Prevalence of diagnosed diabetes and quality of care among Greenlanders and non-Greenlanders in Greenland

High quality of diabetes care in Greenland since the launch of Steno Diabetes Center Greenland 2020 - geographical disparities need attention

The aim of this study was to estimate the prevalence of diagnosed diabetes in Greenland and evaluate quality of care according to sex, region and healthcare unit within regions. Data on all inhabitants registered with diabetes were extracted from the electronic medical record. We found a crude prevalence of diagnosed diabetes in the population aged ≥ 20 years to be 4.7%, and the prevalence of diabetes standardised to the WHO world population was 4.0%. Compared to males, a significantly higher proportion of females had mean glycated haemoglobin (HbA1c) level below 7% (68.9% vs. 57.5%) and blood pressure below 140/90 mmHg (83.4% vs. 73.5%). Regarding healthcare unit within regions, quality of care was higher in regional cities compared to smaller cities, concerning proportion of persons having blood pressure measured regularly (86.0% vs. 71.7%), urine tested for albuminuria (70.6% vs. 51.2%), receiving eye examination (86.9% vs. 79.5%) and foot examination (87.9% vs. 79.4%). In conclusion, the prevalence of diagnosed diabetes in Greenland is the highest reported yet. The overall quality of diabetes care was high and significantly improved compared to 2018. We observed geographical inequality in diabetes care and improvements in the quality of care in specific remote locations are necessary to minimise health care disparities.

Low prevalence of retinopathy among Greenland Inuit

To assess the prevalence of diabetic retinopathy (DR) among persons with diabetes and prediabetes participating in the 2018 Population Health Survey in Greenland (B2018), a follow-up survey of three previous health surveys. Participants were invited to a diabetes complication screening. We assessed the prevalence of DR using Optos Daytona Ultra-wide field fundus camera and assessed differences in prevalence according to demographic and clinical characteristics using chi square test and a t-test and assessed DR based on ethnicity. The overall prevalence of DR was 2% (10/483). Among participants with HbA₁c ≥48 mmol/mol (6.5%) DR prevalence was 9% (9/91), compared with <1% (1/382) among participants with HbA₁c <48 mmol/mol (6.5%). All participants with DR lived in towns. The mean Inuit genetic admixture was lower among participants with DR. The prevalence of DR is low in Greenland and almost non-existent among persons with HbA₁c below the diabetes threshold.

No association between early maternal HbA1c and offspring birthweight among women without pre-existing diabetes in Greenland

Studies of the association between maternal blood glucose measured by glycated haemoglobin (HbA1c) during pregnancy and the offspring’s birthweight have been heterogeneous. The aim of this study was to examine the association between maternal HbA1c level before gestational week 20 and the offspring’s birthweight among predominantly indigenous women in Greenland. A retrospective cohort study including all women (n = 503) and their offspring delivered from September 2015 to September 2016 at Queen Ingrid’s Hospital in Nuuk was conducted. Data were obtained from the electronic medical record. Linear regression models were used to analyse the effect of maternal HbA1c on the offspring’s birthweight with adjustment and stratification for relevant confounders and effect modifiers. Birthweight increased with 3.3 g per mmol/mol increase in HbA1c. Yet, no significant association between maternal HbA1c and the offspring’s birthweight was found after adjustment for maternal age, ethnicity, residence, smoking, and parity (β = 0.058, p = 0.711). Among obese women, a borderline significant positive association (β = 0.657, p = 0.059) was found. For term newborns, this corresponded to an increase in birthweight of 31 g per mmol/mol increase in HbA1c. Based on the current study, the use of HbA1c during pregnancy to detect the risk of delivering a newborn with macrosomia is not recommended in Greenland.

Abbreviation: HbA1c: glycosylated haemoglobin; GA: gestational age; SD: standard deviation; CI: confidence interval.

Are marine n-3 fatty acids protective towards insulin resistance? From cell to human

Marine n-3 fatty acids improve most of the biochemical alterations associated with insulin resistance (IR). Experimental models of dietary-induced IR in rodents have shown their ability (often at a very high dose) to prevent IR, but with sometimes a tissue specific effect. However, in a high sucrose diet-induced IR rat model, they are unable to reverse IR once installed; in other rodent models (dexamethasone, Zucker rats), they are inefficacious perhaps because of the severity of IR. The very low incidence of type-2 diabetes (T2D) in Inuits in the 1960s, which largely increased over the following decades in parallel to the replacement of their traditional marine food for a western diet strongly suggests a protective effect of marine n-3 towards the risk of T2D; this was confirmed by reversal of its incidence in intervention studies reintroducing their traditional food. In healthy subjects and insulin-resistant non-diabetic patients, most trials and meta-analyses conclude to an insulin-sensitising effect and to a very probable preventive or alleviating effect towards IR. Concerning the risk of T2D, concordant data allow us to conclude the protective effect of marine n-3 in Asians while suspicion exists of an aggravation of risk in Westerners, but with the possibility that it could be explained by a high heterogeneity of studies performed in this population. Some longitudinal cohorts in US/European people showed no association or a decreased risk. Further studies using more homogeneous doses, sources of n-3 and assessment of insulin sensitivity methods are required to better delineate their effects in Westerners.

Prevalence, incidence, mortality, and quality of care of diagnosed diabetes in Greenland

AIMS

To estimate prevalence, incidence, and mortality of diagnosed diabetes in Greenland, and to evaluate quality of diabetes care among men and women, and patients living in towns and settlements.

METHODS

This study was designed as an observational cross-sectional study based on review of data obtained from the electronic medical record (EMR) in Greenland. All permanent residents of Greenland registered with a diabetes diagnosis in the EMR (N = 1498) were included.

RESULTS

The age-standardized prevalence of diabetes was 2.19% as of Nov 30, 2018. The age-standardized incidence was 147 per 100,000 per year and the age-standardized mortality was 62 per 10,000 person-year among people aged ≥0 years old (Dec 1, 2017 to Nov 30, 2018). Quality of diabetes care was slightly higher among women compared to men concerning proportion with annual measurement of glycated haemoglobin (HbA_1c) (89.9% vs. 85.8%; p < 0.015), blood pressure (83.7% vs. 76.7%; p < 0.001).The only difference observed in quality of care among settlements and towns was lower proportion tested for microalbuminuria within one year in settlements (50.3% vs. 40.1%; p < 0.001).

CONCLUSIONS

The age-standardized prevalence of diagnosed diabetes in Greenland was 2.19% and the prevalence of diagnosed diabetes among adults aged ≥20 years was 3.7%. Only minor differences in quality of care related to gender and place of residence were observed. Further improvements in quality of care are warranted.

Optos wide-field imaging versus conventional camera imaging in Danish patients with type 2 diabetes

PURPOSE

Diabetic retinopathy (DR) screening methods are costly, requiring specialized personnel and patient mydriasis. The Optos apparatus can be operated by nonspecialists and provides ultra-wide-field imaging, with 200° views of the retina in a single image. We compared DR grading obtained from Optos imaging with DR grading from conventional Topcon imaging.

METHODS

We conducted a cross-sectional study of 101 persons with diabetes who participated in the Addition-DK 10-year follow-up study. Retina fundus photos using both Optos and Topcon imaging were taken for both eyes. All photos were graded by specialist ophthalmologic nurses, using a modified version of the 'Proposed International Clinical DR severity scale'. We constructed frequency tables and assessed levels of agreement between Optos and Topcon gradings using weighted Kappa statistics, separately for peripheral and macular grading. We tested if the agreements between the two cameras were significantly different using a stratified Wilcoxon test.

RESULTS

Significantly, more lesions in the periphery were identified by Optos compared with Topcon (p < 0.01), resulting in a fair Kappa agreement of 0.21. We saw no significant differences in the grading of the macula region (p = 0.97) between the two cameras. Although only 7% of the macula image gradings differed between the cameras, the Kappa agreement of macula grading was only moderate (Kappa = 0.52).

CONCLUSION

The inter-camera agreement was acceptable for macula image grading, but only fair for peripheral grading, with Optos identifying more microvascular changes in the periphery. The clinical significance and impact on screening modality and frequency remain to be explored.

Prevalence of patients treated with anti-diabetic medicine in Greenland and Denmark. A cross-sectional register study

Diabetes mellitus is a large and growing worldwide health issue. Prior to this publication, a direct comparison of the prevalence of persons treated with anti-diabetic medicine in Greenland and Denmark has not been found. Therefore, the aim of this study is to estimate and compare the age- and gender-specific prevalence of patients treated with anti-diabetic medicine comparing Greenland and Denmark. The study was performed as a cross-sectional register study using data from population and medical registers in Greenland and Denmark. A total of 784 Greenlandic and 215,580 Danish patients treated with anti-diabetic medicine were included. The prevalence of patients aged 20-79 years treated with anti-diabetic medicine in Greenland was 2.6% (95% CI 2.4-2.8), much lower (p < 0.001) compared to Denmark with 5.2% (95% CI 5.2-5.2). The difference was less pronounced after excluding those treated with insulin and women below 45 years treated with metformin. In conclusion, this study showed a lower prevalence of patients treated with anti-diabetic medicine in Greenland than Denmark. The main reason may be a much higher prevalence of undiagnosed diabetes in Greenland, particularly among the middle-aged. Differences in awareness of diabetes and access to continued primary healthcare may be contributing factors.

Diabetes care in the dispersed population of Greenland. A new model based on continued monitoring, analysis and adjustment of initiatives taken

Diabetes used to be a rare condition among Inuit in Greenland. However, research in recent decades has shown a high prevalence of undiagnosed diabetes. Addressing diabetes in the geographically dispersed population of Greenland presents a challenge to the health care system. In 2008, a new model of diabetes care was introduced in Greenland that included continual monitoring, analysis, and adjustment of initiatives taken. The overall aim of this review was to review the feasibility of the monitoring of an ongoing national diabetes care programme. After ten years of observation it was clear that monitoring of such a programme based on information in electronic medical records in Greenland was feasible. It was found that the majority of the population in Greenland was in contact with the health care system. Increased diagnostic activity resulted in an increased prevalence of diagnosed diabetes. The quality of diabetes care in Greenland and the testing effectiveness of gestational diabetes were improved. Microvascular complications were frequently observed among Greenlandic diabetic patients, except for retinopathy that was as an exception. In summary, this model may improve diabetes care and potentially care for other chronic conditions in Greenland, and may also be helpful in other remote settings where chronic disease care is difficult.Abbreviations: AD: Anno Domini; ADA: American Diabetes Association; BC: Before Christ; BMI: Body Mass Index; BP: Blood Pressure; CWB: Capillary Whole Blood; EMR: Electronic Medical Record; EASD: European Association for Study of Diabetes; GA: Gestational Age; GDM: Gestational Diabetes Mellitus; FIGO: The International Federation of Gynaecology and Obstetrics; HbA1c: Glycosylated haemoglobin; IDF: International Diabetes Federation; LDL: Low density lipoprotein; NDQIA: National Diabetes Quality Improvement Alliancel; NICE: National Institute for Health and Care Excellence; OECD: Organisation for Economic Co-operation and Development; OGTT: Oral Glucose Tolerance Test; QIH: Queen Ingrid Hospital; RCT: Randomised Controlled Tria;l T1D: Type 1 Diabetes; T2D: Type 2 Diabetes; UACR: Urine Albumin Creatinine Ratio; WHO: World Health Organisation.

Genetics of metabolic traits in Greenlanders: lessons from an isolated population

In this review, we describe the extraordinary population of Greenland, which differs from large outbred populations of Europe and Asia, both in terms of population history and living conditions. Many years in isolation, small population size and an extreme environment have shaped the genetic composition of the Greenlandic population. The unique genetic background combined with the transition from a traditional Inuit lifestyle and diet, to a more Westernized lifestyle, has led to an increase in the prevalence of metabolic conditions like obesity, where the prevalence from 1993 to 2010 has increased from 16.4% to 19.4% among men, and from 13.0% to 25.4% among women, type 2 diabetes and cardiovascular diseases. The genetic susceptibility to metabolic conditions has been explored in Greenlanders, as well as other isolated populations, taking advantage of population-genetic properties of these populations. During the last 10 years, these studies have provided examples of loci showing evidence of positive selection, due to adaption to Arctic climate and Inuit diet, including TBC1D4 and FADS/CPT1A, and have facilitated the discovery of several loci associated with metabolic phenotypes. Most recently, the c.2433-1G>A loss-of-function variant in ADCY3 associated with obesity and type 2 diabetes was described. This locus has provided novel biological insights, as it has been shown that reduced ADCY3 function causes obesity through disrupted function in primary cilia. Future studies of isolated populations will likely provide further genetic as well as biological insights.

Microvascular complications in Nuuk, Greenland, among Greenlanders and non-Greenlanders diagnosed with type 2 diabetes

AIM

The objective of this study was to estimate and compare between Greenlanders and non-Greenlanders living in Nuuk the proportion of patients with type 2 diabetes with microvascular complications.

METHODS

This study was performed as a cross-sectional register study based on information in the Electronic Medical Record (EMR). All patients diagnosed with type 2 diabetes and with permanent addresses in Nuuk were included. Patients born in Greenland were considered to be Greenlanders, while patients born outside Greenland were considered as non-Greenlanders. Proportions of patients with retinopathy, microalbuminuria, nephropathy and neuropathy were estimated based on information from the EMR.

RESULTS

A total of 393 patients (295 Greenlanders and 98 non-Greenlanders) were included. In total 83.0% of all patients have been screened for retinopathy, while 66.4% were screened for microalbuminuria and 64.6% for neuropathy within a two year period. The most frequent microvascular complication was neuropathy, which was observed among half (49.6%) of all patients followed by microalbuminuria (28.4%), retinopathy (10.7%) and nephropathy (7.3%). Retinopathy was observed among 21.4% of the non-Greenlanders compared to only 7.0% of the Greenlanders (p = .001). Microalbuminuria was also observed more frequently (p = .047) among non-Greenlanders (37.5%) than among Greenlanders (24.9%).

CONCLUSION

Greenlanders seem to be less prone to especially retinopathy than are non-Greenlanders.

High awareness of diabetes in the health care system in Greenland measured as a proportion of population tested with glycated haemoglobin within 2 years

BACKGROUND

Sixty years ago diabetes was almost non-existent in Greenland and until the beginning of this century awareness of diabetes was quite minimal. A high prevalence of undiagnosed diabetes has been reported in repeated population surveys. Increased focus on diabetes has been made a priority within the health care system since 2008, and in 2010 glycated haemoglobin was introduced as a diagnostic tool to further facilitate the diagnosis of diabetes.

OBJECTIVE

The aim of this study was to estimate the age and gender specific use of glycated haemoglobin in 2014 and 2015, as an indicator of diagnostic activity and awareness of diabetes, and to estimate the prevalence of diagnosed pre-diabetes and diabetes among adults in Greenland aged 20-79 years of age.

METHODS

The study was performed as an observational, cross sectional register study based on information gleaned from the electronically laboratory system used in Greenland including all patients tested with glycated haemoglobin at least once in 2014 or 2015.

RESULTS

A total of 10,127 patients were tested with glycated haemoglobin in 2014 or 2015 corresponding to 18.1% of the whole population. Among adults aged 20-79 years 9506 patients were tested corresponding to 24.0% of the total adult population. More females (32.5%) than males (16.5%) aged 20-79 years old were tested (p < 0.001). The prevalence of diagnosed diabetes and high risk pre-diabetes among adults aged 20-79 years was 4.3 and 6.8% respectively.

CONCLUSION

In conclusion use of glycated haemoglobin is widely used in the health care system in Greenland indicating a high awareness of diabetes in the population and by the health care system. Still, awareness of undiagnosed diabetes remains an important issue and additional strategies targeting males under 70 years old must be considered.