabetic ketoacidosis at onset of type 1 diabetes in relatives screened for islet autoantibodies

OBJECTIVE

To determine whether screening for islet autoantibodies in children prevents ketoacidosis and other metabolic complications at diabetes onset and improves the clinical course after diagnosis.

SUBJECTS AND METHODS

The German BABYDIAB and the Munich Family Study follow children with a first-degree family history of type 1 diabetes for the development of islet autoantibodies and type 1 diabetes. The Diabetes Prospective Documentation (DPV) Initiative registers and collects information on pediatric patients with type 1 diabetes throughout Germany. Here, clinical characteristics at diabetes onset [ketoacidosis, mean hemoglobin A1c (HbA1c), and length of hospitalization] and the 5-yr clinical course (HbA1c and insulin dose) of screened and followed islet autoantibody-positive children (n = 101) and 49 883 non-screened children within the DPV registry were compared.

RESULTS

At diabetes onset, children who were followed after screening and were positive for islet autoantibodies had lower HbA1c (8.6 vs. 11%, p < 0.001) and a lower prevalence of diabetic ketoacidosis (3.3 vs. 29.1%, p < 0.001). Screened children also had a shorter hospitalization period at onset (11.4 vs. 14.9 d, p = 0.005). Similar results were observed when the analysis was restricted to 759 non-screened DPV children with a first-degree family history of type 1 diabetes. No differences between screened and non-screened children were observed with respect to HbA1c and insulin dose during the first 5 yr after diagnosis.

CONCLUSIONS

Screening for islet autoantibodies in children likely leads to earlier diabetes diagnosis resulting in less complications at diagnosis. However, no substantial benefit in the clinical outcome during the first 5 yr after diagnosis was observed.

Neighborhood context and incidence of type 1 diabetes: the SEARCH for Diabetes in Youth study

Findings regarding type 1 diabetes mellitus (T1DM) and neighborhood-level characteristics are mixed, with few US studies examining the influence of race/ethnicity. We conducted an ecologic study using SEARCH for Diabetes in Youth Study data to explore the association of neighborhood characteristics and T1DM incidence. 2002-2003 incident cases among youth at four SEARCH centers were included. Residential addresses were geocoded to US Census Tract. Standardized incidence ratios tended to increase with increasing education and median household income. Results from Poisson regression mixed models were similar and stable across race/ethnic groups and population density. Our study suggests a relationship of T1DM incidence with neighborhood-level socioeconomic status, independent of individual-level race/ethnic differences.

Early introduction of root vegetables in infancy associated with advanced ß-cell autoimmunity in young children with human leukocyte antigen-conferred susceptibility to Type 1 diabetes

AIMS

Early introduction of supplementary foods has been implicated to play a role in the development of ß-cell autoimmunity. We set out to study the effects of breastfeeding and age at introduction of supplementary foods on the development of ß-cell autoimmunity.

METHODS

A prospective birth cohort of 6069 infants with HLA-DQB-conferred susceptibility to Type 1 diabetes was recruited between 1996 and 2004. Antibodies against islet cells, insulin, glutamate dehydroxylase and islet antigen 2 were measured at 3- to 12-month intervals. The families recorded at home the age at introduction of new foods and, for each visit, completed a structured dietary questionnaire. The endpoint was repeated positivity for islet cell antibodies plus at least one other antibody and/or clinical Type 1 diabetes (n = 265).

RESULTS

Early introduction of root vegetables (by the age of 4 months) was related to increased risk of developing positivity for the endpoint [hazard ratio (95% CI) for the earliest third 1.75 (1.11-2.75) and for the middle third 1.79 (1.22-2.62) compared with the last third (> 4 months), likelihood ratio test P = 0.006], independently of the introduction of other foods and of several putative socio-demographic and perinatal confounding factors. Introducing wheat, rye, oats and/or barley cereals (P = 0.013) and egg (P = 0.031) early was related to an increased risk of the endpoint, but only during the first 3 years of life.

CONCLUSIONS

Early introduction of root vegetables during infancy is independently associated with increased risk of ß-cell autoimmunity among Finnish children with increased genetic susceptibility to Type 1 diabetes.

High levels of education are associated with an increased risk of latent autoimmune diabetes in adults: results from the Nord-Trøndelag health study

OBJECTIVE

To investigate whether the risk for autoimmune diabetes in adults differs between socioeconomic groups and to compare such risk with that for type 2 diabetes.

RESEARCH DESIGN AND METHODS

The inhabitants of the Norwegian county of Nord-Trøndelag were investigated by questionnaires and clinical examinations on three occasions during 1984-2008. We used information from a subset consisting of 56,296 subjects (participating in at least two surveys), including 122 incident cases of autoimmune diabetes in adults (aged ≥35 and anti-GAD positive) and 1,555 cases of type 2 diabetes (aged ≥35 and anti-GAD negative). Hazard ratios (HRs) of diabetes associated with self-reported education and occupation were estimated by Cox proportional hazards models.

RESULTS

High levels of education (university versus primary school) were associated with an increased risk of autoimmune diabetes (HR 1.98 [95% CI 1.21-3.26]), after adjustment for BMI, lifestyle factors, and family history of diabetes. Case subjects with high levels of education had lower levels of C-peptide, tended to have higher levels of anti-GAD, and were more often treated with insulin. Conversely, these subjects had a reduced risk of type 2 diabetes (HR 0.69 [95% CI 0.57-0.82]), a risk that was partly explained by lower BMI and more physical activity (adjusted HR 0.89 [95% CI 0.74-1.06]).

CONCLUSIONS

High levels of education are associated with an increased risk of autoimmune diabetes in adults, a finding that may be mediated by effects on autoimmune activity. Because the association is not explained by traditional risk factors, other, currently unidentified, environmental factors are likely to be involved.

Long-term detrimental consequences of the onset of type 1 diabetes on annual earnings--evidence from annual registry data in 1990-2005

AIMS/HYPOTHESIS

Young adults in the early stages of their participation in the labour market may be particularly vulnerable to the effects of onset of a chronic disease. Our aim was to quantify the consequences of the onset of type 1 diabetes in young adults on annual earnings, using individual-level longitudinal data before and after the onset of diabetes.

METHODS

The Econ-DISS database contains annual socioeconomic information for 1990-2005 from Statistics Sweden. Econ-DISS includes data for persons with diabetes onset at the age of 15-34 years between 1983 and 2005, registered in the national Diabetes Incidence Study in Sweden (DISS) database, and for controls. Considering the onset of type 1 diabetes as an unanticipated and significant life event, we compared the progression of annual earnings for 3,650 cases born between 1949 and 1970 before and after onset of diabetes with that of 14,629 controls. Possible confounders--education, participation in the labour market, sick leave and parental education--were analysed.

RESULTS

We found no differences between the groups in annual earnings or participation in the labour market before onset of diabetes. After onset, persons with type 1 diabetes gradually lagged behind the controls. Their median annual earnings were lower in each year from 1995 to 2005 (p < 0.01). The difference in 2005 was euro (EUR) 1,411 (5.3%). Controlling for confounders, duration of type 1 diabetes > or = 10 years was associated with 4.2% (men) and 8.1% (women) lower average annual earnings for persons with upper secondary education only who were active in the labour market.

CONCLUSION/INTERPRETATION

The onset of type 1 diabetes in young adults has long-term detrimental consequences on earnings that cannot be attributed to confounders.

Time for new guidelines in advanced diabetes care: Paradigm change from delayed interventional approach to predictive, preventive & personalized medicine

Global burden of diabetes mellitus clearly demonstrate inadequacy of current diabetes care measures: the costs of caring for patients with diabetes mellitus are the highest compared to other frequent pathologies. Nonetheless, for every 10 s one patient dies of diabetes-related consequences. Thus, there is urgent need for highly effective measures that would lead to reduced prevalence, better long-term outcomes and improved quality of life for diabetic patients reducing associated economic burden. Such targeted measures would require the creation of new guidelines for advanced diabetes care that would provide for regulation, for timely predictive diagnostics as well as an effective prevention and creation of individualized treatment algorithms. Effective communication among the research community healthcare providers, policy-makers, educators and organized patient groups (Federations of Diabetics) is of paramount importance and essential for (pre)diabetes care. The ultimate mission of the "European Association for Predictive, Preventive & Personalised Medicine" is to promote this process in Europe and across the globe.

Evaluating geographic variation in type 1 and type 2 diabetes mellitus incidence in youth in four US regions

We evaluated geographic variation in type 1 and type 2 diabetes mellitus (T1DM, T2DM) in four regions of the United States. Data on 807 incident T1DM cases diabetes and 313 T2DM cases occurring in 2002-03 in South Carolina (SC) and Colorado (CO), 5 counties in Washington (WA), and an 8 county region around Cincinnati, Ohio (OH) among youth aged 10-19 years were obtained from the SEARCH for Diabetes in Youth Study. Geographic patterns were evaluated in a Bayesian framework. Incidence rates differed between the study regions, even within race/ethnic groups. Significant small-area variation within study region was observed for T1DM and T2DM. Evidence for joint spatial correlation between T1DM and T2DM was present at the county level for SC (r(SC)=0.31) and CO non-Hispanic Whites (r(CO)=0.40) and CO Hispanics (r(CO)=0.72). At the tract level, no evidence for meaningful joint spatial correlation was observed (r(SC)=-0.02; r(CO)=-0.02; r(OH)=0.03; and r(WA=)0.09). Our study provides evidence for the presence of both regional and small area, localized variation in type 1 and type 2 incidence among youth aged 10-19 years in the United States.

Hip fractures and area level socioeconomic conditions: a population-based study

BACKGROUND

Only a limited number of studies have analyzed the association between hip fracture incidence and socioeconomic conditions. Most, but not all found an association, and results are in part conflicting. The aim of our study was to evaluate the association between hip fractures and socioeconomic conditions in Germany, from 1995 to 2004, on a census tract area level.

METHODS

We used data from the national hospital discharge diagnosis register and data on socioeconomic and demographic characteristics of 131 census tracts from official statistics. Associations between the hip fracture incidence and socioeconomic conditions were analyzed by multiple Poisson regression models, taking overdispersion into account.

RESULTS

The risk of hip fracture decreased by 4% with a 7% increase (about one interquartile range) of non-German nationals. It decreased by 10% with a 6% increased rate of unemployment, increased by 7% with a 2% increase of the proportion of welfare recipients, and also increased by 3% with an increase of the proportion of single parent families of 1.9%.

CONCLUSION

Our results showed weak associations between indicators of socioeconomic conditions at area level and hip fracture risk; the varied by type of indicator. We conclude that hip fracture incidence might be influenced by the socioeconomic context of a region, but further analysis using more specific markers for deprivation on a smaller scale and individual-level data are needed.

Regional and social differences concerning overweight, participation in health check-ups and vaccination. Analysis of data from a whole birth cohort of 6-year old children in a prosperous German city

Background

Studies on health inequalities still focus mostly on adults. Research about social disparities and health in children is slowly increasing, also in Germany, but these studies are mostly restricted to individual social variables derived from the parents to determine social class. This paper analyses the data of the medical check-up prior to school enrolment to determine differences concerning overweight, participation in health check-ups and immunization; it includes individual social variables but also regional variables describing the social environment of the children.

Methods

The dataset includes 9,353 children who started school in 2004 in Munich, Germany. Three dependent variables are included (i.e. overweight, health check-ups, vaccinations). The individual level social variables are: children's sex, mother tongue of the parents, Kindergarten visit. On the small scale school district level, two regional social variables could be included as well, i.e. percentage of single-parent households, percentage of households with low educational level. Associations are assessed by cross tables and regression analyses. The regional level variables are included by multilevel analyses.

Results

The analyses indicate that there is a large variation between the school districts concerning the three dependent variables, and that there is no district with very 'problematic values' for all three of them (i.e. high percentage of overweight, low levels of health check-ups and vaccinations). Throughout the bivariate and multivariate analyses, the mother tongue of the children's parents shows the most pronounced association with these dependent variables; i.e. children growing up in non-German-speaking families tend to be more overweight and don't visit preventive check-ups as often as children of German-speaking parents. An opposite association can be seen concerning vaccinations. Regional level influences are present as well, but they are rather small when the individual level social variables are controlled for.

Conclusion

The dataset of the medical check-up prior to school enrolment offers a great opportunity for public health research, as it comprises a whole age cohort. The number and scope of variables is quite limited, though. On one hand, it includes only few variables on health or health related risks. On the other, it would be important to have more information from the region where the children live, e.g. the availability of community and health care services for parents and children, social networks of families with children, areas where children can play outside, traffic noise and air pollution. Despite these shortcomings, the need for specific interventions can already be derived from the data analyzed here, e.g. programs to reduce overweight in children should focus on parents with a mother tongue other than German.

Caesarean section is associated with an increased risk of childhood-onset type 1 diabetes mellitus: a meta-analysis of observational studies

AIMS/HYPOTHESIS

The aim of this study was to investigate the evidence of an increased risk of childhood-onset type 1 diabetes in children born by Caesarean section by systematically reviewing the published literature and performing a meta-analysis with adjustment for recognised confounders.

METHODS

After MEDLINE, Web of Science and EMBASE searches, crude ORs and 95% CIs for type 1 diabetes in children born by Caesarean section were calculated from the data reported in each study. Authors were contacted to facilitate adjustments for potential confounders, either by supplying raw data or calculating adjusted estimates. Meta-analysis techniques were then used to derive combined ORs and to investigate heterogeneity between studies.

RESULTS

Twenty studies were identified. Overall, there was a significant increase in the risk of type 1 diabetes in children born by Caesarean section (OR 1.23, 95% CI 1.15-1.32, p < 0.001). There was little evidence of heterogeneity between studies (p = 0.54). Seventeen authors provided raw data or adjusted estimates to facilitate adjustments for potential confounders. In these studies, there was evidence of an increase in diabetes risk with greater birthweight, shorter gestation and greater maternal age. The increased risk of type 1 diabetes after Caesarean section was little altered after adjustment for gestational age, birth weight, maternal age, birth order, breast-feeding and maternal diabetes (adjusted OR 1.19, 95% CI 1.04-1.36, p = 0.01).

CONCLUSIONS/INTERPRETATION

This analysis demonstrates a 20% increase in the risk of childhood-onset type 1 diabetes after Caesarean section delivery that cannot be explained by known confounders.