Increasing socio-economic inequality in type 2 diabetes prevalence--repeated cross-sectional surveys in England 1994-2006

The impact of a diabetes diagnosis on health and well-being: Findings from the English Longitudinal Study of Ageing

BACKGROUND

Poorer health and well-being are associated with diabetes risk. However, little is known about the trajectory of health and well-being from before to after diabetes diagnosis. We compared depressive symptoms, quality of life, self-rated health, and loneliness at three time points (prediagnosis, diagnosis, 2-4 years post diagnosis) in individuals who developed diabetes and a comparison group.

METHODS

Health and well-being measures were self-reported by 3474 participants from the English Longitudinal Study of Ageing. Repeated measures analysis of variance and generalized estimating equations were used to investigate differences by group, time, and group-by-time interactions.

RESULTS

A total of 473 (13.6%) participants developed diabetes. The diabetes group reported greater depressive symptoms (W2(1) = 20.67, p < .001) and lower quality of life (F = 1, 2535 = 10.30, p = .001) and were more likely to rate their health as fair/poor (W2(1) = 67.11, p < .001) across time points, adjusting for age, sex, and wealth. They also reported greater loneliness (F = 1, 2693 = 9.70, p = .002) in unadjusted analyses. However, this was attenuated to the null in adjusted analyses. The group-by-time interaction was significant for quality of life (F = 1.97, 5003.58 = 5.60, p = .004) and self-rated health (W2(2) = 11.69, p = .003), with a greater decline in these measures over time in the diabetes group in adjusted analyses.

CONCLUSION

People who received a diabetes diagnosis had greater depressive symptoms, lower quality of life, and poorer self-rated health than those who did not develop diabetes. Quality of life and self-rated health deteriorated more rapidly following a diagnosis. Screening for these factors around the time of diagnosis could allow for interventions to improve the health and well-being of those with diabetes.

Socioeconomic inequalities in type 2 diabetes mellitus: a study based on a population-based survey in Iran

BACKGROUND

Type 2 diabetes mellitus (T2DM) is the most prevalent form of Diabetes Mellitus (DM), with social and economic determinants significantly influencing its prevalence. This study aimed to analyze the socioeconomic inequalities associated with T2DM in Iran.

METHODS

Data from an observational survey in Iran, titled "Diabetes Care (DiaCare)," were utilized for this study. Socioeconomic inequalities were assessed through variables including Hemoglobin A1C (HbA1c), Fasting Blood Glucose (FBG), and Triple target (HbA1c, blood pressure, LDL-C), using concentration indices (CIs) and a multivariate logistic regression analysis. Individual socioeconomic status (SES) was determined by calculating an asset index using principle component analysis (PCA) based on their properties. Data analysis was conducted using STATA software version 14.

RESULTS

A total of 13,321 participants were included in the study. The CIs were significantly positive for controlled HbA1c (0.0324) and triple target (0.1067), while for controlled FBG, it was 0.0125, although not significant. Among females, the CIs were significantly positive for controlled HbA1c (0.0745), FBG (0.0367), and triple target (0.209). Additionally, in the 45-55 and 65-75 age groups, the CIs were significantly positive for controlled HbA1c (0.0607) and FBG (0.0708), respectively. This index was significant for controlled Triple target in the 35-45 (0.376) and 65-75 (0.124) age groups. The CI for controlled FBG was significant in rural dwellers (-0.044) while the concentration of controlled triple target was significant in urban dwellers (0.0967). Controlled HbA1c showed significant concentration in both urban (0.0306) and rural (-0.0576) dwellers. Furthermore, the CIs were significant for controlled HbA1c in regions with medium prevalence (0.0534) and FBG in regions with low prevalence (-0.0277). This index was significantly positive for controlled triple target in regions with high prevalence (0.124).

CONCLUSIONS

Diabetes care is more concentrated among individuals with higher SES. Policymakers should consider this to mitigate the inequality and alleviate the burden of T2DM.

Inequalities in Diabetes Mortality Between Microregions in Hungary

Objectives: Regional differences in diabetes mortality are high in Hungary. In our cross-sectional study, we aim to reveal the drivers of the inequalities in diabetes mortality across the 197 microregions of Hungary. To account for the influence of changes in healthcare and social conditions, we compared two periods (2009-12 and 2013-16). Methods: Traditional and re-conceptualized deprivation- and healthcare provison measures were used in OLS regression models. Results: Microregions with a high proportion of population living in "service deserts," especially in regard to the lack of grocery stores, suffer the highest rates of diabetes mortality. Alcohol-related mortality has been proven to be a similarly and surprisingly strong predictor of diabetes mortality. Conclusion: Food provision should be supported in areas characterized by low service density, and alcohol policy should be strengthened and targeted.

Socioeconomic inequalities in type 2 diabetes comorbidities in different population subgroups: trend analyses using German health insurance data

While socioeconomic inequalities in the prevalence and management of type 2 diabetes (T2D) are well established, little is known about whether inequalities exist in the prevalence and the temporal development of T2D comorbidities. Previous research points towards expansion of morbidity in T2D as depicted mainly by a rising trend of T2D comorbidities. Against this background, and using German claims data, this study aims to examine whether socioeconomic status (SES) inequalities exist in the rates and the temporal development of T2D comorbidities. Since previous research indicates varying risk levels for T2D prevalence in the population subgroups: working individuals, nonworking spouses and pensioners, the analyses are stratified by these three population subgroups. The study is done on a large population of statutory insured individuals with T2D in three time-periods between 2005 and 2017. Predicted probabilities of three comorbidity groups and the number of comorbidities were estimated using logistic and ordinal regression analyses among different income, education and occupation groups. Interaction analyses were applied to examine whether potential SES inequalities changed over time. The study showed that neither the cross-sectional existence, nor the temporal development of T2D comorbidities differed significantly among SES groups, ruling out SES inequalities in the prevalence and the temporal development of T2D comorbidities in Germany. In men and women of all examined population subgroups, predicted probabilities for less severe cardiovascular (CVD) comorbidities, other vascular diseases and the number of comorbidities per individual rose significantly over time regardless of SES, but little if any change took place for more severe CVD comorbidities. Another important finding is that the population subgroup of nonworking spouses had markedly higher predicted probabilities for most of the examined outcomes compared to working individuals. The study indicates that the expansion of morbidity in T2D in Germany does not appear to be SES-dependent, and applies equally to different population subgroups. Yet, the study highlights that nonworking spouses are a susceptible population subgroup that needs to be focused upon when planning and implementing T2D management interventions.

Perceptions of multiple chronic conditions and coping strategies among migrants from Sub-Saharan Africa living in France with diabetes mellitus and HIV: An interview-based qualitative study

Although diabetes is common among people living with HIV/AIDS (PLWHA), few data exists on how migrants from Sub-Saharan Africa (SSA) experience living with these two coexisting conditions in France. The objective of this study was to analyze perception of polypathology among PLWHA from SSA with type 2 diabetes and identify barriers and facilitators to their self-management. A qualitative study was conducted using semi-structured interviews from November 2019 to April 2020 with participants selected from a cohort of PLWHA and diabetes at Avicenne University Hospital. A total of 12 semi-structured interviews were conducted and analyzed using thematic analysis with inductive approach. Stigma remained a major issue in self-managing HIV, and some participants did not consider themselves as having a polypathology, as HIV has always been considered as a distinct condition. In general, emotion-based resources (e.g spirituality, trust in the medical discourse) and social support were mobilized more than problem-solving resources (e.g perception of medication as life-saving). Participants used the same main resource in self-management of HIV and diabetes, and resources used differed from participant to participant. This study highlighted challenges in self-management of diabetes and HIV in this population and complexity related to the socioeconomic and cultural specificities. Self-management could be more successful if patients and carers move in the same direction, having identified the individual coping resources to reach objectives.

Obesity mediates the opposite association of education and diabetes in Chinese men and women: Results from the REACTION study

BACKGROUND

Evidence regarding the impact of education on diabetes risk is scarce in developing countries. We aimed to explore the association between education and diabetes within a large population in China and to identify the possible mediators between them.

METHODS

Information on educational level and lifestyle factors was collected through questionnaires. Diabetes was diagnosed from self-report and biochemical measurements. A structural equation model was constructed to quantify the mediation effect of each mediator.

RESULTS

Compared with their least educated counterparts, men with college education had a higher risk of diabetes (odds ratio [OR] 1.19; 95% confidence interval [CI], 1.12-1.27), while college-educated women were less likely to have diabetes (OR 0.77; 95% CI, 0.73-0.82). Obesity was the strongest mediator in both genders (proportion of mediation: 11.6% in men and 23.9% in women), and its association with education was positive in men (β[SE] 0.0387 [0.0037]) and negative in women (β[SE] -0.0824 [0.0030]). Taken together, all behavioral factors explained 12.4% of the excess risk of diabetes in men and 33.3% in women.

CONCLUSIONS

In a general Chinese population, the association between education level and diabetes was positive in men but negative in women. Obesity was the major mediator underlying the education disparities of diabetes risk, with a stronger mediation effect among women.

Socioeconomic inequalities in the continuum of care across women’s reproductive life cycle in Bangladesh

We examined the association between socioeconomic status (SES) and continuum of care (CoC) completion rate in maternal, neonatal, and child health among mothers in Bangladesh. We used data from the Bangladesh Demographic Health Survey (BDHS) from 2017 to 2018. Our findings were based on the responses of 1527 married women who had at least one child aged 12 to 23 months at the time of the survey. As a measure of SES, we focused on the standard of living (hereinafter referred to as wealth). The CoC for maternal and child health (MNCH) services is the study's outcome variable. The CoC was calculated using seven MNCH interventions: four or more antenatal care (ANC) visits with a skilled practitioner, delivery by a skilled birth attendant, post-natal care for mothers (PNCM) within two days of giving birth, post-natal care for newborns (PNCM) within two days of birth, immunization, age-appropriate breastfeeding, and maternal current use of modern family planning (FP) methods. Only 18.1% of Bangladeshi women completed all seven MNCH care interventions during the reproductive life span. Participants in the high SES group were 2.30 times (95% confidence interval [CI] 1.61–3.28) more likely than those in the low SES group to have higher composite care index (CCI) scores. Women with secondary or higher secondary education, as well as women who were exposed to mass media at least once a week, women who lived in an urban setting, women who had an intended pregnancy, and women with one parity, are associated with high CCI scores when other sociodemographic variables are considered. The complete CoC for MNCH reveals an extremely low completion rate, which may suggest that Bangladeshi mothers, newborns, and children are not receiving the most out of their present health care. Participants in the high SES group displayed higher CCI values than those in the low SES group, indicating that SES is one of the primary drivers of completion of CoC for MNCH services.

Helicobacter pylori infection and increased diabetes prevalence were the risks of colorectal adenoma for adults: A systematic review and meta-analysis (PRISMA-compliant article)

BACKGROUND

Helicobacter pylori infection and hyperglycemia are associated with an increased risk of colorectal neoplasm, and may have a synergistic effect in combination. However, these 2 factors that affect colorectal neoplasm remain controversial. We aimed to carry out a meta-analysis to evaluate the study population diabetes prevalence rate and H pylori infection rate with colorectal adenoma risk for adults.

METHODS

We conducted systemic research through English databases for medical reports. We also recorded the diabetes prevalence and H pylori infection prevalence in each study. We classified these studies into 4 subgroups as their background population diabetes prevalence <6% (Group 1); between 6% and 8% (Group 2); between 8% and 10% (Group 3), and more than 10% (Group 4). The random-effects model had used to calculate pooled prevalence estimates with 95% confidence interval (CI).

RESULTS

Twenty-seven studies were finally eligible for meta-analysis. The random-effects model of the meta-analysis was chosen, showing pooled odds ratio (OR) equal to 1.51 (95% CI 1.39-1.63). The subgroup meta-analyses showed in Group 1 the H pylori infection associated colorectal adenoma risk OR was 1.24 (95% CI 0.86-1.78). As the diabetes rate exceed 6%, the H pylori infection became the more significant increased risk of colorectal adenoma (Group 2: OR 2.16 (95% CI 1.61-2.91); Group 3: OR 1.40 (95% CI 1.24-1.57); and Group 4: OR 1.52 (95% CI 1.46-1.57)).

CONCLUSIONS

The results of this meta-analysis showed elevated diabetes prevalence combined H pylori infection increasing the risks of colorectal adenoma in the adult population.

Gender-specific trends of educational inequality in diagnosed diabetes from 1999 to 2014 in Hong Kong: a serial cross-sectional study of 97,481 community-dwelling Chinese adults

Background

Gender differences in the trend of educational inequality in diabetes have been widely observed in the Western populations, indicating the increasing importance of educational attainment as a social determinant of diabetes among women. Nonetheless, relevant evidence is scarce in developed Asian settings for comparisons. This study examined the gender-specific trends of educational inequality in diagnosed diabetes in Hong Kong between 1999 and 2014.

Methods

A series of eight territory-wide population-representative samples of 97,481 community-dwelling Hong Kong Chinese adults aged 45 or above were surveyed between 1999 and 2014. Regression-based Relative Index of Inequality (RII) and age-standardized Slope Index of Inequality (SII) were adopted to examine the extent and trend of gender-specific educational inequality in self-reported physician-diagnosed diabetes.

Results

Age-standardized prevalence of diabetes increased in both genders over time, with a steeper surge among men. In addition, educational inequalities in diabetes, in both relative and absolute terms, significantly widened among women over the study period (annual RII change = 1.04; 95% CI = 1.02–1.07, annual SII change = 0.36%; 95% CI = 0.16–0.56%), with the peak in 2011 (RII = 2.44; 95% CI = 1.83–3.24, SII = 9.21%; 95% CI = 6.47–11.96%). However, no significant widening inequality was found among men. Further adjustment for household income level did not attenuate the observed educational inequality.

Conclusions

Despite a greater increase in diabetes prevalence among men, disparity in diabetes substantially widened across education levels among women in the past decade in Hong Kong. The gender perspective should be taken into considerations for policy making to alleviate the prevalence surge and rising educational inequality in diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00268-x.

Obesity and impairment of pancreatic β-cell function in early adulthood, independent of obesity age of onset: The Santiago Longitudinal Study

AIM

We investigated the relation of time of onset and length of obesity with biomarkers of β-cell function in early adulthood in an infancy cohort.

MATERIAL AND METHODS

In 1039 23-year-olds, body-mass index (BMI) was measured at multiple time-points from enrollment. BMI trajectories were interpolated with cubic polynomials. Fasting glucose, insulin and adiponectin were measured at 23 years. Homeostatic model assessment-insulin resistance (HOMA-IR), HOMA-S, HOMA-β, HOMA-adiponectin (AD) and disposition index (DI) were estimated. IR and non-alcoholic fatty liver (NAFL) were diagnosed. According to the BMI trajectory, five groups were defined: participants who were never obese (NOB); participants with obesity starting in adolescence and remained obese into adulthood (recent-onset obesity, ROB); participants who were obese in early childhood but transitioned to non-obesity as preadolescents (former obesity, FOB); participants who were obese in early childhood and remained obese into adulthood (persistent obesity, POB); participants with obesity starting in preadolescence and transitioned to non-obesity as adolescents (transient obesity; TOB).

RESULTS

Obesity was present in 47% of participants during at least one time-point. ROBs and POBs had higher insulin, HOMA-IR and HOMA-β, lower HOMA-S and DI, and higher prevalence of IR and NAFL at 23 years than NOBs, TOBs and FOBs. No differences were found in the β-cell functionality of NOBs, TOBs and FOBs.

CONCLUSIONS

Persistent and recent obesity are both related to IR, NAFL and a decline of β-cell function in emerging adulthood. Defeating obesity in childhood or adolescence allows reaching emerging adulthood with β-cell functioning similar to that of subjects who were NOB.

Evidence generated from a realist synthesis of trials on educational weight loss interventions in type 2 diabetes mellitus

BACKGROUND

Obesity and diabetes are major public health problems. Current approaches to weight loss show varying success. Complex community-based interventions work through several interconnected stages. An individual's actions in response to an intervention depend on many known and unknown factors, which vary among individuals.

AIM

To conduct a realist synthesis to identify in which context, for whom, in what circumstances, and how weight loss interventions work in obese or overweight individuals with type 2 diabetes.

METHODS

A total of 49 trials identified during a systematic review were subsequently analysed using realist methodology. This iterative process involved hypothesis generation about how participants within a particular context respond to an intervention's resources producing the outcomes. We used established behaviour change theory to look for repeating themes. Theory and 'mechanisms' were tested against the literature on what is shown to be effective. Where established theory was lacking, we discussed issues during discussion groups with individuals living with the condition to generate our own programme theories.

RESULTS

Mechanisms that were repeatedly identified included high-frequency contact with those delivering the intervention, social support, education increasing awareness of diabetes-related modifiable risk factors, motivational interviewing and counselling, goal-setting, self-monitoring and feedback and meal replacements. The central theme underlying successful mechanisms was personalising each intervention component to the participants' gender, culture and family setting.

CONCLUSION

This is the first comprehensive realist synthesis in this field. Our findings suggest that, for weight loss interventions to be successful in those with diabetes, they must be personalized to the individual and their specific context.

Disentangling socioeconomic inequalities of type 2 diabetes mellitus in Chile: A population-based analysis

Introduction

Chile experiences a growing prevalence of DM2 in its adult population over time. The country has prioritised the diagnosis and treatment of DM2 through a universal health care package, largely focused on the clinical dimensions of the disease. We analysed the significance of socioeconomic variables in the prevalence of DM2, as well as its related dimensions of presence of complications (diabetic foot and ophthalmologic complications), attendance to health checks and acquisition of recommended lifestyle changes due to this condition.

Methods

Secondary analysis of the national health survey (ENS) 2016–2017 (n = 6,233 respondents). Crude and income-adjusted odds of reporting DM2 was estimated, as well as the relationship between complications due to diabetes and a number of clinical and sociodemographic variables using weighted log-linear multiple regression models.

Results

We found a clear social gradient of the prevalence of DM2 by household income quintiles and educational level in the adult population. Income quintile and educational level gradients remained significantly associated with the presence of complications and attendance to health checks. We found no significant association, however; between income quintile and reported lifestyle change. The association between complications due to DM2 and socioeconomic variables, particularly income, remained relevant even after adjusting for all sociodemographic variables.

Conclusion

This is the first study to analyse the association between DM2 and socioeconomic variables in Chile, useful for monitoring and policy planning. Income was strongly associated with DM2 prevalence and with related clinical variables (complications and attendance to health checks). Age, health care provision and educational level were also relevant factors, but lost significance in the fully adjusted model.

Educational inequalities in the prevalence and outcomes of diabetes in the Emilian Longitudinal Study

BACKGROUND AND AIM

Studies carried out in Italy in the last decades reported an effect modification in the association between socioeconomic position and diabetes outcomes, and the disease integrated care approach has been suggested as an explanatory factor. Whether this is true in Emilia-Romagna region in recent years is unknown and the aim of this study is to describe the role of educational level both on diabetes prevalence and health outcomes among the adult population with and without diabetes enrolled in the Emilian Longitudinal Study.

METHODS AND RESULTS

Inequalities in diabetes prevalence were evaluated through standardised estimates and prevalence ratios by educational level and inequalities in outcomes through standardised hospitalisation and mortality ratios and rate ratios by educational level. The lower the education the greater the diabetes prevalence; such differences were larger among women and younger age groups. Diabetes conferred a higher risk of hospitalisation and mortality; those outcomes also presented a social gradient with the less educated bearing the higher risk. However, educational differences were slightly stronger among the disease-free subjects, especially in the case of mortality. In both genders, inequalities tended to disappear with age.

CONCLUSION

This study confirms that diabetes increases the risk of unfavourable outcomes, but does not increase social inequalities in outcomes as might be expected. Similarly to what has been previously shown, it is likely that the protective effect of diabetes on the negative health effects of the low social position is attributable to the disease integrated care approach.

How does socioeconomic development in Brazil shape social inequalities in diabetes?

Many countries, including Brazil, are facing growing social inequalities in diabetes prevalence. The different states in Brazil represent different levels of development and by comparing diabetes inequalities across states we aim to get a better understanding of how educational inequalities in diabetes are linked to social development. We use the latest cross-sectional national health survey of Brazil - PNS-2013 (N = 60,202) and analyse the disparities in diabetes as well as the differential exposure and susceptibility to the effect of obesity across states for men and women. Among women in high-HDI states the prevalence of diabetes is 11.7 percentage units (CI: 9.3; 14.0) higher among the lowest compared to the highest educated. In less-developed states the disparity is smaller. Among men, there is no social gradient found for diabetes, but obesity is positively associated with education. The association between obesity and diabetes is stronger among the low educated particularly for men in high-HDI states. Here the interaction effect between low education and obesity is 11.7 (CI 8.1; 15.4) percentage units. The fact that economic development is associated with increasingly unequal levels of diabetes and with unequal levels of exposure and susceptibility to obesity indicates that other interacting determinants are important for the development of the diabetes epidemic in Brazil.

Novel Digital Architecture of a "Low Carb Program" for Initiating and Maintaining Long-Term Sustainable Health-Promoting Behavior Change in Patients with Type 2 Diabetes

Globally, the burden of noncommunicable diseases such as type 2 diabetes is crippling health care systems. Type 2 diabetes, a disease linked with obesity, affects 1 in every 30 people today and is expected to affect 1 in 10 people by 2030. Current provisions are struggling to manage the trajectory of type 2 diabetes prevalence. Offline, face-to-face education for patients with type 2 diabetes has shown to lack long-term impact or the capacity for widespread democratized adoption. Digitally delivered interventions have been developed for patients with type 2 diabetes, and the evidence shows that some interventions provide the capacity to support hyperpersonalization and real-time continuous support to patients, which can result in significant engagement and health outcomes. However, digital health app engagement is notoriously difficult to achieve. This paper reviews the digital behavior change architecture of the Low Carb Program and the application of health behavioral theory underpinning its development and use in scaling novel methods of engaging the population with type 2 diabetes and supporting long-term behavior change.

Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

The Play of Genes and Non-genetic Factors on Type 2 Diabetes

Diabetes has been a disease of public health concern for a number of decades. It was in the 1930s when scientists made an interesting discovery that the disease is actually divided into two types as some patients were insensitive to insulin treatment then. Type 2 Diabetes which happens to be the non-insulin dependent one is the most common form of the disease and is caused by the interaction between genetic and non-genetic factors. Despite conflicting results, numerous studies have identified genetic and non-genetic factors associated with this common type of diabetes. This review has summarized literature on some genes and non-genetic factors which have been identified to be associated with Type 2 diabetes. It has sourced literature from PubMed, Web of Science and Medline without any limitation to regions, publication types, or languages. The paper has started with the introduction, the play of non-genetic factors, the impact of genes in general, and ended with the interaction between some genes and environmental factors.

Influence of Educational Level on Psychosocial Correlates and Perceived Environmental Correlates of Physical Activity in Adults at Risk for Type 2 Diabetes: The Feel4Diabetes-Study

BACKGROUND

This study aimed to investigate whether the relationship between psychosocial and perceived environmental factors and physical activity (PA) in adults at risk for type 2 diabetes is influenced by educational level.

METHODS

Based on the Finnish Diabetes Risk Score questionnaire, this study selected 164 adults (Mage: 38 (5.34) y, 13.4% men) at type 2 diabetes risk from 11 low socioeconomic neighborhoods in Flanders (Belgium). Participants filled out questionnaires on psychosocial and perceived environmental factors and wore an ActiGraph accelerometer for 5 consecutive days. Statistical analyses were performed using analysis of covariance in SPSS.

RESULTS

Educational level significantly influenced the association between perception of body weight and light PA (P = .01) and total PA (P = .03) on weekend days. Educational level did not influence the associations between other psychosocial and perceived environmental factors (ie, perceived social influence; environmental, time and attitudinal barriers, perceived self-efficacy; knowledge and fatalism) and PA.

CONCLUSIONS

Educational level did not influence the relationship between most psychosocial and perceived environmental factors and PA in this sample of adults at type 2 diabetes risk. This suggests that addressing different psychosocial and perceived environmental correlates in lower and higher educated participants might not be necessary. However, more research in this specific population is needed.

Socio-economic inequalities in diabetes prevalence in the Kingdom of Saudi Arabia

BACKGROUND

Rising prevalence of non-communicable diseases, including diabetes in the Middle East, is a major public health concern of the 21st century. However, there is a paucity of literature to understand and measure socio-economic inequalities in diabetes prevalence in this region, including the Kingdom of Saudi Arabia (KSA).

METHODS

This study investigated socio-economic inequalities in diabetes prevalence in the KSA using data from the Saudi Arabia Health Interview Survey. Concentration curve, concentration index, and multivariate logistic regression were used to measure and examine income- and education-related inequalities in diabetes prevalence.

RESULTS

The results showed significant socio-economic inequalities in the prevalence of diabetes through analysing a nationally representative sample of the KSA population. Diabetes prevalence was concentrated among the poor and among people with less education. In addition, education-related inequality was higher than income-related inequality.

CONCLUSIONS

The findings of this study are important for policymakers to combat both the increasing prevalence of and socio-economic inequalities in diabetes. The government should promote health education programmes and increase the level of public awareness of diabetes management, especially among the lower educated population in the KSA.

Post-war (1946-2017) population health change in the United Kingdom: A systematic review

We systematically reviewed the evidence on secular trends in main chronic conditions, disability and self-assessed general health among adults in the United Kingdom, as reported in primary/secondary care databases and population-based surveys. Searches were conducted separately for: (1) trends in age-standardised or age-specific prevalence of major non-communicable diseases, disability, and self-reported general health; (2) trends in health expectancy. The databases searched were MEDLINE, EMBASE/EMBASE Classic and Web of Science (all from 1946/7). The evidence was synthesised narratively. There were 39 studies reporting trends in prevalence of health conditions and 15 studies in health expectancy. We did not find evidence for improvement in the age-standardised or age-specific prevalence of any of the studied major chronic conditions over the last few decades, apart from Alzheimer's disease and other dementias. Both increasing or stable prevalence rates with simultaneous rising life expectancy support the expansion of morbidity theory, meaning that people are expected to spend a greater number of years with chronic condition(s). The evidence on disability-expressed as prevalence or health expectancy-was mixed, but also appeared to support the expansion of morbidity among those aged 65 or over. The evidence on trends in disability for younger age is lacking. Across the studied period (1946-2017), the UK population endured more years with chronic morbidity and disability, which may place a serious strain on the health care system, the economy and the society.

Health behaviour changes after type 2 diabetes diagnosis: Findings from the English Longitudinal Study of Ageing

Healthy lifestyle is key for type 2 diabetes (T2D) management. It is unclear whether individuals change health behaviours in response to T2D diagnosis. We compared smoking, physical activity, fruit and vegetable intake and alcohol consumption at three times (pre-diagnosis, at diagnosis, 2-4 years post-diagnosis) in individuals who developed T2D and controls. Behaviours were assessed in 6877 individuals at waves 3-7 of the English Longitudinal Study of Ageing. Generalized estimating equations were used to examine differences by group and time and group-by-time interactions. The T2D group were less active (p < 0.001) and consumed less alcohol (p < 0.001). Smoking (p < 0.001), alcohol consumption (p = 0.037) and physical activity (p = 0.042) decreased over time in the overall sample, fruit and vegetable intake (p = 0.012) and sedentary activity (p < 0.001) increased. A group-by-time interaction was found for smoking, with the T2D group having greater reductions in smoking over time (p < 0.001). No significant interactions were detected for other behaviours. We found limited evidence that T2D diagnosis encourages behaviour change, other than a reduction in smoking. Given the importance of lifestyle for T2D outcomes, strategies for motivating behaviour change need to be identified.

Socio-economic inequalities in secondhand smoke exposure at home in the context of mother-child pairs in Bangladesh

OBJECTIVES

This study aimed to examine socio-economic disparities in mother-child pairs' self-reported and cotinine-measured secondhand smoke (SHS) exposure at home.

STUDY DESIGN

This is a cross-sectional study.

METHODS

This study was conducted in the Rajshahi district of Bangladesh from May to July 2017. A total of 541 mother-child pairs were interviewed for self-reported measured SHS; cotinine-measured saliva test was performed on 263 mothers and 236 children. Mother-child pairs' SHS exposure at home was the outcome of interest.

RESULTS

Overall self-reported prevalence of SHS exposure at home was 49.0%. Self-reported SHS exposure among mothers (50.2%) and children (51.3%) were lower than the prevalence rate of cotinine-measured exposure for mothers (60.5%) and their children (58.9%). Maternal rich bands of wealth were found to be associated with lower likelihood of self-reported (adjusted odds ratio [AOR] = 0.59, 95% confidence interval [CI] = 0.35-0.99) and cotinine-measured SHS exposure among mothers (AOR = 0.17, 95% CI = 0.08-0.37). Maternal rich bands of wealth were also found to be associated with lower likelihood of cotinine-measured SHS exposure among children (AOR = 0.11, 95% CI = 0.07-0.26).

CONCLUSIONS

Socio-economic inequalities exist in exposure to SHS at home. Interventional approaches aimed at reducing SHS at home are urgently needed at public health and healthcare service level, with special focus given to the socioeconomically disadvantaged groups.

The relationship between socio-economic status and diagnosed Type 2 diabetes is changing with economic growth in Nanjing, China

AIM

In developed countries, the relationship between socio-economic status (SES) and Type 2 diabetes was positive several decades ago but is now negative. However, in developing societies such as China the relationship remains positive. It is likely that at some stage of economic development the SES-Type 2 diabetes association will become negative in developing communities. This study aimed to examine whether this inflexion is approaching in China.

METHODS

Two cross-sectional surveys were undertaken in Nanjing, China, in 2000 and 2011. The same sampling approach was used to randomly select participants. Diagnosed Type 2 diabetes was the outcome variable. SES was measured using monthly family average income and divided into thirds. Mixed-effects models were used to calculate the association between SES and Type 2 diabetes.

RESULTS

There were 19 861 (response rate, 90.1%) and 7824 (response rate, 82.8%) participants in 2000 and 2011, respectively. A 2.6-fold increase in Type 2 diabetes prevalence was observed from 3.0% (95% confidence interval 2.8%, 3.3%) in 2000 to 8.2% (7.7%, 8.8%) in 2011 (P < 0.01). After controlling for potential confounders, the odds ratios of having Type 2 diabetes decreased from 2.06 (95% CI 1.55, 2.73) and 1.83 (1.40, 2.37) in 2000 to 1.58 (1.23, 2.02) and 1.35 (1.06, 1.74) in 2011 for the higher and middle SES groups respectively, compared with those in the lower SES category.

CONCLUSIONS

The SES-Type 2 diabetes association remained positive in Nanjing, China, in 2011 but the disparity diminished significantly compared with 2000. These results can inform the delivery of appropriate interventions to people at risk of developing Type 2 diabetes.

Inequalities in the prevalence of diabetes mellitus and its risk factors in Sri Lanka: a lower middle income country

BACKGROUND

Explorations into quantifying the inequalities for diabetes mellitus (DM) and its risk factors are scarce in low and lower middle income countries (LICs/LMICs). The aims of this study were to assess the inequalities of DM and its risk factors in a suburban district of Sri Lanka.

METHODS

A sample of 1300 participants, (aged 35-64 years) randomly selected using a stratified multi-stage cluster sampling method, were studied employing a cross sectional descriptive design. The socioeconomic indicators (SEIs) of the individual were education level and occupational category, and at the household level, the household income, social status level and area deprivation level. DM was diagnosed if the fasting plasma glucose was ≥126 and a body mass index (BMI) of > 27.5 kg/m2 was considered high. Asian cut-off values were used for high waist circumference (WC). Validated tools were used to assess the diet and level of physical activity. The slope index of inequality (SII), relative index of inequality (RII) and concentration index (CI) were used to assess inequalities.

RESULTS

The prevalence of DM and its risk factors (at individual or household level) showed no consistent relationship with the three measures of inequality (SII, RII and CI) of the different indices of socio economic status (education, occupation, household income, social status index or area unsatisfactory basic needs index). The prevalence of diabetes showed a more consistent pro-rich distribution in females compared to males. Of the risk factors in males and females, the most consistent and significant pro-rich relationship was for high BMI and WC. In males, the significant positive relationship with high BMI for SII ranged from 0.18 to 0.35, and RII from 1.56 to 2.25. For high WC, the values were: SII from 0.13 to 0.27 and RII from 1.9 to 3.97. In females the significant positive relationship with high BMI in SII ranged from 0.13 to 0.29, and RII from 2.3 to 4.98. For high WC the values were: SII from 028 to 0.4 and RII 1.99 to 2.39. Of the other risk factors, inadequate fruit intake showed a consistent significant pro-poor distribution only in males using SII (- 0.25 to - 0.36) and in both sexes using CI. Smoking also showed a pro-poor distribution in males especially using individual measures of socio-economic status (i.e. education and occupation).

CONCLUSIONS

The results show a variable relationship between socioeconomic status and prevalence of diabetes and its risk factors. The inequalities in the prevalence of diabetes and risk factors vary depending on gender and the measures used. The study suggests that measures to prevent diabetes should focus on targeting specific factors based on sex and socioeconomic status. The priority target areas for interventions should include prevention of obesity (BMI and central obesity) specifically in more affluent females. Males who have a low level of education and in non-skilled occupations should be especially targeted to reduce smoking and increase fruit intake.

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.

Temporal trends in educational inequalities in non-communicable diseases in Korea, 2007-2015

Background

Socioeconomic inequalities in non-communicable diseases are known to exist; however there is a paucity of research describing the secular trends in these inequalities. To this end, the current study aims to explore the recent time trends in social patterning of selected non-communicable diseases among Korean adults between 2007 and 2015.

Methods

Using data from the Korea National Health and Nutrition Examination Survey (KNHANES), temporal trends in socioeconomic inequalities in diabetes, arthritis, asthma and depressive symptoms were assessed across three time points. Respondents were adults aged 20 years or over (N = 47,091, 20,180 men and 26,911 women). Socioeconomic circumstance was assessed based on highest level of educational attainment. We estimated prevalence ratios with 95% confidence intervals using Poisson regression with robust variance estimation (adjusted for age, smoking status, alcohol consumption, obesity, and physical activity) separately for men and women. The magnitude of the inequalities was computed using the relative index of inequality (RII).

Results

In men, diabetes was not associated with educational attainment, while there was evidence of a negative association in women across surveys. Similar inverse associations were found with arthritis and depressive symptoms, but these associations were less clear for asthma. RII showed a non-significant increasing trend in educational disparities in depressive symptoms. Meanwhile, relative inequalities in diabetes, arthritis and asthma have narrowed. These trends were, in general, more pronounced in women.

Conclusions

The findings of this study indicate higher burden of selected NCDs among the lower educational groups, particularly among women. In addition, our results indicated some improvements in inequalities in diabetes, arthritis and asthma in recent years. These findings have important implications for understanding the causes of social patterning of NCDs and for the targeting of effective interventions.

Socioeconomic inequality of diabetes patients' health care utilization in Denmark

Understanding socioeconomic inequalities in health care is critical for achieving health equity. The aim of this paper is threefold: 1) to quantify inequality in diabetes health care service utilization; 2) to understand determinants of these inequalities in relation to socio-demographic and clinical morbidity factors; and 3) to compare the empirical outcome of using income level and educational level as proxies for Socio Economic Status (SES).Data on the entire Danish population of diabetes patients in 2011 (N = 318,729) were applied. Patients' unique personal identification number enabled individual patient data from several national registers to be linked. A concentration index approach with decomposition into contributing factors was applied. Differences in diabetes patients' health care utilization patterns suggest that use of services differ among patients of lower and higher SES, despite the Danish universal health care system. Especially, out-patient services, rehabilitation and specialists in primary care show different utilization patterns according to SES. Comparison of the empirical outcome from using educational level and income level as proxy for patients' SES indicate important differences in inequality estimates. While income, alike other measures of labor market attachment, to a certain extent is explained by morbidity and thus endogenous, education is more decisive for patients' ability to take advantage of the more specialized services provided in a universal health care system.

Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease

This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016.

Social inequality in diabetes patients' morbidity patterns from diagnosis to death - A Danish register-based investigation

AIM

Measuring socioeconomic inequalities in health and health care, and understanding determinants of such inequalities, are critical for achieving higher equity in health. Equity in health is a prerequisite for public health and welfare. The aim of the paper is (1) to quantify inequality in diabetes morbidity patterns over patients' entire life span, and (2) to compare levels of inequality measured through income and educational level, respectively, as proxies for socioeconomic status (SES).

METHOD

Historic individual register data on the entire Danish diabetes population alive in 2011 were gathered. Cox survival analysis and a concentration index decomposition approach were applied to analyse relevant morbidity indicators reflecting patients' health state at diagnosis and throughout their lives with diabetes.

RESULTS

Patients with high education have approximately 26% lower mortality hazard when diagnosed with diabetes and 10-15% lower hazard of developing complications as compared with patients with short education. The outcome variables: 'severe complications at diagnosis' and 'years with severe complications' inhibit the highest negative concentration index value, indicating that morbidity is concentrated among the lower SES groups, whereas the outcome variables 'years without complications' and 'duration of diabetes' concentrate among the socioeconomically better-off patients.

CONCLUSIONS

Significant differences in diabetes patients' morbidity patterns and survival indicate that diabetes impacts harder on patients of lower SES; these patients experience more severe complications and die earlier. Hence to reduce inequality in health, it is important to invest in efforts targeted towards socially vulnerable groups.

Trends in socioeconomic inequalities in five major risk factors for cardiovascular disease in the Korean population: a cross-sectional study using data from the Korea National Health and Nutrition Examination Survey, 2001-2014

OBJECTIVES

To examine trends in socioeconomic inequalities in major cardiovascular disease (CVD) risk factors among the Korean population.

DESIGN

Cross-sectional study.

SETTING

A nationally representative population survey database.

PARTICIPANTS

A total of 42 725 Koreans, aged 25-64 years, who participated in the Korean National Health and Nutrition Examination Survey (KNHANES) II (2001) to VI (2013-2014).

MAIN OUTCOME MEASURES

Trends in socioeconomic inequalities in five major CVD risk factors (smoking, obesity, diabetes, hypertension and hypercholesterolaemia).

RESULTS

Gender differences were noted in the time trends in socioeconomic inequalities in smoking, obesity, diabetes and hypertension. Among men, low socioeconomic status (SES) was associated with higher prevalence of smoking, but not with obesity, diabetes or hypertension. The magnitudes of socioeconomic inequalities in smoking, obesity and diabetes remained unchanged, and the magnitude of the inequality in hypertension decreased over time. However, among women, low SES was associated with higher prevalence of smoking, obesity, diabetes and hypertension. Time trends towards increasing socioeconomic inequalities, measured by income, in smoking, obesity and diabetes were found in women. Unlike the other CVD risk factors, hypercholesterolaemia was not associated with socioeconomic inequality.

CONCLUSIONS

SES had a stronger impact on major CVD risk factors among Korean women than men. Moreover, socioeconomic inequalities in smoking, obesity and diabetes worsened among Korean women over time. Public policies to prevent smoking, obesity and diabetes in women with lower SES are needed to address inequalities.

Secular trends in the prevalence of type 2 diabetes in adults in China from 1995 to 2014: A meta-analysis

BACKGROUND

The aim of the present study was to estimate trends in the prevalence of type 2 diabetes mellitus (T2DM) in adults in China.

METHODS

A systematic search was conducted for studies of T2DM prevalence in adults in China from 2000 to 2014. Pooled prevalence was calculated by a random-effects model. Subgroup and sensitivity analyses were performed. Chi-squared and Cochran-Mantel-Haenszel tests were used to assess differences among subgroups and pooled prevalence, respectively.

RESULTS

Forty-six studies (data from 1995 to 2014; 1 463 079 adults) were included in the meta-analysis. The overall prevalence of T2DM was 7.9 %. The pooled prevalence overall and by location (urban and rural), gender (male and female), and age category (18-39, 40-59, and ≥60 years) was 4.5 %, 5.1 % and 3.0 %, 4.0 % and 4.2 %, and 1.4 %, 5.0 %, and 10.3 %, respectively, from 1995 to 1999; 6.6 %, 9.3 % and 5.6 %, 7.4 % and 7.5 %, and 1.8 %, 5.9 %, and 12.4 %, respectively, from 2000 to 2004; 10.3 %, 11.8 % and 6.8 %, 10.0 % and 8.6 %, and 2.8 %, 10.3 %, and 20.0 %, respectively, from 2005 to 2009; and 8.3 %, 12.5 % and 7.6 %, 8.6 % and 8.0 %, and 3.5 %, 8.5 %, and 15.3 %, respectively, from 2010 to 2014. The prevalence increased from 5.8 % to 11.6 % with per-capita gross domestic product and differed by diagnostic criteria.

CONCLUSIONS

There was a trend of increasing prevalence of T2DM in adults in China from 1995 to 2009, with a decrease in 2010-14 and a greater increase over time in urban versus rural areas, males versus females, and older versus younger adults.

Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants

BACKGROUND

One of the global targets for non-communicable diseases is to halt, by 2025, the rise in the age-standardised adult prevalence of diabetes at its 2010 levels. We aimed to estimate worldwide trends in diabetes, how likely it is for countries to achieve the global target, and how changes in prevalence, together with population growth and ageing, are affecting the number of adults with diabetes.

METHODS

We pooled data from population-based studies that had collected data on diabetes through measurement of its biomarkers. We used a Bayesian hierarchical model to estimate trends in diabetes prevalence-defined as fasting plasma glucose of 7.0 mmol/L or higher, or history of diagnosis with diabetes, or use of insulin or oral hypoglycaemic drugs-in 200 countries and territories in 21 regions, by sex and from 1980 to 2014. We also calculated the posterior probability of meeting the global diabetes target if post-2000 trends continue.

FINDINGS

We used data from 751 studies including 4,372,000 adults from 146 of the 200 countries we make estimates for. Global age-standardised diabetes prevalence increased from 4.3% (95% credible interval 2.4-7.0) in 1980 to 9.0% (7.2-11.1) in 2014 in men, and from 5.0% (2.9-7.9) to 7.9% (6.4-9.7) in women. The number of adults with diabetes in the world increased from 108 million in 1980 to 422 million in 2014 (28.5% due to the rise in prevalence, 39.7% due to population growth and ageing, and 31.8% due to interaction of these two factors). Age-standardised adult diabetes prevalence in 2014 was lowest in northwestern Europe, and highest in Polynesia and Micronesia, at nearly 25%, followed by Melanesia and the Middle East and north Africa. Between 1980 and 2014 there was little change in age-standardised diabetes prevalence in adult women in continental western Europe, although crude prevalence rose because of ageing of the population. By contrast, age-standardised adult prevalence rose by 15 percentage points in men and women in Polynesia and Micronesia. In 2014, American Samoa had the highest national prevalence of diabetes (>30% in both sexes), with age-standardised adult prevalence also higher than 25% in some other islands in Polynesia and Micronesia. If post-2000 trends continue, the probability of meeting the global target of halting the rise in the prevalence of diabetes by 2025 at the 2010 level worldwide is lower than 1% for men and is 1% for women. Only nine countries for men and 29 countries for women, mostly in western Europe, have a 50% or higher probability of meeting the global target.

INTERPRETATION

Since 1980, age-standardised diabetes prevalence in adults has increased, or at best remained unchanged, in every country. Together with population growth and ageing, this rise has led to a near quadrupling of the number of adults with diabetes worldwide. The burden of diabetes, both in terms of prevalence and number of adults affected, has increased faster in low-income and middle-income countries than in high-income countries.

FUNDING

Wellcome Trust.

Disparities in type 2 diabetes prevalence among ethnic minority groups resident in Europe: a systematic review and meta-analysis

Many ethnic minorities in Europe have a higher type 2 diabetes (T2D) prevalence than their host European populations. The risk size differs between ethnic groups, but the extent of the differences in the various ethnic minority groups has not yet been systematically quantified. We conducted a meta-analysis of published data on T2D in various ethnic minority populations resident in Europe compared to their host European populations. We systematically searched MEDLINE (using PUBMED) and EMBASE for papers on T2D prevalence in ethnic minorities in Europe published between 1994 and 2014. The ethnic minority groups were classified into five population groups by geographical origin: South Asian (SA), Sub-Saharan African (SSA), Middle Eastern and North African (MENA), South and Central American (SCA), and Western Pacific (WP). Pooled odds ratios with corresponding 95 % confidence interval (CI) were calculated using Review Manager 5.3. Twenty articles were included in the analysis. Compared with the host populations, SA origin populations had the highest odds for T2D (3.7, 95 % CI 2.7-5.1), followed by MENA (2.7, 95 % CI 1.8-3.9), SSA (2.6, 95 % CI 2.0-3.5), WP (2.3, 95 % CI 1.2-4.1), and lastly SCA (1.3, 95 % CI 1.1-1.6). Odds ratios were in all ethnic minority populations higher for women than for men except for SCA. Among SA subgroups, compared with Europeans, Bangladeshi had the highest odds ratio of 6.2 (95 % CI 3.9-9.8), followed by Pakistani (5.4, 95 % CI 3.2-9.3) and Indians (4.1, 95 % CI 3.0-5.7). The risk of T2D among ethnic minority groups living in Europe compared to Europeans varies by geographical origin of the group: three to five times higher among SA, two to four times higher among MENA, and two to three times higher among SSA origin. Future research and policy initiatives on T2D among ethnic minority groups should take the interethnic differences into account.

Diabetes in migrants and ethnic minorities in a changing World

On a worldwide scale, the total number of migrants exceeds 200 million and is not expected to reduce, fuelled by the economic crisis, terrorism and wars, generating increasing clinical and administrative problems to National Health Systems. Chronic non-communicable diseases (NCD), and specifically diabetes, are on the front-line, due to the high number of cases at risk, duration and cost of diseases, and availability of effective measures of prevention and treatment. We reviewed the documents of International Agencies on migration and performed a PubMed search of existing literature, focusing on the differences in the prevalence of diabetes between migrants and native people, the prevalence of NCD in migrants vs rates in the countries of origin, diabetes convergence, risk of diabetes progression and standard of care in migrants. Even in universalistic healthcare systems, differences in socioeconomic status and barriers generated by the present culture of biomedicine make high-risk ethnic minorities under-treated and not protected against inequalities. Underutilization of drugs and primary care services in specific ethnic groups are far from being money-saving, and might produce higher hospitalization rates due to disease progression and complications. Efforts should be made to favor screening and treatment programs, to adapt education programs to specific cultures, and to develop community partnerships.

Cardiovascular risk factors, lifestyle, and social determinants: a cross-sectional population study

BACKGROUND

The influence of socioeconomic development is often disregarded in epidemiological studies into the prevalence of cardiovascular risk factors.

AIM

To analyse the relationship between major cardiovascular risk factors and socioeconomic indicators.

DESIGN AND SETTING

Cross-sectional, population-wide study in primary care practices in the health area of Don Benito-Villanueva de la Serena, Badajoz, Extremadura, Spain.

METHOD

A total of 2833 people aged 25-79 years (mean age 51.2 years), representative of the population, participated in the study. The prevalence and odds ratios (ORs) were calculated for diabetes, arterial hypertension, obesity, hypercholesterolaemia, smoking, and sedentary behaviour, according to level of education and employment status.

RESULTS

A high prevalence of cardiovascular risk factors related to the level of education and employment status. Females who had not studied at university had a higher risk of obesity (OR = 2.5, 95% confidence interval [CI] = 1.5 to 4.2), smoking (OR 2.5, 95% CI = 1.7 to 3.7), and sedentary behaviour (OR = 2.5, 95% CI = 1.5 to 3.9) than females with a university education. Males who had not studied at university showed an increased risk of smoking (OR = 2.1, 95% CI = 1.4 to 3.1), arterial hypertension (OR = 1.5, 95% CI = 1.0 to 2.4), hypercholesterolaemia (OR = 1.5, 95% CI = 1.0 to 2.2), and obesity (OR = 1.5, 95% CI = 1.0 to 2.3) than males with a university education. The risk of obesity was higher in unemployed females than those in paid employment (OR =1.4, 95% CI = 1.1 to 1.9), but they showed a lower risk of smoking (OR = 0.7, 95% CI = 0.5 to 0.9).

CONCLUSION

The study results confirm an inverse association between the level of education and the prevalence of cardiovascular risk factors. Public health studies and interventions are needed to understand this association and develop interventions targeted at the population that is at greatest risk.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes

CONTEXT

Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population.

OBJECTIVE

To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes.

SEARCH STRATEGY

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched.

INCLUSION CRITERIA

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

MAIN RESULTS

Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied.

DISCUSSION AND CONCLUSIONS

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

British-Pakistani women's perspectives of diabetes self-management: the role of identity

AIMS AND OBJECTIVES

To explore the effects of type 2 diabetes on British-Pakistani women's identity and its relationship with self-management.

BACKGROUND

Type 2 diabetes is more prevalent and has worse outcomes among some ethnic minority groups. This may be due to poorer self-management and an inadequate match of health services to patient needs. The influence that type 2 diabetes has on British-Pakistani women's identity and subsequent self-management has received limited attention.

DESIGN

An explorative qualitative study.

METHODS

Face-to-face semi-structured English and Urdu language interviews were conducted with a purposively selected heterogeneous sample of 15 British-Pakistani women with type 2 diabetes. Transcripts were analysed thematically.

RESULTS

Four themes emerged: Perceived change in self emphasised how British-Pakistani women underwent a conscious adaptation of identity following diagnosis; Familiarity with ill health reflected women's adjustment to their changed identity over time; Diagnosis improves social support enabled women to accept changes within themselves and Supporting family is a barrier to self-management demonstrated how family roles were an aspect of women's identities that was resilient to change. The over-arching theme Role re-alignment enables successful self-management encapsulated how self-management was a continuous process where achievements needed to be sustained. Inter-generational differences were also noted: first generation women talked about challenges associated with ageing and co-morbidities; second generation women talked about familial and work roles competing with self-management.

CONCLUSIONS

The complex nature of British-Pakistani women's self-identification requires consideration when planning and delivering healthcare.

RELEVANCE TO CLINICAL PRACTICE

Culturally competent practice should recognise how generational status influences self-identity and diabetes self-management in ethnically diverse women. Health professionals should remain mindful of effective self-management occurring alongside, and being influenced by, other aspects of life.

Effect of socio-economic status on the prevalence of diabetes

PURPOSE

As Korean society has become industrialized and westernized, the prevalence of diabetes has increased rapidly. Environmental factors, especially socio-economic status (SES), may account for the increased prevalence of diabetes. We evaluated the associations between the prevalence of diabetes and SES as reflected by household income and education level.

MATERIALS AND METHODS

This study was based on data obtained from the fifth Korea National Health and Nutrition Examination Survey, conducted in 2010-2012. Diabetes referred to a fasting plasma glucose ≥126 mg/dL in the absence of known diabetes, previous diagnosis of diabetes made by a physician, and/or current use of oral hypoglycemic agents or insulin.

RESULTS

Household income and education level were inversely associated with the prevalence of diabetes among individuals aged 30 years or older. These associations were more prominent in females aged 30-64 years. According to household income, the odds ratio (OR) [95% confidence interval (CI)] for the lowest quartile group versus the highest quartile group was 4.96 (2.87-8.58). According to education level, the OR (95% CI) for the lowest quartile group versus the highest quartile group was 8.02 (4.47-14.4).

CONCLUSION

Public policies for the prevention and management of diabetes should be targeted toward people of lower SES, especially middle-aged females.

Different socioeconomic inequalities exist in terms of the prevention, diagnosis and control of diabetes

OBJECTIVE

To evaluate socioeconomic disadvantage in prevalence, awareness and control of diabetes in universal coverage healthcare system.

METHODS

Data from the fifth KNHNES (2010-12) were analyzed. The sample included 10,208 individuals with diabetes aged ≥30 years. Diabetes was defined by (i) a self-reported previous diagnosis of diabetes made by a physician, (ii) the current use of oral hypoglycaemic agents and/or insulin or (iii) fasting plasma glucose ≥126 mg/dl. Subjects who were first diagnosed by the survey were classified as 'undiagnosed'. Inadequate control was defined as HbA1c ≥6.5%.

RESULTS

It was estimated that 26.4% of subjects with diabetes were not aware of their condition and 73.1% of cases of diabetes were not adequately controlled. Inequalities in socioeconomic status were related to the diabetes prevalence in both men and women. Educational level was not predictive of diagnosis or control in men or women, whereas lower household income level was associated with diagnosis in men only.

CONCLUSIONS

This widespread lack of awareness and inadequate control underscore the need for intensive efforts in these domains. Monitoring is expected to highlight the gaps in the preventive and care services offered to the most vulnerable individuals and it may induce governments and practitioners to address these issues.

Growing social inequality in the prevalence of type 2 diabetes in Canada, 2004-2012

OBJECTIVES

The prevalence of diabetes in Canada has nearly doubled since 2000. Trends in social inequalities in diabetes across Canada and its different regions have not been assessed. We estimated relative and absolute social inequalities in type 2 diabetes prevalence in Canada between 2004 and 2012.

METHODS

We used the relative (RII) and slope (SII) indices of inequality to measure relative and absolute education-based inequalities respectively in type 2 diabetes prevalence in a sample of 413,453 men and women surveyed as part of the Canadian Community Health Survey between 2004 and 2012.

RESULTS

Across regions and time periods, inequalities were more pronounced for women than for men, both on the absolute and relative scales. The difference in the prevalence of type 2 diabetes between individuals with the highest level of educational attainment compared to the lowest, as reflected by the SII, expanded from approximately 2.5% to 4.5% for women and 1.4% to 2.3% for men between 2004 and 2012.

CONCLUSIONS

Monitoring and tracking social inequalities in the burden of diabetes over time can help to assess whether Canadian diabetes strategies are effective at reaching marginalized populations and mitigating inequalities. Our results signal the need for interventions to address growing social inequalities in Canada with regard to type 2 diabetes, particularly among women.

Educational inequalities in diabetes mortality across Europe in the 2000s: the interaction with gender

Objectives

To evaluate educational inequalities in diabetes mortality in Europe in the 2000s, and to assess whether these inequalities differ between genders.

Methods

Data were obtained from mortality registries covering 14 European countries. To determine educational inequalities in diabetes mortality, age-standardised mortality rates, mortality rate ratios, and slope and relative indices of inequality were calculated. To assess whether the association between education and diabetes mortality differs between genders, diabetes mortality was regressed on gender, educational rank and ‘gender × educational rank’.

Results

An inverse association between education and diabetes mortality exists in both genders across Europe. Absolute educational inequalities are generally larger among men than women; relative inequalities are generally more pronounced among women, the relative index of inequality being 2.8 (95 % CI 2.0–3.9) in men versus 4.8 (95 % CI 3.2–7.2) in women. Gender inequalities in diabetes mortality are more marked in the highest than the lowest educated.

Conclusions

Education and diabetes mortality are inversely related in Europe in the 2000s. This association differs by gender, indicating the need to take the socioeconomic and gender dimension into account when developing public health policies.

Socioeconomic inequalities and diabetes: A systematic review from Iran

Socioeconomic factor is a determinant of health may contribute to diabetes. We conducted a systematic review to summarizing evidences on associations between socioeconomic factors and diabetes in Iranian population. We systematically searched international databeses; ISI, PubMed/Medline, Scopus, and national databases Iranmedex, Irandoc, and Scientific Information Database (SID) to retrieve relevant articles to socioeconomic factors and diabetes without limitation on time. All identified articles were screened, quality assessed and data extracted by two authors independently. From 74 retrieved articles, 15 cases were relevant. We found increased diabetes prevalence among female sex, over 50 years' old age, illiterate population, retired status, unemployed, urban residents, and low economic status. There was a negative association between social capital and diabetes control. Diabetes complications were more frequent in upper age group, higher education levels and low income populations. Socioeconomic factors were associated with diabetes that leads to inequality. Improving modifiable factors through priority based interventions helps to diabetes prevention and control.

Inequality in diabetes-related hospital admissions in England by socioeconomic deprivation and ethnicity: facility-based cross-sectional analysis

Objective

To investigate the effect of social deprivation and ethnicity on inpatient admissions due to diabetes in England.

Design

Facility-based cross-sectional analysis.

Setting

National Health Service (NHS) trusts in England reporting inpatient admissions with better than 80% data reporting quality from 2010–2011 (355 facilities).

Participants

Non-obstetric patients over 16 years old in all NHS facilities in England. The sample size after exclusions was 5,147,859 all-cause admissions.

Main Outcome Measures

The relative risk of inpatient admissions and readmissions due to diabetes adjusted for confounders.

Results

There were 445,504 diabetes-related hospital admissions in England in 2010, giving a directly (age-sex) standardized rate of 1049.0 per 100,000 population (95% confidence interval (CI): 1046.0–1052.1). The relative risk of inpatient admission in the most deprived quintile was 2.08 times higher than that of the least deprived quintile (95% CI: 2.02–2.14), and the effect of deprivation varied across ethnicities. About 30.1% of patients admitted due to diabetes were readmitted at least once due to diabetes. South Asians showed 2.62 times (95% CI: 2.51 – 2.74) higher admission risk. Readmission risk increased with IMD among white British but not other ethnicities. South Asians showed slightly lower risk of readmission than white British (0.86, 95% CI: 0.80 – 0.94).

Conclusions

More deprived areas had higher rates of inpatient admissions and readmissions due to diabetes. South Asian British showed higher admission risk and lower readmission risk than white British. However, there was almost no difference by ethnicity in readmission due to diabetes. Higher rates of admission among deprived people may not necessarily reflect higher prevalence, but higher admission rates in south Asian British may be explained by their higher prevalence because their lower readmission risk suggests no inequality in primary care to prevent readmission. Better interventions in poorer areas, are needed to reduce these inequalities.

Impact of socioeconomic status and gender on glycaemic control, cardiovascular risk factors and diabetes complications in type 1 and 2 diabetes: a population based analysis from a Scottish region

AIMS

In this cross-sectional study, the aims were to investigate the association of the socioeconomic status and gender on the prevalence of type 1 and 2 diabetes, glycaemic control, cardiovascular risk factors plus the complications of diabetes in a population-based analysis in the county of Ayrshire and Arran, Scotland.

METHODS

Quality Outcome Framework data was obtained from General Practices in Ayrshire and Arran, Scotland (n=15,351 patients).

RESULTS

In type 1 diabetes, there was an increasing linear trend in HbA1c across deprivation levels (P<0.01). In type 1 diabetes, obesity in women (P<0.01) and increased non-fasting triglyceride levels in both men and women were associated with deprivation (P<0.05). In type 2 diabetes, there was a significant prevalence trend with deprivation for women (P<0.01) but not with glycaemic control (P=0.12). Smoking, ischaemic heart disease and neuropathy (P<0.01) were all associated with increasing deprivation with gender differences. In type 2 diabetes, reduced HDL cholesterol (P<0.01 both genders), and percentage of people on lipid lowering therapy (men P<0.05; women P<0.01) were associated with deprivation. Smoking, ischaemic heart disease, peripheral vascular disease and neuropathy plus foot ulcers (P<0.05) were all associated with increasing deprivation with gender differences.

CONCLUSIONS

Socioeconomic status and gender are associated with changes in glycaemic control and cardiovascular risk factors plus complication development in both type 1 and 2 diabetes. The mechanisms are unclear but follow-up of these patients should allow greater understanding.

Environments perceived as obesogenic have lower residential property values

BACKGROUND

Studies have tried to link obesity rates and physical activity with multiple aspects of the built environment.

PURPOSE

To determine the relation between residential property values and multiple perceived (self-reported) measures of the obesogenic environment.

METHODS

The Seattle Obesity Study (SOS) used a telephone survey of a representative, geographically distributed sample of 2,001 King County adults, collected in 2008-2009 and analyzed in 2012-2013. Home addresses were geocoded. Residential property values at the tax parcel level were obtained from the King County tax assessor. Mean residential property values within a 10-minute walk (833-m buffer) were calculated for each respondent. Data on multiple perceived measures of the obesogenic environment were collected by self-report. Correlations and multivariable linear regression analyses, stratified by residential density, were used to examine the associations among perceived environmental measures, property values, and BMI.

RESULTS

Perceived measures of the environment such as crime, heavy traffic, and proximity to bars, liquor stores, and fast food were all associated with lower property values. By contrast, living in neighborhoods that were perceived as safe, quiet, clean, and attractive was associated with higher property values. Higher property values were associated, in turn, with lower BMIs among women. The observed associations between perceived environment measures and BMI were largely attenuated after accounting for residential property values.

CONCLUSIONS

Environments perceived as obesogenic are associated with lower property values. Studies in additional locations need to explore to what extent other perceived environment measures can be reflected in residential property values.

Global estimates of diabetes prevalence for 2013 and projections for 2035

INTRODUCTION

Diabetes is a serious and increasing global health burden and estimates of prevalence are essential for appropriate allocation of resources and monitoring of trends.

METHODS

We conducted a literature search of studies reporting the age-specific prevalence for diabetes and used the Analytic Hierarchy Process to systematically select studies to generate estimates for 219 countries and territories. Estimates for countries without available source data were modelled from pooled estimates of countries that were similar in regard to geography, ethnicity, and economic development. Logistic regression was applied to generate smoothed age-specific prevalence estimates for adults 20-79 years which were then applied to population estimates for 2013 and 2035.

RESULTS

A total of 744 data sources were considered and 174 included, representing 130 countries. In 2013, 382 million people had diabetes; this number is expected to rise to 592 million by 2035. Most people with diabetes live in low- and middle-income countries and these will experience the greatest increase in cases of diabetes over the next 22 years.

CONCLUSION

The new estimates of diabetes in adults confirm the large burden of diabetes, especially in developing countries. Estimates will be updated annually including the most recent, high-quality data available.

Trends in cardiovascular risk factors among people with diabetes in a population based study, Health Survey for England 1994-2009

AIMS

We evaluated trends in cardiovascular risk factors in a population-based sample of people with diabetes in England from 1994 to 2009.

METHODS

Data were obtained from Health Survey for England for 1994, 1998, 2003, 2006, 2008 and 2009. Participants were aged ≥30 years with self-reported diabetes.

RESULTS

The standerdised prevalence of diabetes increased from 2.8% in 1994 to 6.4% in 2009 and the prevalence among males was higher than females throughout. The trend in prevalence was more apparent in manual workers. From 1994 to 2009, mean systolic blood pressure declined from 148 mmHg to 137 mmHg; mean diastolic pressure declined from 80 mmHg to 70 mmHg; mean total cholesterol declined from 6.1 mmol/L to 4.5 mmol/L over the 15 years with linear trends. The proportion prescribed lipid lowering drugs increased from 2.2% to 47.4%. The percentage of current smokers declined from 17.5% to 13.4%. Mean body mass index increased from 27.7 kg/m(2) to 31.6 kg/m(2) with an overall increase of 0.24 kg/m(2) per year. Risk factor trends were generally similar between genders and social classes but the decline in smoking was not significant for men or for manual workers.

CONCLUSIONS

People with clinical diabetes have experienced substantial reductions in blood pressure, total cholesterol and smoking over 15 years. Increasing body mass index and persistence of smoking in lower socioeconomic groups, may compromise these improvements.