Regional and neighborhood disparities in the odds of type 2 diabetes: results from 5 population-based studies in Germany (DIAB-CORE consortium)

Association of greenspaces exposure with cardiometabolic risk factors: a systematic review and meta-analysis

BACKGROUND

Cardiometabolic conditions are major contributors to the global burden of disease. An emerging body of evidence has associated access to and surrounding public open spaces (POS) and greenspace with cardiometabolic risk factors, including obesity, body mass index (BMI), hypertension (HTN), blood glucose (BG), and lipid profiles. This systematic review aimed to synthesize this evidence.

METHODS

This systematic review was conducted based on the PRISMA guidelines. Four electronic databases including Web of Science, PubMed, Scopus, and Google Scholar were searched for eligible articles published until July 2023. All observational studies which assessed the association of greenspace and POS with cardiometabolic risk factors including obesity, BMI, HTN, BG, and lipid profiles were included and reviewed by two authors independently. Heterogeneity between studies was assessed using the I2 index and Cochrane's Q test. Random/fixed effect meta-analyses were used to combine the association between greenspace exposure with cardiometabolic risk factors.

RESULTS

Overall, 118 relevant articles were included in our review. The majority of the articles were conducted in North America or Europe. In qualitative synthesis, access or proximity to greenspaces or POS impacts BMI and blood pressure or HTN, BG, and lipid profiles via various mechanisms. According to the random effect meta-analysis, more access to greenspace was significantly associated with lower odds of HTN (odds ratio (OR): 0.81, 95% confidence intervals (CIs): 0.61-0.99), obesity (OR: 0.83, 95% CIs: 0.77-0.90), and diabetes (OR:0.79, 95% CI: 0.67,0.90).

CONCLUSIONS

Findings of this systematic review and meta-analysis suggested that greenspace accessibility is associated with some cardiometabolic risk factors. Improving greenspace accessibility could be considered as one of the main strategies to reduce cardiometabolic risk factors at population level.

The Impact of Neighborhoods on Diabetes Risk and Outcomes: Centering Health Equity

Neighborhood environments significantly influence the development of diabetes risk factors, morbidity, and mortality throughout an individual's life. The social, economic, and physical environments of a neighborhood all affect the health risks of individuals and communities and also affect population health inequities. Factors such as access to healthy food, green spaces, safe housing, and transportation options can impact the health outcomes of residents. Social factors, including social cohesion and neighborhood safety, also play an important role in shaping neighborhood environments and can influence the development of diabetes. Therefore, understanding the complex relationships between neighborhood environments and diabetes is crucial for developing effective strategies to address health disparities and promote health equity. This review presents landmark findings from studies that examined associations between neighborhood socioeconomic, built and physical, and social environmental factors and diabetes-related risk and outcomes. Our framework emphasizes the historical context and structural and institutional racism as the key drivers of neighborhood environments that ultimately shape diabetes risk and outcomes. To address health inequities in diabetes, we propose future research areas that incorporate health equity principles and place-based interventions.

Environmental risk factors of type 2 diabetes-an exposome approach

Type 2 diabetes is one of the major chronic diseases accounting for a substantial proportion of disease burden in Western countries. The majority of the burden of type 2 diabetes is attributed to environmental risks and modifiable risk factors such as lifestyle. The environment we live in, and changes to it, can thus contribute substantially to the prevention of type 2 diabetes at a population level. The 'exposome' represents the (measurable) totality of environmental, i.e. nongenetic, drivers of health and disease. The external exposome comprises aspects of the built environment, the social environment, the physico-chemical environment and the lifestyle/food environment. The internal exposome comprises measurements at the epigenetic, transcript, proteome, microbiome or metabolome level to study either the exposures directly, the imprints these exposures leave in the biological system, the potential of the body to combat environmental insults and/or the biology itself. In this review, we describe the evidence for environmental risk factors of type 2 diabetes, focusing on both the general external exposome and imprints of this on the internal exposome. Studies provided established associations of air pollution, residential noise and area-level socioeconomic deprivation with an increased risk of type 2 diabetes, while neighbourhood walkability and green space are consistently associated with a reduced risk of type 2 diabetes. There is little or inconsistent evidence on the contribution of the food environment, other aspects of the social environment and outdoor temperature. These environmental factors are thought to affect type 2 diabetes risk mainly through mechanisms incorporating lifestyle factors such as physical activity or diet, the microbiome, inflammation or chronic stress. To further assess causality of these associations, future studies should focus on investigating the longitudinal effects of our environment (and changes to it) in relation to type 2 diabetes risk and whether these associations are explained by these proposed mechanisms.

Cardiovascular risk factors, living and ageing in Halle: the CARLA study

The CARLA study (Cardiovascular Disease, Living and Ageing in Halle) is a longitudinal population-based cohort study of the general population of the city of Halle (Saale), Germany. The primary aim of the cohort was to investigate risk factors for cardiovascular diseases based on comprehensive cardiological phenotyping of study participants and was extended to study factors associated with healthy ageing. In total, 1779 probands (812 women and 967 men, aged 45–83 years) were examined at baseline (2002–2005), with a first and second follow-up performed 4 and 8 years later. The response proportion at baseline was 64.1% and the reparticipation proportion for the first and second follow-up was 86% and 77% respectively. Sixty-four percent of the study participants were in retirement while 25% were full- or partially-employed and 11% were unemployed at the time of the baseline examination. The currently running third follow-up focuses on the assessment of physical and mental health, with an intensive 4 h examination program, including measurement of cardiovascular, neurocognitive, balance and gait parameters. The data collected in the CARLA Study resulted in answering various research questions in over 80 publications, of which two thirds were pooled analyses with other similar population-based studies. Due to the extensiveness of information on risk factors, subclinical conditions and evident diseases, the biobanking concept for the biosamples, the cohort representativeness of an elderly population, and the high level of quality assurance, the CARLA cohort offers a unique platform for further research on important indicators for healthy ageing.

Regional variation in type 2 diabetes: evidence from 137 820 adults on the role of neighbourhood body mass index

BACKGROUND

Body mass index (BMI) is a key covariate in the study of type 2 diabetes, but can also be theorized as a contextual effect. The purpose of this study was to explore the extent to which variation in individual risk factors and neighbourhood BMI explain the variation in type 2 diabetes prevalence across neighbourhoods and municipalities.

METHODS

Cross-sectional data were collected from 137 820 adults aged ≥18 years from 3296 neighbourhoods in 296 municipalities in the Northern Netherlands. The odds of type 2 diabetes was assessed using a multilevel model. Median odds ratios were calculated and choropleth maps were created to visually assess neighbourhood variation in type 2 diabetes prevalence.

RESULTS

The overall prevalence of type 2 diabetes was 4%, ranging from 0 to ≥10 and 0-7% across neighbourhoods and municipalities, respectively. Of the regional variation, 67.0 and 71.6% is explained through variation of individual risk factors at the neighbourhood and municipality level, respectively. Analysis on the smallest spatial scale, i.e. the neighbourhood, best captured the regional variance. Statistically significant interaction between individual and neighbourhood BMI was found (OR = 1.06; 95% CI = 1.03-1.08, P for interaction < 0.001), adjusted for the individual risk profile.

CONCLUSION

The results suggest a more cautious interpretation of neighbourhood effects in type 2 diabetes is warranted, and reveals the need for further investigation into risk-prone groups to guide the design of community-level interventions to halt the rise in type 2 diabetes prevalence.

Association of community types and features in a case-control analysis of new onset type 2 diabetes across a diverse geography in Pennsylvania

OBJECTIVES

To evaluate associations of community types and features with new onset type 2 diabetes in diverse communities. Understanding the location and scale of geographic disparities can lead to community-level interventions.

DESIGN

Nested case-control study within the open dynamic cohort of health system patients.

SETTING

Large, integrated health system in 37 counties in central and northeastern Pennsylvania, USA.

PARTICIPANTS AND ANALYSIS

We used electronic health records to identify persons with new-onset type 2 diabetes from 2008 to 2016 (n=15 888). Persons with diabetes were age, sex and year matched (1:5) to persons without diabetes (n=79 435). We used generalised estimating equations to control for individual-level confounding variables, accounting for clustering of persons within communities. Communities were defined as (1) townships, boroughs and city census tracts; (2) urbanised area (large metro), urban cluster (small cities and towns) and rural; (3) combination of the first two; and (4) county. Community socioeconomic deprivation and greenness were evaluated alone and in models stratified by community types.

RESULTS

Borough and city census tract residence (vs townships) were associated (OR (95% CI)) with higher odds of type 2 diabetes (1.10 (1.04 to 1.16) and 1.34 (1.25 to 1.44), respectively). Urbanised areas (vs rural) also had increased odds of type 2 diabetes (1.14 (1.08 to 1.21)). In the combined definition, the strongest associations (vs townships in rural areas) were city census tracts in urban clusters (1.41 (1.22 to 1.62)) and city census tracts in urbanised areas (1.33 (1.22 to 1.45)). Higher community socioeconomic deprivation and lower greenness were each associated with increased odds.

CONCLUSIONS

Urban residence was associated with higher odds of type 2 diabetes than for other areas. Higher community socioeconomic deprivation in city census tracts and lower greenness in all community types were also associated with type 2 diabetes.

Cross-sectional study of area-level disadvantage and glycaemic-related risk in community health service users in the Southern.IML Research (SIMLR) cohort

Objectives The aim of the present study was to determine the association between area-level socioeconomic disadvantage and glycaemic-related risk in health service users in the Illawarra-Shoalhaven region of New South Wales, Australia. Methods HbA1c values recorded between 2010 and 2012 for non-pregnant individuals aged ≥18 years were extracted from the Southern.IML Research (SIMLR) database. Individuals were assigned quintiles of the Socioeconomic Indices for Australia (SEIFA) Index of Relative Socioeconomic Disadvantage (IRSD) according to their Statistical Area 1 of residence. Glycaemic risk categories were defined as HbA1c 5.0-5.99% (lowest risk), 6.0-7.49% (intermediate risk) and ≥7.5% (highest risk). Logistic regression models were fit with glycaemic risk category as the outcome variable and IRSD as the study variable, adjusting for age and sex. Results Data from 29064 individuals were analysed. Higher disadvantage was associated with belonging to a higher glycaemic risk category in the fully adjusted model (most disadvantaged vs least disadvantaged quintile; odds ratio 1.74, 95% confidence interval 1.58, 1.93; P<0.001). Conclusion In this geocoded clinical dataset, area-level socioeconomic disadvantage was a significant correlate of increased glycaemic-related risk. Geocoded clinical data can inform more targeted use of health service resources, with the potential for improved health care equity and cost-effectiveness. What is known about the topic? The rapid increase in the prevalence of Type 2 diabetes (T2D), both globally and nationally within Australia, is a major concern for the community and public health agencies. Individual socioeconomic disadvantage is a known risk factor for abnormal glucose metabolism (AGM), including T2D. Although small-area-level socioeconomic disadvantage is a known correlate of AGM in Australia, less is known of the association of area-level disadvantage and glycaemic-related risk in individuals with AGM. What does this paper add? This study demonstrates a robust association between small-area-level socioeconomic disadvantage and glycaemic-related risk in regional New South Wales. The study demonstrates that it is feasible to use geocoded, routinely collected clinical data to identify communities at increased health risk. What are the implications for practitioners? The identification of at-risk populations is an essential step towards targeted public health policy and programs aimed at reducing the burden of AGM, its complications and the associated economic costs. Collaboration between primary care and public health in the collection and use of data described in the present study has the potential to enhance the effectiveness of both sectors.

Patient and disease characteristics of type-2 diabetes patients with or without chronic kidney disease: an analysis of the German DPV and DIVE databases

BACKGROUND

To evaluate the characteristics of type 2 diabetes (T2DM) patients with or without chronic kidney disease (CKD) in Germany.

METHODS

Using combined DPV/DIVE registry data, the analysis included patients with T2DM at least ≥ 18 years old who had an estimated glomerular filtration rate (eGFR) value available. CKD was defined as an eGFR < 60 mL/min/1.73 m2 or eGFR ≥ 60 mL/min/1.73 m2 and albuminuria (≥ 30 mg/g). Median values of the most recent treatment year per patient are reported.

RESULTS

Among 343,675 patients with T2DM 171,930 had CKD. Patients with CKD had a median eGFR of 48.9 mL/min/1.73 m2 and 51.2% had a urinary albumin level ≥ 30 mg/g. They were older, had a longer diabetes duration and a higher proportion was females compared to patients without CKD (all p < 0.001). More than half of CKD patients (53.5%) were receiving long-acting insulin-based therapy versus around 39.1% of those without (p < 0.001). CKD patients also had a higher rate of hypertension (79.4% vs 72.0%; p < 0.001). The most common antihypertensive drugs among CKD patients were renin-angiotensin-aldosteron system inhibitors (angiotensin converting enzyme inhibitors 33.8%, angiotensin receptor blockers 14.2%) and diuretics (40.2%). CKD patients had a higher rate of dyslipidemia (88.4% vs 86.3%) with higher triglyceride levels (157.9 vs 151.0 mg/dL) and lower HDL-C levels (men: 40.0 vs 42.0 mg/dL; women: 46.4 vs 50.0 mg/dL) (all p < 0.001) and a higher rate of hyperkalemia (> 5.5 mmol/L: 3.7% vs. 1.0%). Comorbidities were more common among CKD patients (p < 0.001).

CONCLUSION

The results illustrate the prevalence and morbidity burden associated with diabetic kidney disease in patients with T2DM in Germany. The data call for more attention to the presence of chronic kidney disease in patients with diabetes, should trigger intensified risk factor control up and beyond the control of blood glucose and HbA1c in these patients. They may also serve as a trigger for future investigations into this patient population asking for new treatment options to be developed.

Individual and area-level determinants associated with C-reactive protein as a marker of cardiometabolic risk among adults: Results from the German National Health Interview and Examination Survey 2008-2011

BACKGROUND

High-sensitivity C-reactive protein (hsCRP) is a sensitive biomarker of systemic inflammation and is related to the development and progression of cardiometabolic diseases. Beyond individual-level determinants, characteristics of the residential physical and social environment are increasingly recognized as contextual determinants of systemic inflammation and cardiometabolic risks. Based on a large nationwide sample of adults in Germany, we analyzed the cross-sectional association of hsCRP with residential environment characteristics. We specifically asked whether these associations are observed independent of determinants at the individual level.

METHODS

Data on serum hsCRP levels and individual sociodemographic, behavioral, and anthropometric characteristics were available from the German Health Interview and Examination Survey for Adults (2008-2011). Area-level variables included, firstly, the predefined German Index of Socioeconomic Deprivation (GISD) derived from the INKAR (indicators and maps on spatial and urban development in Germany and Europe) database and, secondly, population-weighted annual average concentration of particulate matter (PM10) in ambient air provided by the German Environment Agency. Associations with log-transformed hsCRP levels were analyzed using random-intercept multi-level linear regression models including 6,768 participants aged 18-79 years nested in 162 municipalities.

RESULTS

No statistically significant association of PM10 exposure with hsCRP was observed. However, adults residing in municipalities with high compared to those with low social deprivation showed significantly elevated hsCRP levels (change in geometric mean 13.5%, 95%CI 3.2%-24.7%) after adjusting for age and sex. The observed relationship was independent of individual-level educational status. Further adjustment for smoking, sports activity, and abdominal obesity appeared to markedly reduce the association between area-level social deprivation and hsCRP, whereas all individual-level variables contributed significantly to the model.

CONCLUSIONS

Area-level social deprivation is associated with higher systemic inflammation and the potentially mediating role of modifiable risk factors needs further elucidation. Identifying and assessing the source-specific harmful components of ambient air pollution in population-based studies remains challenging.

Study protocol: a pragmatic, stepped-wedge trial of tailored support for implementing social determinants of health documentation/action in community health centers, with realist evaluation

BACKGROUND

National leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action.

METHODS

This paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics' implementation efforts.

DISCUSSION

Results will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03607617 , registration date: 7/31/2018-retrospectively registered.

'Learning to shape life' - a qualitative study on the challenges posed by a diagnosis of diabetes mellitus type 2

Background

Diabetes mellitus type 2 is a central challenge for health policy and healthcare in all advanced countries. For the affected persons, living with a diagnosis of type 2 diabetes is difficult because the disease and its treatment have a considerable effect on daily life. The aim of this study was to investigate the challenges associated with a diagnosis of type 2 diabetes for those affected and the range, depth and complexities of the subjective perspectives of the patients under the conditions of the German healthcare system.

Methods

A cross-sectional qualitative study was conducted using a sample of 19 adult patients with type 2 diabetes mellitus. Patients were recruited successively from two specialized diabetological practices, three general practitioner’s offices, and two hospitals. The patients were interviewed once in person using semi-structured interviews. All interviews were recorded, transcribed, and analysed based on grounded theory.

Results

Persons affected by diabetes mellitus type 2 seem to feel responsible for managing their disease. Two strategies of action could be identified: 1) patients strictly followed the recommendations of the physicians, or 2) they showed that they are knowledgably managing their diabetes mellitus type 2. The action strategy to address the disease seemed to be influenced by patients’ confidence in themselves, the effectiveness of the interventions, or the patients’ locus of control. Minor differences in educational status could be discovered, and patients who were less educated tended to follow the recommendations of the physicians very strictly and seemed to place more emphasis on being compliant, which goes hand in hand with a life with prohibitions and restrictions. In contrast, being perceived as competent patients who make their own rules to manage the disease in daily life appeared to be more important for people with higher education levels.

Conclusion

Patient education and self-management programmes for diabetes mellitus type 2 should take different types of learners into account. Giving less-educated patients specific recommendations for successful diabetes self-management is particularly important.

Trial registration

German clinical trial register (DRKS-ID: DRKS00007847).

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0924-3) contains supplementary material, which is available to authorized users.

Association of neighbourhood socioeconomic status and diabetes burden using electronic health records in Madrid (Spain): the HeartHealthyHoods study

OBJECTIVE

To study the association between neighbourhood socioeconomic status and diabetes prevalence, incidence, and control in the entire population of northeastern Madrid, Spain.

SETTING

Electronic health records of the primary-care system in four districts of Madrid (Spain).

PARTICIPANTS

269 942 people aged 40 or older, followed from 2013 to 2014.

EXPOSURE

Neighbourhoodsocioeconomic status (NSES), measured using a composite index of seven indicators from four domains of education, wealth, occupation and living conditions.

PRIMARY OUTCOME MEASURES

Diagnosis of diabetes based on ICPC-2 codes and glycated haemoglobin (HbA1c %).

RESULTS

In regression analyses adjusted by age and sex and compared with individuals living in low NSES neighbourhoods, men living in medium and high NSES neighbourhoods had 10% (95% CI: 6% to 15%) and 29% (95% CI: 25% to 32%) lower prevalence of diabetes, while women had 27% (95% CI: 23% to 30%) and 50% (95% CI: 47% to 52%) lower prevalence of diabetes. Moreover, the hazard of diabetes in men living in medium and high NSES neighbourhoods was 13% (95% CI: 1% to 23%) and 20% (95% CI: 9% to 29%) lower, while the hazard of diabetes in women living in medium and high NSES neighbourhoods was 17% (95% CI: 3% to 29%) and 31% (95% CI: 20% to 41%) lower. Individuals living in medium and high SES neighbourhoods had 8% (95% CI: 2% to 15%) and 15% (95% CI: 9% to 21%) lower prevalence of lack of diabetes control, and a decrease in average HbA1c % of 0.05 (95% CI: 0.01 to 0.10) and 0.11 (95% CI: 0.06 to 0.15).

CONCLUSIONS

Diabetes prevalence, incidence and lack of control increased with decreasing NSES in a southern European city. Future studies should provide mechanistic insights and targets for intervention to address this health inequity.

Neighborhood Environments and Diabetes Risk and Control

PURPOSE OF REVIEW

The objective of this review is to highlight the evidence on the association between contextual characteristics of residential environments and type 2 diabetes, to provide an overview of the methodological challenges and to outline potential topics for future research in this field.

RECENT FINDINGS

The link between neighborhood socioeconomic status or deprivation and diabetes prevalence, incidence, and control is robust and has been replicated in numerous settings, including in experimental and quasi-experimental studies. The association between characteristics of the built environment that affect physical activity, other aspects of the built environment, and diabetes risk is robust. There is also evidence for an association between food environments and diabetes risk, but some conflicting results have emerged in this area. While the evidence base on the association of neighborhood socioeconomic status and built and physical environments and diabetes is large and robust, challenges remain related to confounding due to neighborhood selection. Moreover, we also outline five paths forward for future research on the role of neighborhood environments on diabetes.

Associations of Residential Socioeconomic, Food, and Built Environments With Glycemic Control in Persons With Diabetes in New York City From 2007-2013

In the present study, we examined the longitudinal associations between residential environmental factors and glycemic control in 182,756 adults with diabetes in New York City from 2007 to 2013. Glycemic control was defined as a hemoglobin A1c (HbA1c) level less than 7%. We constructed residential-level measures and performed principle component analysis to formulate a residential composite score. On the basis of this score, we divided residential areas into quintiles, with the lowest and highest quintiles reflecting the least and most advantaged residential environments, respectively. Several residential-level environmental characteristics, including more advantaged socioeconomic conditions, greater ratio of healthy food outlets to unhealthy food outlets, and residential walkability were associated with increased glycemic control. Individuals who lived continuously in the most advantaged residential areas took less time to achieve glycemic control compared with the individuals who lived continuously in the least advantaged residential areas (9.9 vs. 11.5 months). Moving from less advantaged residential areas to more advantaged residential areas was related to improved diabetes control (decrease in HbA1c = 0.40%, 95% confidence interval: 0.22, 0.55), whereas moving from more advantaged residential areas to less advantaged residential areas was related to worsening diabetes control (increase in HbA1c = 0.33%, 95% confidence interval: 0.24, 0.44). These results show that residential areas with greater resources to support healthy food and residential walkability are associated with improved glycemic control in persons with diabetes.

Regional differences in antihyperglycemic medication are not explained by individual socioeconomic status, regional deprivation, and regional health care services. Observational results from the German DIAB-CORE consortium

AIMS

This population-based study sought to extend knowledge on factors explaining regional differences in type 2 diabetes mellitus medication patterns in Germany.

METHODS

Individual baseline and follow-up data from four regional population-based German cohort studies (SHIP [northeast], CARLA [east], HNR [west], KORA [south]) conducted between 1997 and 2010 were pooled and merged with both data on regional deprivation and regional health care services. To analyze regional differences in any or newer anti-hyperglycemic medication, medication prevalence ratios (PRs) were estimated using multivariable Poisson regression models with a robust error variance adjusted gradually for individual and regional variables.

RESULTS

The study population consisted of 1,437 people aged 45 to 74 years at baseline, (corresponding to 49 to 83 years at follow-up) with self-reported type 2 diabetes. The prevalence of receiving any anti-hyperglycemic medication was 16% higher in KORA (PR 1.16 [1.08-1.25]), 10% higher in CARLA (1.10 [1.01-1.18]), and 7% higher in SHIP (PR 1.07 [1.00-1.15]) than in HNR. The prevalence of receiving newer anti-hyperglycemic medication was 49% higher in KORA (1.49 [1.09-2.05]), 41% higher in CARLA (1.41 [1.02-1.96]) and 1% higher in SHIP (1.01 [0.72-1.41]) than in HNR, respectively. After gradual adjustment for individual variables, regional deprivation and health care services, the effects only changed slightly.

CONCLUSIONS

Neither comprehensive individual factors including socioeconomic status nor regional deprivation or indicators of regional health care services were able to sufficiently explain regional differences in anti-hyperglycemic treatment in Germany. To understand the underlying causes, further research is needed.

Inner-city green space and its association with body mass index and prevalent type 2 diabetes: a cross-sectional study in an urban German city

OBJECTIVE

The accessibility of green space is an important aspect of the urban residential environment and has been found to be beneficial for health and well-being. This study investigates the association between different indicators of green space and the outcomes body mass index (BMI) and prevalent type 2 diabetes in an urban population.

DESIGN

Population-based cross-sectional study.

SETTING

Dortmund, a city located in the industrial Ruhr area in Western Germany.

PARTICIPANTS

1312 participants aged 25-74 years from the Dortmund Health Study.

METHODS

The participants' addresses were geocoded and shapefiles of statistical districts, road network and land use, as well as data on neighbourhood characteristics were obtained at baseline. Three indicators of green space were constructed using geographical information systems: proportion of green space, recreation location quotient (RLQ) weighted by population and distance to the next park or forest. Multilevel linear and logistic regression analyses on the association of green space with BMI and type 2 diabetes were performed, adjusted by individual-level characteristics and neighbourhood unemployment rate.

RESULTS

The multilevel regression analyses showed no association between green space and BMI. In contrast, the three indicators of green space were significantly associated with type 2 diabetes. Residents of neighbourhoods with a low RLQ had a 2.44 (95% CI 1.01 to 5.93) times higher odds to have type 2 diabetes compared with residents of high RLQ neighbourhoods. Likewise, residing more than 0.8 km away from the nearest park or forest increased the odds of type 2 diabetes (OR 1.71, 95% CI 1.05 to 2.77).

CONCLUSIONS

This study indicates that green space and its spatial accessibility might play a role in the development of type 2 diabetes. Further research is needed to clarify this association.

The association of unemployment with glucose metabolism: a systematic review and meta-analysis

OBJECTIVES

Unemployment has been linked with poor health. We hypothesized that being unemployed is associated with disorders of glucose metabolism and performed a systematic review and meta-analysis of the literature to ascertain the relationship.

METHODS

We searched the databases of Scopus, Medline Ovid and Web of Science for population-based original studies for past 20 years. Random effects meta-analyses were used to estimate odds ratios (OR) with 95% confidence intervals (CI) for prediabetes and type 2 diabetes among the unemployed as compared to those employed, separately for men and women when possible.

RESULTS

Out of 981 articles found, 12 articles were included in the systematic review and eight articles in the meta-analyses. Unemployment was associated with 1.6-fold odds for prediabetes (OR 1.58; 95% CI 1.07-2.35), and 1.7-fold odds for type 2 diabetes (OR 1.72; 95% CI 1.14-2.58) in the total sample. The corresponding associations for type 2 diabetes were also found stratified for men (OR 1.53; 95% CI 1.47-1.60) and women (OR 1.60; 95% CI 1.33-1.92).

CONCLUSIONS

Unemployment is associated with prediabetes and type 2 diabetes, global concerns of public health with potential for prevention.

Is a hilly neighborhood environment associated with diabetes mellitus among older people? Results from the JAGES 2010 study

BACKGROUND

Although living in a hilly environment may promote muscular activity in the daily lives of residents, and such activity may prevent diabetes mellitus, few studies have focused on the impact of living in a hilly environment on diabetes mellitus. The purpose of this study was to investigate the impact of a hilly neighborhood environment on DM in older people.

METHODS

We used data from the Japan Gerontological Evaluation Study, a population-based, cross-sectional study of individuals aged 65 or older without long-term care needs in Japan, which was conducted in 2010. A total of 8904 participants in 46 neighborhoods had responded to the questionnaire and undergone a health check. Diabetes mellitus was diagnosed as HbA_1c ≥ 6.5% and those undergoing treatment for diabetes mellitus. Poorly controlled diabetes mellitus was diagnosed in those without other chronic diseases who had an HbA_1c > 7.5%, and in those with other chronic diseases if their HbA_1c was >8.0%. Neighborhood environment was evaluated based on the percentage of positive responses in the questionnaire and geographical information system data. A multilevel analysis was performed, adjusted for individual-level risk factors. Furthermore, sensitivity analysis was conducted for those who were undergoing treatment for diabetes mellitus (n = 1007).

RESULTS

After adjustment for other physical environmental and individual covariates, a 1 interquartile range increase (1.48°) in slope in the neighborhood decreased the risk of poorly controlled diabetes mellitus by 18% (odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.70-0.97). Sensitivity analysis confirmed that larger slopes in the neighborhood showed a significant protective effect against diabetes mellitus among those who were undergoing treatment for diabetes mellitus (OR: 0.73, 95% CI: 0.59-0.90).

CONCLUSION

A hilly neighborhood environment was not associated with diabetes mellitus, but was protective against poorly controlled diabetes mellitus.

Neighborhood Sociodemographics and Change in Built Infrastructure

While increasing evidence suggests an association between physical infrastructure in neighbourhoods and health outcomes, relatively little research examines how neighbourhoods change physically over time and how these physical improvements are spatially distributed across populations. This paper describes the change over 25 years (1985-2010) in bicycle lanes, off-road trails, bus transit service, and parks, and spatial clusters of changes in these domains relative to neighbourhood sociodemographics in four U.S. cities that are diverse in terms of geography, size and population. Across all four cities, we identified increases in bicycle lanes, off-road trails, and bus transit service, with spatial clustering in these changes that related to neighbourhood sociodemographics. Overall, we found evidence of positive changes in physical infrastructure commonly identified as supportive of physical activity. However, the patterning of infrastructure change by sociodemographic change encourages attention to the equity in infrastructure improvements across neighbourhoods.

Implications of supermarket access, neighbourhood walkability and poverty rates for diabetes risk in an employee population

OBJECTIVE

Diabetes is a growing public health problem, and the environment in which people live and work may affect diabetes risk. The goal of the present study was to examine the association between multiple aspects of environment and diabetes risk in an employee population.

DESIGN

This was a retrospective cross-sectional analysis. Home environment variables were derived using employees' zip code. Descriptive statistics were run on all individual- and zip-code-level variables, stratified by diabetes risk and worksite. A multivariable logistic regression analysis was then conducted to determine the strongest associations with diabetes risk.

SETTING

Data were collected from employee health fairs in a Midwestern health system, 2009-2012.

SUBJECTS

The data set contains 25 227 unique individuals across four years of data. From this group, using an individual's first entry into the database, 15 522 individuals had complete data for analysis.

RESULTS

The prevalence of high diabetes risk in this population was 2·3 %. There was significant variability in individual- and zip-code-level variables across worksites. From the multivariable analysis, living in a zip code with higher percentage of poverty and higher walk score was positively associated with high diabetes risk, while living in a zip code with higher supermarket density was associated with a reduction in high diabetes risk.

CONCLUSIONS

Our study underscores the important relationship between poverty, home neighbourhood environment and diabetes risk, even in a relatively healthy employed population, and suggests a role for the employer in promoting health.

Normal liver enzymes are correlated with severity of metabolic syndrome in a large population based cohort

Key features of the metabolic syndrome are insulin resistance and diabetes. The liver as central metabolic organ is not only affected by the metabolic syndrome as non-alcoholic fatty liver disease (NAFLD), but may contribute to insulin resistance and metabolic alterations. We aimed to identify potential associations between liver injury markers and diabetes in the population-based Heinz Nixdorf RECALL Study. Demographic and laboratory data were analyzed in participants (n = 4814, age 45 to 75y). ALT and AST values were significantly higher in males than in females. Mean BMI was 27.9 kg/m² and type-2-diabetes (known and unkown) was present in 656 participants (13.7%). Adiponectin and vitamin D both correlated inversely with BMI. ALT, AST, and GGT correlated with BMI, CRP and HbA1c and inversely correlated with adiponectin levels. Logistic regression models using HbA1c and adiponectin or HbA1c and BMI were able to predict diabetes with high accuracy. Transaminase levels within normal ranges were closely associated with the BMI and diabetes risk. Transaminase levels and adiponectin were inversely associated. Re-assessment of current normal range limits should be considered, to provide a more exact indicator for chronic metabolic liver injury, in particular to reflect the situation in diabetic or obese individuals.

Longitudinal Associations Between Neighborhood Physical and Social Environments and Incident Type 2 Diabetes Mellitus: The Multi-Ethnic Study of Atherosclerosis (MESA)

IMPORTANCE

Neighborhood environments may influence the risk for developing type 2 diabetes mellitus (T2DM), but, to our knowledge, no longitudinal study has evaluated specific neighborhood exposures.

OBJECTIVE

To determine whether long-term exposures to neighborhood physical and social environments, including the availability of healthy food and physical activity resources and levels of social cohesion and safety, are associated with incident T2DM during a 10-year period.

DESIGN, SETTING, AND PARTICIPANTS

We used data from the Multi-Ethnic Study of Atherosclerosis, a population-based cohort study of adults aged 45 to 84 years at baseline (July 17, 2000, through August 29, 2002). A total of 5124 participants free of T2DM at baseline underwent 5 clinical follow-up examinations from July 17, 2000, through February 4, 2012. Time-varying measurements of neighborhood healthy food and physical activity resources and social environments were linked to individual participant addresses. Neighborhood environments were measured using geographic information system (GIS)- and survey-based methods and combined into a summary score. We estimated hazard ratios (HRs) of incident T2DM associated with cumulative exposure to neighborhood resources using Cox proportional hazards regression models adjusted for age, sex, income, educational level, race/ethnicity, alcohol use, and cigarette smoking. Data were analyzed from December 15, 2013, through September 22, 2014.

MAIN OUTCOMES AND MEASURES

Incident T2DM defined as a fasting glucose level of at least 126 mg/dL or use of insulin or oral antihyperglycemics.

RESULTS

During a median follow-up of 8.9 years (37,394 person-years), 616 of 5124 participants (12.0%) developed T2DM (crude incidence rate, 16.47 [95% CI, 15.22-17.83] per 1000 person-years). In adjusted models, a lower risk for developing T2DM was associated with greater cumulative exposure to indicators of neighborhood healthy food (12%; HR per interquartile range [IQR] increase in summary score, 0.88 [95% CI, 0.79-0.98]) and physical activity resources (21%; HR per IQR increase in summary score, 0.79 [95% CI, 0.71-0.88]), with associations driven primarily by the survey exposure measures. Neighborhood social environment was not associated with incident T2DM (HR per IQR increase in summary score, 0.96 [95% CI, 0.88-1.07]).

CONCLUSIONS AND RELEVANCE

Long-term exposure to residential environments with greater resources to support physical activity and, to a lesser extent, healthy diets was associated with a lower incidence of T2DM, although results varied by measurement method. Modifying neighborhood environments may represent a complementary, population-based approach to prevention of T2DM, although further intervention studies are needed.

Association of neighbourhood unemployment rate with incident Type 2 diabetes mellitus in five German regions

AIM

To analyse the association of neighbourhood unemployment with incident self-reported physician-diagnosed Type 2 diabetes in a population aged 45-74 years from five German regions.

METHODS

Study participants were linked via their addresses at baseline to particular neighbourhoods. Individual-level data from five population-based studies were pooled and combined with contextual data on neighbourhood unemployment. Type 2 diabetes was assessed according to a self-reported physician diagnosis of diabetes. We estimated proportional hazard models (Weibull distribution) in order to obtain hazard ratios and 95% CIs of Type 2 diabetes mellitus, taking into account interval-censoring and clustering.

RESULTS

We included 7250 participants residing in 228 inner city neighbourhoods in five German regions in our analysis. The incidence rate was 12.6 per 1000 person-years (95% CI 11.4-13.8). The risk of Type 2 diabetes mellitus was higher in men [hazard ratio 1.79 (95% CI 1.47-2.18)] than in women and higher in people with a low education level [hazard ratio 1.55 (95% CI 1.18-2.02)] than in those with a high education level. Independently of individual-level characteristics, we found a higher risk of Type 2 diabetes mellitus in neighbourhoods with high levels of unemployment [quintile 5; hazard ratio 1.72 (95% CI 1.23-2.42)] than in neighbourhoods with low unemployment (quintile 1).

CONCLUSIONS

Low education level and high neighbourhood unemployment were independently associated with an elevated risk of Type 2 diabetes mellitus. Studies examining the impact of the residential environment on Type 2 diabetes mellitus will provide knowledge that is essential for the identification of high-risk populations.

How social inequalities impact the course of treatment and care for patients with type 2 diabetes mellitus: study protocol for a qualitative cross-sectional study from the patient's perspective

INTRODUCTION

Studies from various scientific disciplines have demonstrated that socioeconomic inequalities in type 2 diabetes mellitus negatively affect groups with a low socioeconomic status. Furthermore, socioeconomic inequalities also exist in terms of access to, and utilisation and perceived quality of, diabetological care. The aim of this qualitative study, which focuses on the patient's perspective, is to provide insights into the ways socioeconomic inequalities impact the course of treatment and care of patients with type 2 diabetes mellitus. The study aims to develop an understanding of how socioeconomic inequalities in care arise.

METHODS AND ANALYSIS

A cross-sectional qualitative study will be conducted using a sample of about 20 patients with type 2 diabetes mellitus aged 18 and older. Patients will be recruited successively from the University Hospital in Halle/Saale, Germany, a general practitioner's office, and in a specialised diabetological practice. The patients will be interviewed personally once, using semistructured qualitative interviews. All interviews will be recorded, transcribed, and analysed based on Grounded Theory.

ETHICS AND DISSEMINATION

All interviewees will receive comprehensive written information about the study and sign a declaration of consent prior to the interview. The study will comply rigorously with data protection legislation. The research team has obtained the approval of the Ethical Review Committee at the MLU Halle-Wittenberg, Germany. The results of the study will be published in high-quality, peer-reviewed international journals, presented at several congresses and used for developing follow-up research projects.

TRIAL REGISTRATION NUMBER

This study has been registered with the German Clinical Trials Register and assigned DRKS00007847.

The role of neighborhood characteristics in racial/ethnic disparities in type 2 diabetes: results from the Boston Area Community Health (BACH) Survey

Racial/ethnic disparities in the prevalence of type 2 diabetes mellitus (T2DM) are well documented and until recently, research has focused almost exclusively on individual-based determinants as potential contributors to these disparities (health behaviors, biological/genetic factors, and individual-level socio-demographics). Research on the role of neighborhood characteristics in relation to racial/ethnic disparities in T2DM is very limited. Therefore, the aim of this research is to identify and estimate the contribution of specific aspects of neighborhoods that may be associated with racial/ethnic disparities in T2DM. Data from the Boston Area Community Health III Survey (N = 2764) was used in this study, which is a community-based random-sample survey of adults in Boston, Massachusetts from three racial/ethnic groups (Black, Hispanic, and White). We applied two-level random intercepts logistic regression to assess the associations between race/ethnicity, neighborhood characteristics (census tract socioeconomic status, racial composition, property and violent crime, open space, geographic proximity to grocery stores, convenience stores, and fast food, and neighborhood disorder) and prevalent T2DM (fasting glucose > 125 mg/dL, HbA1c ≥ 6.5%, or self-report of a T2DM diagnosis). Black and Hispanic participants had 2.89 times and 1.48 times the odds of T2DM as White participants, respectively. Multilevel models indicated a significant between-neighborhood variance estimate of 0.943, providing evidence of neighborhood variation. Individual demographics (race/ethnicity, age and gender) explained 22.3% of the neighborhood variability in T2DM. The addition of neighborhood-level variables to the model had very little effect on the magnitude of the racial/ethnic disparities and on the between-neighborhood variability. For example, census tract poverty explained less than 1% and 6% of the excess odds of T2DM among Blacks and Hispanics and only 1.8% of the neighborhood variance in T2DM. While the findings of this study overall suggest that neighborhood factors are not a major contributor to racial/ethnic disparities in T2DM, further research is needed including data from other geographic locations.

Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany

Background

The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES).

Methods

The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity.

Results

We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12–1.64) as well as for obesity (OR 1.14; 95% CI 1.02–1.26). Further analyses showed that these associations were relatively similar for both men and women.

Conclusions

Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.

Regional differences of undiagnosed type 2 diabetes and prediabetes prevalence are not explained by known risk factors

Background

We have previously found regional differences in the prevalence of known type 2 diabetes between northeastern and southern Germany. We aim to also provide prevalence estimates for prediabetes (isolated impaired fasting glucose (i-IFG), isolated glucose intolerance (i-IGT), combined IFG and IGT) and unknown type 2 diabetes for both regions.

Methods

Prevalence (95%CI) of prediabetes (i-IFG: fasting glucose 5.6–6.9 mmol/l; i-IGT: 2 h postchallenge gluose 7.8–11.0 mmol/l, oral glucose tolerance test (OGTT), ≥8 h overnight fasting) and unknown diabetes were analyzed in two regional population-based surveys (age group 35–79 years): SHIP-TREND (Study of Health in Pomerania (northeast), 2008–2012) and KORA F4 (Cooperative Health Research in the region of Augsburg (south), 2006–2008). Both studies used similar methods, questionnaires, and identical protocols for OGTT. Overall, 1,980 participants from SHIP-TREND and 2,617 participants from KORA F4 were included.

Results

Age-sex-standardized prevalence estimates (95%CI) of prediabetes and unknown diabetes were considerably higher in the northeast (SHIP-TREND: 43.1%; 40.9–45.3% and 7.1%; 5.9–8.2%) than in the south of Germany (KORA F4: 30.1%; 28.4–31.7% and 3.9%; 3.2–4.6%), respectively. In particular, i-IFG (26.4%; 24.5–28.3% vs. 17.2%; 15.7–18.6%) and IFG+IGT (11.2%; 9.8–12.6% vs. 6.6%; 5.7–7.5%) were more frequent in SHIP-TREND than in KORA. In comparison to normal glucose tolerance, the odds of having unknown diabetes (OR, 95%CI: 2.59; 1.84–3.65) or prediabetes (1.98; 1.70–2.31) was higher in the northeast than in the south after adjustment for known risk factors (obesity, lifestyle).

Conclusions

The regional differences of prediabetes and unknown diabetes are in line with the geographical pattern of known diabetes in Germany. The higher prevalences in the northeast were not explained by traditional risk factors.

Area level deprivation is an independent determinant of prevalent type 2 diabetes and obesity at the national level in Germany. Results from the National Telephone Health Interview Surveys 'German Health Update' GEDA 2009 and 2010

Objective

There is increasing evidence that prevention programmes for type 2 diabetes mellitus (T2DM) and obesity need to consider individual and regional risk factors. Our objective is to assess the independent association of area level deprivation with T2DM and obesity controlling for individual risk factors in a large study covering the whole of Germany.

Methods

We combined data from two consecutive waves of the national health interview survey ‘GEDA’ conducted by the Robert Koch Institute in 2009 and 2010. Data collection was based on computer-assisted telephone interviews. After exclusion of participants <30 years of age and those with missing responses, we included n = 33,690 participants in our analyses. The outcome variables were the 12-month prevalence of known T2DM and the prevalence of obesity (BMI ≥30 kg/m²). We also controlled for age, sex, BMI, smoking, sport, living with a partner and education. Area level deprivation of the districts was defined by the German Index of Multiple Deprivation. Logistic multilevel regression models were performed using the software SAS 9.2.

Results

Of all men and women living in the most deprived areas, 8.6% had T2DM and 16.9% were obese (least deprived areas: 5.8% for T2DM and 13.7% for obesity). For women, higher area level deprivation and lower educational level were both independently associated with higher T2DM and obesity prevalence [highest area level deprivation: OR 1.28 (95% CI: 1.05–1.55) for T2DM and OR 1.28 (95% CI: 1.10–1.49) for obesity]. For men, a similar association was only found for obesity [OR 1.20 (95% CI: 1.02–1.41)], but not for T2DM.

Conclusion

Area level deprivation is an independent, important determinant of T2DM and obesity prevalence in Germany. Identifying and targeting specific area-based risk factors should be considered an essential public health issue relevant to increasing the effectiveness of diabetes and obesity prevention.

Gender differences in the association of individual social class and neighbourhood unemployment rate with prevalent type 2 diabetes mellitus: a cross-sectional study from the DIAB-CORE consortium

OBJECTIVE

To analyse gender differences in the relationship of individual social class, employment status and neighbourhood unemployment rate with present type 2 diabetes mellitus (T2DM).

DESIGN

Five cross-sectional studies.

SETTING

Studies were conducted in five regions of Germany from 1997 to 2006.

PARTICIPANTS

The sample consisted of 8871 individuals residing in 226 neighbourhoods from five urban regions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalent T2DM.

RESULTS

We found significant multiplicative interactions between gender and the individual variables--social class and employment status. Social class was statistically significantly associated with T2DM in men and women, whereby this association was stronger in women (lower vs higher social class: OR 2.68 (95% CIs 1.66 to 4.34)) than men (lower vs higher social class: OR 1.78 (95% CI 1.22 to 2.58)). Significant associations of employment status and T2DM were only found in women (unemployed vs employed: OR 1.73 (95% CI 1.02 to 2.92); retired vs employed: OR 1.77 (95% CI 1.10 to 2.84); others vs employed: OR 1.64 (95% CI 1.01 to 2.67)). Neighbourhood unemployment rate was associated with T2DM in men (high vs low tertile: OR 1.52 (95% CI 1.18 to 1.96)). Between-study and between-neighbourhood variations in T2DM prevalence were more pronounced in women. The considered covariates helped to explain statistically the variation in T2DM prevalence among men, but not among women.

CONCLUSIONS

Social class was inversely associated with T2DM in both men and women, whereby the association was more pronounced in women. Employment status only affected T2DM in women. Neighbourhood unemployment rate is an important predictor of T2DM in men, but not in women.

Type 2 diabetes: prevalence and relevance of genetic and acquired factors for its prediction

BACKGROUND

The epidemiology of type 2 diabetes in Germany is of major societal interest, as is the question of the predictive value of genetic and acquired risk factors.

METHODS

We present clinically relevant aspects of these topics on the basis of a selective review of pertinent literature retrieved by a PubMed search that centered on population-based studies.

RESULTS

The German Health Interview and Examination Survey for Adults (Studie zur Gesundheit Erwachsener in Deutschland [DEGS1], 2008-2011) revealed that diabetes was diagnosed in 7.2% of the population aged 18 to 79 years (women 7.4%, men 7.0%). These figures are two percentage points higher than those found in the preceding national survey (1998). The percentage of cases that were not captured by these surveys is estimated at 2% to 7% depending on the method. Independently of personal factors (the individual's life style), it seems that living in a disadvantaged region characterized by high unemployment, air pollution, and poor infrastructure raises the risk of diabetes. Moreover, type 2 diabetes has a substantial hereditary component. More than 60 genetic regions have been identified to date that affect the risk of type 2 diabetes, yet all of them together account for only 10% to 15% of the genetic background of the disease.

CONCLUSION

The prevalence of type 2 diabetes in Germany has risen in recent years. The discovery of new genetic variants that confer a higher risk of developing the disease has improved our understanding of insulin secretion in diabetes pathogenesis rather than the prediction of individual diabetes risk ("personalized medicine").