Erroneous inflation of diabetes prevalence: Are there global implications?

Effects of inappropriate cause-of-death certification on mortality from cardiovascular disease and diabetes mellitus in Tonga

BACKGROUND

Cardiovascular disease (CVD) and diabetes mellitus are major health issues in Tonga and other Pacific countries, although mortality levels and trends are unclear. We assess the impacts of cause-of-death certification on coding of CVD and diabetes as underlying causes of death (UCoD).

METHODS

Tongan records containing cause-of-death data (2001-2018), including medical certificates of cause-of-death (MCCD), had UCoD assigned according to International Classification of Diseases 10th revision (ICD-10) coding rules. Deaths without recorded cause were included to ascertain total mortality. Diabetes and hypertension causes were reallocated from Part 1 of the MCCD (direct cause) to Part 2 (contributory cause) if potentially fatal complications were not recorded, and an alternative UCoD was assigned. Proportional mortality by cause based on the alternative UCoD were applied to total deaths then mortality rates calculated by age and sex using census/intercensal population estimates. CVD and diabetes mortality rates for unaltered and alternative UCoD were compared using Poisson regression.

RESULTS

Over 2001-18, in ages 35-59 years, alternative CVD mortality was higher than unaltered CVD mortality in men (p = 0.043) and women (p = 0.15); for 2010-18, alternative versus unaltered measures in men were 3.3/103 (95%CI: 3.0-3.7/103) versus 2.9/103 (95%CI: 2.6-3.2/103), and in women were 1.1/103 (95%CI: 0.9-1.3/103) versus 0.9/103 (95%CI: 0.8-1.1/103). Conversely, alternative diabetes mortality rates were significantly lower than the unaltered rates over 2001-18 in men (p < 0.0001) and women (p = 0.013); for 2010-18, these measures in men were 1.3/103 (95%CI: 1.1-1.5/103) versus 1.9/103 (95%CI: 1.6-2.2/103), and in women were 1.4/103 (95%CI: 1.2-1.7/103) versus 1.7/103 (95%CI: 1.5-2.0/103). Diabetes mortality rates increased significantly over 2001-18 in men (unaltered: p < 0.0001; alternative: p = 0.0007) and increased overall in women (unaltered: p = 0.0015; alternative: p = 0.014).

CONCLUSIONS

Diabetes reporting in Part 1 of the MCCD, without potentially fatal diabetes complications, has led to over-estimation of diabetes, and under-estimation of CVD, as UCoD in Tonga. This indicates the importance of controlling various modifiable risks for atherosclerotic CVD (including stroke) including hypertension, tobacco use, and saturated fat intake, besides obesity and diabetes. Accurate certification of diabetes as a direct cause of death (Part 1) or contributory factor (Part 2) is needed to ensure that valid UCoD are assigned. Examination of multiple cause-of-death data can improve understanding of the underlying causes of premature mortality to better inform health planning.

A sweet deal for domestic industry: the political economy and framing of Vanuatu's sugar-sweetened beverage tax

INTRODUCTION

The Government of Vanuatu introduced an excise tax on sugar-sweetened beverages (SSBs) in 2015. While lauded for its alignment with the WHO's Best Buys recommendations for addressing non-communicable diseases (NCDs), little is known about the tax's adoption process or whose interests it serves.

METHODS

Using case study methodology, this study examined how and why Vanuatu's SSB tax was introduced. Policy documents, key informant interviews (n=33) and direct observations were analysed using theories of policy analysis, power analysis and postcolonial theory to map the policy's adoption, surrounding political economy and the ideas, interests and institutions that shaped the tax and its framing.

RESULTS

The SSB tax emerged during a politically and economically unstable time in Vanuatu's history. The tax's links to the national health agenda were tenuous despite its ostensible framing as a way to combat NCDs. Rather, the tax was designed to respond to tightening economic and trade conditions. Spearheaded by several finance-focused bureaucrats, and with limited input from health personnel, the tax targeted less frequently consumed carbonated SSBs (which are mostly imported) without any revenue reinvestments into health. Driven by the desire to generate much-needed government revenue and instal domestic protections via selective implementation and carve-outs for local producers, the Vanuatu SSB tax did meet national objectives, just not the dual health and economic 'win-win' projected by the NCD Best Buys.

CONCLUSION

Vanuatu's SSB tax adoption process reveals the limitations of decontextualised policy recommendations, such as the NCD Best Buys, whose framing may be overcome by local political realities. This research highlights the need for further political economy considerations in global health recommendations, since contextual forces and power dynamics are key to shaping both how and why policies are enacted and also whose interest they serve.

National Estimates of the Adult Diabetes Care Continuum in India, 2019-2021

Importance

Diabetes is widespread and treatable, but little is known about the diabetes care continuum (diagnosis, treatment, and control) in India and how it varies at the national, state, and district levels.

Objective

To estimate the adult population levels of diabetes diagnosis, treatment, and control in India at national, state, and district levels and by sociodemographic characteristics.

Design, Setting, and Participants

In this cross-sectional, nationally representative survey study from 2019 to 2021, adults in India from 28 states, 8 union territories, and 707 districts were surveyed for India's Fifth National Family Health Survey (NFHS-5). The survey team collected data on blood glucose among all adults (18-98 years) who were living in the same household as eligible participants (pregnant or nonpregnant female individuals aged 15-49 years and male individuals aged 15-54 years). The overall sample consisted of 1 895 287 adults. The analytic sample was restricted to those who either self-reported having diabetes or who had a valid measurement of blood glucose.

Exposures

The exposures in this survey study were district and state residence; urban vs rural residence; age (18-39 years, 40-64 years, or ≥65 years); sex; and household wealth quintile.

Main Outcomes and Measures

Diabetes was defined by self-report or high capillary blood glucose (fasting: ≥126 mg/dL [to convert to mmol/L, multiply by 0.0555]; nonfasting: ≥220 mg/dL). Among respondents who had previously been diagnosed with diabetes, the main outcome was the proportion treated based on self-reported medication use and the proportion controlled (fasting: blood glucose <126 mg/dL; nonfasting: ≤180 mg/dL). The findings were benchmarked against the World Health Organization (WHO) Global Diabetes Compact targets (80% diagnosis; 80% control among those diagnosed). The variance in indicators between and within states was partitioned using variance partition coefficients (VPCs).

Results

Among 1 651 176 adult respondents (mean [SD] age, 41.6 [16.4] years; 867 896 [52.6%] female) with blood glucose measures, the proportion of individuals with diabetes was 6.5% (95% CI, 6.4%-6.6%). Among adults with diabetes, 74.2% (95% CI, 73.3%-75.0%) were diagnosed. Among those diagnosed, 59.4% (95% CI, 58.1%-60.6%) reported taking medication, and 65.5% (95% CI, 64.5%-66.4%) achieved control. Diagnosis and treatment were higher in urban areas, older age groups, and wealthier households. Among those diagnosed in the 707 districts surveyed, 246 (34.8%) districts met the WHO diagnosis target, while 76 (10.7%) districts met the WHO control target. Most of the variability in diabetes diagnosis (VPC, 89.1%), treatment (VPC, 85.9%), and control (VPC, 95.6%) were within states, not between states.

Conclusions and Relevance

In this survey study, the diabetes care continuum in India is represented by considerable district-level variation, age-related disparities, and rural-urban differences. Surveillance at the district level can guide state health administrators to prioritize interventions and monitor achievement of global targets.

LC-MS based metabolomics analysis of okara fermented by Bacillus subtilis DC-15: Insights into nutritional and functional profile

Recent studies emphasize the improved nutritional and functional status of fermented okara; however, little is known about the metabolite change during fermentation and how it alters metabolic pathways. A metabolomics approach based on untargeted LC-MS reveals metabolic changes in okara fermented by Bacillus subtilis DC-15. We identified 761 differential metabolites, with the highest abundances found in amino acids, dipeptides, fatty acids, small molecule sugars, and vitamins. Moreover, these identified metabolites were mapped to their respective biosynthesis pathways in order to gain a better understanding of the biochemical reactions triggered by fermentation. Based on Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, 485 metabolites were enriched to metabolism-related pathways. They include 37 carbohydrate metabolites, 79 amino acid metabolites, and 22 lipid metabolites. As a result of okara fermentation, we observed a gradual enrichment of metabolites and stabilization of the compounds.

The tide of dietary risks for noncommunicable diseases in Pacific Islands: an analysis of population NCD surveys

Objective

To describe changes over time in dietary risk factor prevalence and non-communicable disease in Pacific Island Countries (PICTs).

Methods

Secondary analysis of data from 21,433 adults aged 25–69, who participated in nationally representative World Health Organization STEPs surveys in 8 Pacific Island Countries and Territories between 2002 and 2019. Outcomes of interest were changes in consumption of fruit and vegetables, hypertension, overweight and obesity, and hypercholesterolaemia over time. Also, salt intake and sugar sweetened beverage consumption for those countries that measured these.

Results

Over time, the proportion of adults consuming less than five serves of fruit and vegetables per day decreased in five countries, notably Tonga. From the most recent surveys, average daily intake of sugary drinks was high in Kiribati (3.7 serves), Nauru (4.1) and Tokelau (4.0) and low in the Solomon Islands (0.4). Average daily salt intake was twice that recommended by WHO in Tokelau (10.1 g) and Wallis and Futuna (10.2 g). Prevalence of overweight/obesity did not change over time in most countries but increased in Fiji and Tokelau. Hypertension prevalence increased in 6 of 8 countries. The prevalence of hypercholesterolaemia decreased in the Cook Islands and Kiribati and increased in the Solomon Islands and Tokelau.

Conclusions

While some Pacific countries experienced reductions in diet related NCD risk factors over time, most did not. Most Pacific adults (88%) do not consume enough fruit and vegetables, 82% live with overweight or obesity, 33% live with hypertension and 40% live with hypercholesterolaemia. Population-wide approaches to promote fruit and vegetable consumption and reduce sugar, salt and fat intake need strengthening.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13808-3.

Community Perceptions of the Determinants of Diabetes in Peri-Urban Vanuatu

Health promotion is a core component of the Pacific region's response to noncommunicable diseases (NCDs) prevention and control. However, while health promotion should build on and be informed by contextually specific norms and social discourse, there remains a paucity in research that seeks to understand how people in the Pacific region comprehend chronic conditions and their determinants. Based in peri-urban Vanuatu, this codesigned study utilized an open-ended survey to investigate community perceptions of factors contributing to the development of type 2 diabetes. Results demonstrate a complex picture of diabetes-specific health literacy, with 22 distinct causes identified by 308 respondents. Dietary factors were commonly acknowledged; however, dietary complexity was not well understood. Limited recognition of the role of tobacco and alcohol consumption in disease development was also noted. Overall, findings demonstrate mixed successes in NCD-related health promotion. Moving away from more universalized approaches commonly advocated by donors, this research identifies the need for locally designed and driven health promotion that focuses on more nuanced, culturally sensitive, and contextually grounded messaging.

Age and cohort rise in diabetes prevalence among older Australian women: Case ascertainment using survey and healthcare administrative data

BACKGROUND

Due to the absence and or costliness of biological measures such as glycated haemoglobin, diabetes case ascertainment and prevalence studies are usually conducted using surveys or routine health service use databases. However, the use of each of these sources is associated with its limitations potentially impacting the quality of the case ascertainment and prevalence estimation. This study aimed at ascertaining diabetes cases and estimating prevalence among mid- and older-age women through simultaneous use of a longitudinal survey and multiple healthcare administrative data sources.

METHODS

Data were available for 12,432 and 13,714 women born in 1921-26 and 1946-51 from the Australian Longitudinal Study on Women's Health (ALSWH). Diabetes was ascertained using the ALSWH survey, health service use, and cause of death data. Parsimonious multiple logistic regression analyses tested associations between sociodemographic and health variables and the presence of diabetes.

RESULTS

In both cohorts, two or more of the sources captured more than 80% of the women with diabetes. The point prevalence of diabetes increased from 8.4% when the mean age of the women were aged 73, to 22.0% of surviving women at age 90 in the 1921-26 cohort; and from 2.6% at age 48 to 15.8% at age 68 in the 1946-51 cohort. In the 1921-26 cohort, women who were obese (OR: 3.56; 95 CI: 3.04-4.17) and women who were sedentary (OR: 1.18; 95 CI: 1.09-1.40) were more likely to have diabetes compared to those who had a normal weight and engaged in a moderate level of physical activity. In the 1946-51 cohort, the odds of diabetes increased three times (OR: 2.99; 95 CI: 2.54-3.52) for overweight women and nine times (OR: 8.78; 95 CI: 7.46-10.33) for obese women compared to those who had normal weight.

CONCLUSIONS

The simultaneous use of multiple data sources improved the validity of diabetes case ascertainment. Application of this methodology in future studies may have important benefits including estimation of disease burden, health service needs, and resource allocation with improved precision. Diabetes prevalence increased with age, was much higher in the 1946-51 cohort than in 1921-26 at similar ages, and was significantly associated with physical inactivity and obesity. Interventions to promote physical activity and a healthy weight are needed to prevent the rising prevalence of diabetes across successive generations.

Overview of trends in cardiovascular and diabetes risk factors in Fiji

CONTEXT

Fiji has undergone an epidemiological transition, characterised by declining infectious disease and childhood mortality, that has been offset by rising cardiovascular disease mortality. Other Pacific Island states are in a comparable situation.

OBJECTIVE

With a focus on Fiji, this study reviews and contextualises research performed by the authors and others that examines cardiovascular disease (CVD) and type 2 diabetes (T2DM) and their risk factors in Pacific Island states.

METHODS

This overview covers evidence for the causes and consequences of CVD risk factors and the epidemiological transition and reflects on biological and evolutionary hypotheses. It is based on studies the authors carried out that synthesised disparate population-based CVD risk factor surveys conducted in Fiji over 1980-2012.

RESULTS

Prevalences of obesity, T2DM and hypertension continue to increase in the Fiji population. Tobacco smoking prevalence has decreased, but remains relatively high in men compared to many developed countries. T2DM and hypertension trends, and CVD consequences related to diet, exercise and tobacco smoking, have placed the Fiji population in a variant of the epidemiological transition manifesting as a plateau in life expectancy similar to that of numerous developed countries during the mid-20th century.

CONCLUSION

There is evidence that risk factors and consequent CVD mortality can be reduced in populations. Obesity and T2DM reductions have been observed only in populations surviving in dire circumstances. Interventions to lower the prevalence of CVD and T2DM risk factors in the Fiji population require multi-faceted approaches, with continual monitoring and evaluation for their impact on these risk factors and morbidity and mortality outcomes.

Rapid assessment of avoidable blindness and diabetic retinopathy in people aged 50 years and older in the National Capital District of Papua New Guinea

BACKGROUND/AIMS

To conduct an assessment of avoidable blindness, diabetes mellitus and diabetic retinopathy (DR) in adults aged 50 years and older in the National Capital District (NCD) region of Papua New Guinea (PNG).

METHODS

A cross-sectional population-based survey was performed for which 25 clusters of 50 people aged ≥50 years were randomly selected from the NCD region. The standardised rapid assessment of avoidable blindness (RAAB) with diabetic retinopathy (+DR) methodology was used. Blindness was defined as presenting visual acuity <3/60 in the better eye. Participants were classified as having diabetes if they were known to have diabetes or if their random blood glucose level was ≥200 mg/dL. Dilated fundus examination and Scottish DR grading were performed.

RESULTS

In total, 1192 out of 1250 eligible participants (95.4%) were examined. Of these, 7.8% had known or newly diagnosed diabetes. Seventy-one per cent of participants with known diabetes had a blood glucose level ≥200 mg/dL, and 82.9% had never had an ophthalmological examination for DR. Prevalence of DR and/or maculopathy was 46.4%. The age-adjusted and sex-adjusted prevalence of diabetes was estimated at 8.1% (95% CI 5.7% to 10.4%) in the population aged 50 years or older in the NCD region of PNG.

CONCLUSIONS

Prevalence of diabetes in adults aged 50 years and older was lower than reported elsewhere in the region, and lower than other RAAB+DR surveys. Despite this, the prevalence of DR is high compared with other RAAB+DR surveys and demonstrates the need for increased awareness and accessibility to eye services for people with diabetes.

A Global Cancer Surveillance Framework Within Noncommunicable Disease Surveillance: Making the Case for Population-Based Cancer Registries

The growing burden of cancer among several major noncommunicable diseases (NCDs) requires national implementation of tailored public health surveillance. For many emerging economies where emphasis has traditionally been placed on the surveillance of communicable diseases, it is critical to understand the specificities of NCD surveillance and, within it, of cancer surveillance. We propose a general framework for cancer surveillance that permits monitoring the core components of cancer control. We examine communalities in approaches to the surveillance of other major NCDs as well as communicable diseases, illustrating key differences in the function, coverage, and reporting in each system. Although risk factor surveys and vital statistics registration are the foundation of surveillance of NCDs, population-based cancer registries play a unique fundamental role specific to cancer surveillance, providing indicators of population-based incidence and survival. With an onus now placed on governments to collect these data as part of the monitoring of NCD targets, the integration of cancer registries into existing and future NCD surveillance strategies is a vital requirement in all countries worldwide. The Global Initiative for Cancer Registry Development, endorsed by the World Health Organization, provides a means to enhance cancer surveillance capacity in low- and middle-income countries.