Socio-economic differences in dysglycemia and lifestyle-related risk factors in the Finnish middle-aged population

Association between oral health behavior and chronic diseases among middle-aged and older adults in Beijing, China

OBJECTIVES

To evaluate the association between oral health behavior and multiple chronic diseases among middle-aged and older adults.

METHODS

We obtained data of the Beijing Health Service Survey and used multivariate logistic models to estimate the association between oral hygiene behavior and the risk of chronic diseases.

RESULTS

The risk of any chronic diseases (OR = 1.27, 95% CI: 1.18-1.37), cardiovascular diseases (CVD, OR = 1.30, 95% CI: 1.21-1.39), and endocrine or nutritional metabolic disorders (OR = 1.11, 95% CI: 1.01-1.22) was higher in those who with poor oral health behavior. There was no significant correlation between oral health behavior and the risk of diseases of the musculoskeletal, respiratory, digestive, and genitourinary systems.

CONCLUSIONS

Poor oral hygiene practices were associated with higher risk of chronic diseases, CVD and diabetes mellitus (DM) among middle-aged and older adults. These findings motivate further studies to evaluate whether improved oral health behavior may prevent the incidence of chronic diseases.

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.

Quantile-Dependent Heritability of Glucose, Insulin, Proinsulin, Insulin Resistance, and Glycated Hemoglobin

BACKGROUND

"Quantile-dependent expressivity" is a dependence of genetic effects on whether the phenotype (e.g., insulin resistance) is high or low relative to its distribution.

METHODS

Quantile-specific offspring-parent regression slopes (βOP) were estimated by quantile regression for fasting glucose concentrations in 6,453 offspring-parent pairs from the Framingham Heart Study.

RESULTS

Quantile-specific heritability (h2), estimated by 2βOP/(1 + rspouse), increased 0.0045 ± 0.0007 (p = 8.8 × 10-14) for each 1% increment in the fasting glucose distribution, that is, h2 ± SE were 0.057 ± 0.021, 0.095 ± 0.024, 0.146 ± 0.019, 0.293 ± 0.038, and 0.456 ± 0.061 at the 10th, 25th, 50th, 75th, and 90th percentiles of the fasting glucose distribution, respectively. Significant increases in quantile-specific heritability were also suggested for fasting insulin (p = 1.2 × 10-6), homeostatic model assessment of insulin resistance (HOMA-IR, p = 5.3 × 10-5), insulin/glucose ratio (p = 3.9 × 10-5), proinsulin (p = 1.4 × 10-6), proinsulin/insulin ratio (p = 2.7 × 10-5), and glucose concentrations during a glucose tolerance test (p = 0.001), and their logarithmically transformed values.

DISCUSSION/CONCLUSION

These findings suggest alternative interpretations to precision medicine and gene-environment interactions, including alternative interpretation of reported synergisms between ACE, ADRB3, PPAR-γ2, and TNF-α polymorphisms and being born small for gestational age on adult insulin resistance (fetal origin theory), and gene-adiposity (APOE, ENPP1, GCKR, IGF2BP2, IL-6, IRS-1, KIAA0280, LEPR, MFHAS1, RETN, TCF7L2), gene-exercise (INS), gene-diet (ACSL1, ELOVL6, IRS-1, PLIN, S100A9), and gene-socioeconomic interactions.

Social inequality in type 2 diabetes mellitus in the Faroe Islands: a cross-sectional study

Aims: The Faroe Islands is considered a homogeneous society and has a low Gini coefficient, but the knowledge about the social distribution of health and disease is sparse. In a large population-based sample we investigated: (a) the association between socioeconomic position defined by level of education and the prevalence of type 2 diabetes mellitus by self-report in the Faroe Islands; and (b) to what degree lifestyle factors mediate the association. Methods: We used cross-sectional data from the population-based Public Health Survey Faroes 2015 (n=1095). We present odds ratios for type 2 diabetes mellitus by socioeconomic position from logistic regression models. In our main model we adjusted for potential confounders and in a secondary model we additionally adjusted for potential mediating lifestyle factors. Results: Individuals with middle and low levels of education display higher odds ratios of type 2 diabetes mellitus of 2.80 (95% confidence interval 1.32-5.92) and 4.65 (95% confidence interval 1.93-11.17) in adjusted analysis, respectively, compared to their counterparts with high education. After adjustment for potentially mediating lifestyle factors the estimates were attenuated slightly, but a significant statistical association remained, with lifestyle-related mediating factors in total explaining 21% for middle education and 34% for low education participants. Conclusions: Our results demonstrate that there may be a social gradient in the distribution of type 2 diabetes mellitus in the Faroe Islands, and that the association is partly mediated by lifestyle factors.

Excess body weight, cigarette smoking, and type II diabetes incidence in the national FINRISK studies

PURPOSE

We identify the individual and joint contributions of excess weight and cigarette smoking to national-level type II diabetes (T2D) incidence and to educational and gender disparities therein filling an important gap in T2D epidemiology.

METHODS

Based on the FINRISK surveys conducted in 1997, 2002, and 2007 and linked to the Finnish National Drug Reimbursement Register through 2011, we used a regression-counterfactual approach to estimate the percentage of diagnosed drug-treated incident T2D cases attributable to excess body weight and cigarette smoking. Body mass index (BMI) and waist circumference were evaluated.

RESULTS

T2D incidence was 10.24 in men and 7.04 in women per 1000 person-years. Excess baseline BMI (≥25.0 kg/m²) explained 69% and 63%, and smoking explained 9% and 14% of T2D incidence, in men and women, respectively. Most of the gender difference was explained by the risk factors. Approximately 90% in men and 98% in women of the higher T2D incidence among those in the lower versus upper third of the educational distribution was explained by excess BMI. The results were similar for waist circumference and lifetime maximum BMI.

CONCLUSIONS

Excess body weight is the main risk factor contributing to national-level T2D incidence and disparities by educational attainment and gender in a high-income population.

Electronic Health Records as Valuable Data Sources in the Health Care Quality Improvement Process

BACKGROUND

In North Karelia, Finland, the regional electronic health records (EHRs) enable flexible data retrieval and area-level analyses. The aim of this study was to assess the early detection of type 2 diabetes (T2D) in the region and to evaluate the performed activities in order to improve the processes between the years 2012 and 2017.

METHODS

Patients with T2D were identified from the EHRs using the ICD-10 codes registered during any visit to either primary or specialized care. The prevalence of T2D was calculated for the years 2012, 2015, and 2017 on the municipality level. The number of people found in the EHRs with diabetes was compared with the number found in the national register of medication reimbursement rights.

RESULTS

In 2012, the age-adjusted prevalence of T2D in North Karelia varied considerably between municipalities (5.5%-8.6%). These differences indicate variation in the processes of early diagnosis. The findings were discussed in the regional network of health professionals treating patients with T2D, resulting in sharing experiences and best practices. In 2017, the differences had notably diminished, and in most municipalities, the prevalence exceeded 8%. The regional differences in the prevalence and their downward trend were observed both in the EHRs and in the medication reimbursement rights register.

CONCLUSION

Clear differences in the prevalence of T2D were detected between municipalities. After visualizing these differences and providing information for the professionals, the early detection of T2D improved and the regional differences decreased. The EHRs are a valuable data source for knowledge-based management and quality improvement.

Neighborhood characteristics and lifestyle intervention outcomes: Results from the Special Diabetes Program for Indians

Growing evidence reveals various neighborhood conditions are associated with the risk of developing type 2 diabetes. It is unknown, however, whether the effectiveness of diabetes prevention interventions is also influenced by neighborhood characteristics. The purpose of the current study is to examine the impact of neighborhood characteristics on the outcomes of a lifestyle intervention to prevent diabetes in American Indians and Alaska Natives (AI/ANs). Year 2000 US Census Tract data were linked with those from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention implemented in 36 AI/AN grantee sites across the US. A total of 3394 participants started the intervention between 01/01/2006 and 07/31/2009 and were followed by 07/31/2016. In 2016-2017, data analyses were conducted to evaluate the relationships of neighborhood characteristics with intervention outcomes, controlling for individual level socioeconomic status. AI/ANs from sites located in neighborhoods with higher median household income had 38% lower risk of developing diabetes than those from sites with lower neighborhood income (adjusted hazard ratio = 0.65, 95% CI: 0.47-0.90). Further, those from sites with higher neighborhood concentrations of AI/ANs achieved less BMI reduction and physical activity increase. Meanwhile, participants from sites with higher neighborhood level of vehicle occupancy made more improvement in BMI and diet. Lifestyle intervention effectiveness was not optimal when the intervention was implemented at sites with disadvantaged neighborhood characteristics. Meaningful improvements in socioeconomic and other neighborhood disadvantages of vulnerable populations could be important in stemming the global epidemic of diabetes.

Multimorbidity as an important issue among women: results of a gender difference investigation in a large population-based cross-sectional study in West Asia

OBJECTIVES

To investigate the impact of gender on multimorbidity in northern Iran.

DESIGN

A cross-sectional analysis of the Golestan cohort data.

SETTING

Golestan Province, Iran.

STUDY POPULATION

49 946 residents (age 40-75 years) of Golestan Province, Iran.

MAIN OUTCOME MEASURES

Researchers collected data related to multimorbidity, defined as co-existence of two or more chronic diseases in an individual, at the beginning of a representative cohort study which recruited its participants from 2004 to 2008. The researchers utilised simple and multiple Poisson regression models with robust variances to examine the simultaneous effects of multiple factors.

RESULTS

Women had a 25.0% prevalence of multimorbidity, whereas men had a 13.4% prevalence (p<0.001). Women of all age-groups had a higher prevalence of multimorbidity. Of note, multimorbidity began at a lower age (40-49 years) in women (17.3%) compared with men (8.6%) of the same age (p<0.001). This study identified significant interactions between gender as well as socioeconomic status, ethnicity, physical activity, marital status, education level and smoking (p<0.01).

CONCLUSION

Prevention and control of multimorbidity requires health promotion programmes to increase public awareness about the modifiable risk factors, particularly among women.

The interaction of socioeconomic position and type 2 diabetes mellitus family history: a cross-sectional analysis of the Lifelines Cohort and Biobank Study

BACKGROUND

Low socioeconomic position (SEP) and family history of type 2 diabetes mellitus (T2DM) contribute to increased T2DM risk, but it is unclear whether they exacerbate each other's effect. This study examined whether SEP reinforces the association of T2DM family history with T2DM, and whether behavioural and clinical risk factors can explain this reinforcement.

METHODS

We used cross-sectional data on 51 725 participants from Lifelines. SEP was measured as educational level and was self-reported, just as family history of T2DM. T2DM was diagnosed based on measured fasting plasma glucose and glycated haemoglobin, combined with self-reported disease and recorded medication use. We assessed interaction on the additive scale by calculating the relative excess risk due to interaction (RERI).

RESULTS

ORs of T2DM were highest for males (4.37; 95% CI 3.47 to 5.51) and females (7.77; 5.71 to 10.56) with the combination of low SEP and a family history of T2DM. The RERIs of low SEP and a family history of T2DM were 0.64 (-0.33 to 1.62) for males and 3.07 (1.53 to 4.60) for females. Adjustment for behavioural and clinical risk factors attenuated associations and interactions, but risks remained increased.

CONCLUSION

Low SEP and family history of T2DM are associated with T2DM, but they also exacerbate each other's impact in females but not in males. Behavioural and clinical risk factors partly explain these gender differences, as well as the associations underlying the interaction in females. The exacerbation by low SEP of T2DM risks in T2DM families deserves attention in prevention and community care.

Secular trends and educational differences in the incidence of type 2 diabetes in Finland, 1972-2007

Type 2 diabetes prevalence is rising globally, and varies by socio-economic position. Amongst other factors, rising prevalence may reflect increasing incidence. Worldwide, few studies have examined population-level longitudinal trends in incident type 2 diabetes, and reports on secular trends in diabetes incidence by socio-economic measures such as educational attainment are lacking. Finland has a long-standing, comprehensive disease surveillance infrastructure. Using data collected over four decades from serial FINRISK surveys, the National Drug Reimbursement Register and the National Causes of Death Register, we examined secular trends in type 2 diabetes incidence in Finland from the 1970s to 2007. The diabetes status of 38,689 FINRISK participants aged 30-59 years at baseline assessment and without diagnosed diabetes at the time was followed for 10 years. Among men, incidence of diagnosed, pharmacologically managed type 2 diabetes increased over time. Compared with men surveyed in the 1970s, diabetes incidence was higher among men in the 1980s (adjusted HR 1.44, 95% CI 1.13-1.84) and 1990s (adjusted HR 1.72, 1.32-2.24). Body mass index explained some, but not all of this variation. Increases occurred predominantly among men with low (adjusted HR 1980s: 2.07, 95% CI 1.28-3.35; adjusted HR 1990s: 2.12, 95% CI 1.28-3.53) and middle (adjusted HR 1980s: 1.30, 95% CI 0.85-1.99; adjusted HR 1990s: 1.65, 95% CI 1.05-2.60) educational attainment. No secular changes were apparent among women. This rising diabetes incidence among men over recent decades has occurred despite Finland's sustained health promotion efforts. Renewed public health campaigns are urgently required. In addition to population-level initiatives, lower educational strata should be specifically targeted.

Clinical and lifestyle-related risk factors for incident multimorbidity: 10-year follow-up of Finnish population-based cohorts 1982-2012

BACKGROUND

Multimorbidity is a huge burden to individuals and societies and more attention should be paid on its risk factors and prevention possibilities. The aim of this study was to investigate which clinical and lifestyle characteristics predict the development of multimorbidity both among initially disease-free people and among people who have diabetes or CVD.

METHODS

Data comprised 25-64 year old, randomly selected men and women (n=32,972) who participated in one of the five national FINRISK surveys between 1982 and 2002 in Finland. The surveys included anthropometric measurements, blood samples and structured questionnaire. Data on incident diagnoses of the five most common chronic diseases during 10 years were received from the national registers on mortality, hospitalizations, and reimbursement rights.

RESULTS

Predisposing factors for multimorbidity among disease-free population were smoking, physical inactivity, and BMI. Among men also systolic blood pressure and low education predicted multimorbidity. Among men with DM at baseline, high blood pressure, physical inactivity, and smoking increased the likelihood of incident multimorbidity. Among women, significant predictors of multimorbidity were high BMI and smoking. Among men and women with CVD, the only baseline factor that was significantly associated with the development of multimorbidity in the multivariate prediction model was low fruit and vegetable consumption.

CONCLUSION

Several modifiable clinical and lifestyle risk factors were found to predict incident multimorbidity. Better recognition and management of these risk factors could potentially have a large impact on the development of multimorbidity, and consequently, premature mortality and costs of care among the aging populations.

Associations between parental BMI, socioeconomic factors, family structure and overweight in Finnish children: a path model approach

Background

The aim of this study was to assess the less studied interrelationships and pathways between parental BMI, socioeconomic factors, family structure and childhood overweight.

Methods

The cross-sectional LATE-study was carried out in Finland in 2007–2009. The data for the analyses was classified into four categories: younger boys and girls (ca 3–8 years) (n = 2573) and older boys and girls (ca 11–16 years) (n = 1836). Associations between parental BMI, education, labor market status, self-perceived income sufficiency, family structure and childhood overweight were first examined by logistic regression analyses. As parental BMI and education had the most consistent associations with childhood overweight, the direct and indirect (mediated by parental BMI) associations of maternal and paternal education with childhood overweight were further assessed using a path model.

Results

Parental BMI and education were the strongest determinants of childhood overweight. Children of overweight parents had an increased risk of being overweight. In younger boys, maternal and paternal education had both direct (b-coefficient paternal −0.21, 95% CI −0.34 to −0.09; maternal −0.17, 95% CI −0.28 to −0.07) and indirect (b-coefficient paternal −0.04, 95% CI −0.07 to −0.02; maternal −0.04, 95% CI −0.06 to −0.02) inverse associations with overweight. Among the older boys, paternal education had both direct (b-coefficient −0.12, 95% CI −0.24 to −0.01) and indirect (b-coefficient −0.03, 95% CI −0.06 to −0.01) inverse associations with overweight, but maternal education had only an indirect association (b-coefficient −0.04, 95% CI −0.07 to −0.02). Among older girls, only an indirect association of maternal education with childhood overweight was found (b-coefficient −0.03, 95% CI −0.06 to −0.01). In younger girls, parental education was not associated with childhood overweight.

Conclusion

The observed pathways between parental BMI and education and childhood overweight emphasize a need for evidence-based health promotion interventions tailored for families identified with parental overweight and low level of education.

Age- and sex-specific relationships between household income, education, and diabetes mellitus in Korean adults: the Korea National Health and Nutrition Examination Survey, 2008-2010

Background

To investigate the effects of age and sex on the relationship between socioeconomic status (SES) and the prevalence and control status of diabetes mellitus (DM) in Korean adults.

Methods

Data came from 16,175 adults (6,951 men and 9,227 women) over the age of 30 who participated in the 2008-2010 Korea National Health and Nutrition Examination Survey. SES was measured by household income or education level. The adjusted odds ratios (ORs) and corresponding 95% confidence intervals (95% CI) for the prevalence or control status of diabetes were calculated using multiple logistic regression analyses across household income quartiles and education levels.

Results

The household income-DM and education level-DM relationships were significant in younger age groups for both men and women. The adjusted ORs and 95% CI for diabetes were 1.51 (0.97, 2.34) and 2.28 (1.29, 4.02) for the lowest vs. highest quartiles of household income and education level, respectively, in women younger than 65 years of age (both P for linear trend < 0.05 with Bonferroni adjustment). The adjusted OR and 95% CI for diabetes was 2.28 (1.53, 3.39) for the lowest vs. highest quartile of household income in men younger than 65 (P for linear trend < 0.05 with Bonferroni adjustment). However, in men and women older than 65, no associations were found between SES and the prevalence of DM. No significant association between SES and the status of glycemic control was detected.

Conclusions

We found age- and sex-specific differences in the relationship of household income and education with the prevalence of DM in Korea. DM preventive care is needed for groups with a low SES, particularly in young or middle-aged populations.

Educational attainment and obesity: a systematic review

Although previous systematic reviews considered the relationship between socioeconomic status and obesity, almost 200 peer-reviewed articles have been published since the last review on that topic, and this paper focuses specifically on education, which has different implications. The authors systematically review the peer-reviewed literature from around the world considering the association between educational attainment and obesity. Databases from public health and medicine, education, psychology, economics, and other social sciences were searched, and articles published in English, French, Portuguese and Spanish were included. This paper includes 289 articles that report on 410 populations in 91 countries. The relationship between educational attainment and obesity was modified by both gender and the country's economic development level: an inverse association was more common in studies of higher-income countries and a positive association was more common in lower-income countries, with stronger social patterning among women. Relatively few studies reported on lower-income countries, controlled for a comprehensive set of potential confounding variables and/or attempted to assess causality through the use of quasi-experimental designs. Future research should address these gaps to understand if the relationship between educational attainment and obesity may be causal, thus supporting education policy as a tool for obesity prevention.

Comparison of normal fasting and one-hour glucose levels as predictors of future diabetes during a 34-year follow-up

INTRODUCTION

Early identification of those at risk of developing type 2 diabetes (T2DM) is essential. We examined how normoglycemic levels of fasting blood glucose (FBG) and 1-hour glucose predict the development of diabetes among men initially at low risk.

METHODS

In the Helsinki Businessmen Study (men born in 1919- 1934), 1,145 men had normal FBG (< 5.0 mmol/L) in 1974, and 1-hour glucose values available. Multivariate, adjusted models were used to investigate how fasting and 1-hour glucose at baseline related to new-onset diabetes during a follow-up of 34 years.

RESULTS

The median FBG and 1-hour glucose values at baseline were 4.4 and 6.6 mmol/L, respectively. During follow-up, 108 men developed diabetes. The risk of incident diabetes was doubled for the highest quintile of FBG (fully adjusted relative risk (RR) 2.22, 95% confidence interval (CI) 1.10-4.50), and quadrupled for that of 1-hour glucose (RR 4.23, 95% CI 2.49-7.17). FBG could not separate the risk for those with higher levels of glucose in the range < 5.0 mmol/L, whereas 1-hour glucose discriminated the risk better at higher values.

CONCLUSIONS

Higher values in the normoglycemic range for both fasting and 1-hour glucose predicted long-term incidence of diabetes in healthy middle-aged men.

Participation, socioeconomic status and group or individual counselling intervention in individuals at high risk for type 2 diabetes: one-year follow-up study of the FIN-D2D-project

AIMS

To describe socioeconomic characteristics of participants and their effect on uptake and completion of the implementation project (FIN-D2D) for the National Type 2 Diabetes Prevention Programme. Furthermore, to assess the effectiveness of individual vs. group intervention during one-year follow-up.

METHODS

At baseline, 2820 men and 5764 women aged <65 years participated in the non-randomized implementation project in primary health care setting; one-year follow-up was available for 1067 men and 2122 women. Socioeconomic status included education and occupation. Interventions were individual and/or group-based. The changes in cardiovascular risk factors and glucose tolerance were used as measures of the effectiveness of intervention.

RESULTS

68.4% of the men and 69.8% of the women participated in some of the intervention modalities offered. Low education and not working were related to active participation in the intervention in men. 88.2% of men and 76.1% of women selected the individual instead of group intervention. The effectiveness of individual vs. group interventions did not differ, except for minor changes in systolic blood pressure in women and glucose tolerance in men.

CONCLUSIONS

Socioeconomic status modulated participation in interventions. Both types of intervention worked equally well, but participation in group intervention was low.

Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study

OBJECTIVE

To assess the contribution of modifiable risk factors to social inequalities in the incidence of type 2 diabetes when these factors are measured at study baseline or repeatedly over follow-up and when long term exposure is accounted for.

DESIGN

Prospective cohort study with risk factors (health behaviours (smoking, alcohol consumption, diet, and physical activity), body mass index, and biological risk markers (systolic blood pressure, triglycerides and high density lipoprotein cholesterol)) measured four times and diabetes status assessed seven times between 1991-93 and 2007-09.

SETTING

Civil service departments in London (Whitehall II study).

PARTICIPANTS

7237 adults without diabetes (mean age 49.4 years; 2196 women).

MAIN OUTCOME MEASURES

Incidence of type 2 diabetes and contribution of risk factors to its association with socioeconomic status.

RESULTS

Over a mean follow-up of 14.2 years, 818 incident cases of diabetes were identified. Participants in the lowest occupational category had a 1.86-fold (hazard ratio 1.86, 95% confidence interval 1.48 to 2.32) greater risk of developing diabetes relative to those in the highest occupational category. Health behaviours and body mass index explained 33% (-1% to 78%) of this socioeconomic differential when risk factors were assessed at study baseline (attenuation of hazard ratio from 1.86 to 1.51), 36% (22% to 66%) when they were assessed repeatedly over the follow-up (attenuated hazard ratio 1.48), and 45% (28% to 75%) when long term exposure over the follow-up was accounted for (attenuated hazard ratio 1.41). With additional adjustment for biological risk markers, a total of 53% (29% to 88%) of the socioeconomic differential was explained (attenuated hazard ratio 1.35, 1.05 to 1.72).

CONCLUSIONS

Modifiable risk factors such as health behaviours and obesity, when measured repeatedly over time, explain almost half of the social inequalities in incidence of type 2 diabetes. This is more than was seen in previous studies based on single measurement of risk factors.