Ethnicity and Type 2 diabetes in the UK

Prognostic value of stress hyperglycemia ratio in patients with acute myocardial infarction: A systematic review with Bayesian and frequentist meta-analysis

The present systematic review and meta-analysis aimed to investigate the prognostic value of stress hyperglycemia ratio (SHR) in patients with acute myocardial infarction (AMI). A total of 26 cohort studies, involving 87,974 patients, were analyzed. The frequentist meta-analysis showed that AMI patients with SHR in the upper quantile had a significantly higher hazard of major adverse cardiovascular and cerebrovascular events (MACCE, HR = 1.7; 95 % CI= [1.42, 2.03]; P < 0.001; I2 = 71 %; P <0.01), long-term (HR = 1.64; 95 % CI= [1.49, 1.8]; P < 0.001; I2 = 16 %; P = 0.29) and in-hospital all-cause mortality (OR = 3.87; 95 % CI= [2.98, 5.03]; P < 0.001; I2 = 54 %; P = 0.03) compared to those with lower SHR. Prespecified subgroup analyses revealed that these results were consistent irrespective of diabetes status (P = 0.32 and 0.73 for subgroup differences) and that SHR was a significant predictor of MACCE both in AMI with obstructive coronary arteries (HR = 1.57; 95 % CI= [1.34, 1.83]; P < 0.001; I2 = 66 %; P < 0.01) and MINOCA (HR = 2.57; 95 % CI= [1.86, 3.56]; P < 0.001; I2 = 0 %; P = 0.84). The Bayesian analyses with weakly prior assumptions yielded comparable results with the frequentist approach and provided strong evidence that higher SHR values were associated with significantly greater hazard of MACCE, short-term and long-term mortality. Further, prospective research is warranted to provide deeper insights into this newer index of stress hyperglycemia before its potential incorporation in clinical prediction scores.

Comparison of race- and ethnicity-specific BMI cutoffs for categorizing obesity severity: a multicountry prospective cohort study

OBJECTIVE

The objective of this study was to compare race- and ethnicity-specific BMI cutoffs for the three classes of obesity based on equivalent risk of type 2 diabetes (T2D).

METHODS

Participants without T2D were included from the UK Biobank, the China Health and Nutrition Survey, and the Singapore Chinese Health Study. Poisson regressions with restricted cubic splines were applied to determine BMI cutoffs for each non-White race and ethnicity for equivalent incidence rates of T2D at BMI values of 30.0, 35.0, and 40.0 kg/m2 in White adults.

RESULTS

During a median follow-up of 13.8 years among 507,763 individuals, 5.2% developed T2D. In women, BMI cutoffs for an equivalent incidence rate of T2D as observed at 40.0 kg/m2 in White adults were 31.6 kg/m2 in Black, 29.2 kg/m2 in British Chinese, 27.3 kg/m2 in South Asian, 26.9 kg/m2 in Native Chinese, and 25.1 kg/m2 in Singapore Chinese adults. In men, the corresponding BMI cutoffs were 31.9 kg/m2 in Black, 30.6 kg/m2 in British Chinese, 29.0 kg/m2 in South Asian, 29.6 kg/m2 in Native Chinese, and 27.6 kg/m2 in Singapore Chinese adults. The race and ethnicity order was consistent when equivalent BMI cutoffs were estimated for class I and II obesity.

CONCLUSIONS

Establishing a race- and ethnicity-tailored classification of the three classes of obesity is urgently needed.

Ethnic disparities in quality of diabetes care in Scotland: A national cohort study

AIMS

The aim of this study is to compare quality of diabetes care in people with type 2 diabetes by ethnicity, in Scotland.

METHODS

Using a linked national diabetes registry, we included 162,122 people newly diagnosed with type 2 diabetes between 2009 and 2018. We compared receipt of nine guideline indicated processes of care in the first-year post-diabetes diagnosis using logistic regression, comparing eight ethnicity groups to the White group. We compared annual receipt of HbA1c and eye screening during the entire follow-up using generalised linear mixed effects. All analyses adjusted for confounders.

RESULTS

Receipt of diabetes care was lower in other ethnic groups compared to White people in the first-year post-diagnosis. Differences were most pronounced for people in the: African, Caribbean or Black; Indian; and other ethnicity groups for almost all processes of care. For example, compared to White people, odds of HbA1c monitoring were: 44% lower in African, Caribbean or Black people (OR 0.56 [95% CI 0.48, 0.66]); 47% lower in Indian people (OR 0.53 [95% CI 0.47, 0.61]); and 50% lower in people in the other ethnicity group (OR 0.50 [95% CI 0.46, 0.58]). Odds of receipt of eye screening were 30%-40% lower in most ethnic groups compared to the White group. During median 5 year follow-up, differences in HbA1c monitoring and eye screening largely persisted, but attenuated slightly for the former.

CONCLUSIONS

There are marked ethnic disparities in routine diabetes care in Scotland in the short- and medium-term following diabetes diagnosis. Further investigation is needed to establish and effectively address the underlying reasons.

Ethnic differences in the manifestation of early-onset type 2 diabetes

INTRODUCTION

We undertook phenotypic characterization of early-onset and late-onset type 2 diabetes (T2D) in adult black African and white European populations with recently diagnosed T2D to explore ethnic differences in the manifestation of early-onset T2D.

RESEARCH DESIGN AND METHODS

Using the Uganda Diabetes Phenotype study cohort of 500 adult Ugandans and the UK StartRight study cohort of 714 white Europeans with recently diagnosed islet autoantibody-negative T2D, we compared the phenotypic characteristics of participants with early-onset T2D (diagnosed at <40 years) and late-onset T2D (diagnosed at ≥40 years).

RESULTS

One hundred and thirty-four adult Ugandans and 113 white Europeans had early-onset T2D. Compared with late-onset T2D, early-onset T2D in white Europeans was significantly associated with a female predominance (52.2% vs 39.1%, p=0.01), increased body mass index (mean (95% CI) 36.7 (35.2-38.1) kg/m2 vs 33.0 (32.4-33.6) kg/m2, p<0.001), waist circumference (112.4 (109.1-115.6) cm vs 108.8 (107.6-110.1) cm, p=0.06), and a higher frequency of obesity (82.3% vs 63.4%, p<0.001). No difference was seen with the post-meal C-peptide levels as a marker of beta-cell function (mean (95% CI) 2130.94 (1905.12-2356.76) pmol/L vs 2039.72 (1956.52-2122.92), p=0.62).In contrast, early-onset T2D in Ugandans was associated with less adiposity (mean (95% CI) waist circumference 93.1 (89.9-96.3) cm vs 97.4 (95.9-98.8) cm, p=0.006) and a greater degree of beta-cell dysfunction (120 min post-glucose load C-peptide mean (95% CI) level 896.08 (780.91-1011.24) pmol/L vs 1310.10 (1179.24-1440.95) pmol/L, p<0.001), without female predominance (53.0% vs 57.9%, p=0.32) and differences in the body mass index (mean (95% CI) 27.3 (26.2-28.4) kg/m2 vs 27.9 (27.3-28.5) kg/m2, p=0.29).

CONCLUSIONS

These differences in the manifestation of early-onset T2D underscore the need for ethnic-specific and population-specific therapeutic and preventive approaches for the condition.

Glycaemic outcomes in people living with diabetes under 65 and over 65 years old using an intermittently scanned continuous glucose monitoring system

Objective

Intermittently scanned continuous glucose monitoring (isCGM) has revolutionised the care of people with diabetes but its uptake and benefits in older adults are not well known. We examined the impact of isCGM (Freestyle Libre, FSL) on glycaemic outcomes in younger (⩽65 years) and older adults (>65 years) with diabetes.

Design and methods

In total, 2260 adult patients registered on the Libreview account at University Hospitals Birmingham NHS Foundation Trust, UK, were included. Inclusion criteria: all patients with type 1 and type 2 diabetes aged >18 years, use of isCGM >6 months, scanning at least 6 times/day. Demographics, diabetes history and glycaemic outcomes (time in range (TIR), time above range and time below range (TBR), estimated HbA1c, HbA1c at start and at end of study) were collected by accessing electronic patient records and Libreview. Outcomes were compared between age groups ⩽65 or >65 years old.

Results

Most patients were of Caucasian ethnicity (⩽65 years 68%, >65 years 73%) and had type 1 diabetes. Mean duration of diabetes was 19.5 years (range 0-65 years) and 34.5 years (range 0-79 years) for ⩽65 and >65 years, respectively. Only a quarter of those ⩽65 years achieved (219/943; 23.2%) their age specific TIR target compared to 69% (78/113) of those >65 years cohort, while 70.1% (663/946) of ⩽65 years and 40.7% (46/113) of >65 years achieved their age-specific TBR target. When the less strict ⩽65 years TBR target was applied, 75% (85/113) of >65 years cohort achieved this.

Conclusion

FSL use was associated with improved glycaemic outcomes across all age groups. Individualised targets may be needed to improve TBR in those aged >65 years.

Diet and Physical Activity Interventions for People from Minority Ethnic Backgrounds in the UK: A Scoping Review Exploring Barriers, Enablers and Cultural Adaptations

BACKGROUND

Type 2 diabetes (T2D) and cardiovascular disease (CVD) are a global pandemic, driven by obesity, poor diet and physical inactivity. In the UK, the prevalence of T2D and CVD is higher in minority ethnic groups. Lifestyle prevention interventions can be effective but uptake amongst minority ethnic groups in the UK is low and the extent of cultural adaptations to increase engagement unknown.

AIM

To explore barriers, enablers and culturally adapted lifestyle interventions in UK minority ethnic groups.

METHODS

Four electronic databases were searched from to January 2013-2023. Two independent reviewers carried out manuscript selection and data extraction. Barriers and enablers were mapped to the Capability + Opportunity + Motivation = Behaviour (COM-B) theoretical model. Intervention adaptations were linked to behaviour change strategies and reported within a Cultural Adaptation framework.

RESULTS

Twenty-three studies were included, reporting barriers/enablers, culturally adapted interventions or both. Barriers and enablers mostly mapped to social and physical opportunity, and reflective motivation. Common adaptation strategies considered behavioural influences related to culture, values, religious beliefs and/or traditions. Most impactful strategies were associated with using credible sources of information and reorganising social and environmental contexts.

DISCUSSION AND CONCLUSIONS

The current umbrella approach to preventative intervention delivery is unlikely to promote sustained participation in behaviour change amongst UK ethnic minorities. Engagement strategies for this population should consider key determinants such as social contexts, beliefs and cultural norms. Important research gaps include interventions investigating tailored interventions for Black populations, and the impact of negative social experiences (e.g., racism) on engagement.

Estimating the contribution of overweight and obesity to ethnic inequalities in cardio-metabolic diseases in the Netherlands: a simulation study

OBJECTIVES

Overweight and obesity (OWOB) starts in childhood, influences adult cardiovascular risk, and is not equally distributed across ethnic groups. It is unclear which effects can be expected from reductions in OWOB across the life course on inequalities in cardio-metabolic diseases in a multi-ethnic population. This study aims to estimate the effects of three scenarios of changes in OWOB (the Normal-Weight-for-All scenario, the No-Ethnic-Difference-over-the-Life-Course scenario, the and No-Ethnic-Differences-in-Childhood scenario).

STUDY DESIGN

A simulation study.

METHODS

We combine data from multiple data sources and use the Dynamic Modeling for Health Impact Assessment (DYNAMO-HIA) model to estimate the effects of three scenarios on the cumulative incidence of diabetes mellitus, ischaemic heart disease (IHD) and stroke between 18 and 70 years in the five largest ethnic groups in the Netherlands.

RESULTS

In the scenario where all individuals have normal weight, the cumulative incidence decreased in all ethnic minority groups for all diseases, with largest decreases among South-Asian Surinamese, where the reduction of diabetes incidence exceeded 50%. In the scenario where the prevalence of OWOB in each ethnic-minority group was reduced to the current level among the Dutch-origin population, ethnic inequalities in cardio-metabolic diseases were substantially reduced, particularly when lowered prevalence of OWOB persisted across the lifespan. Reductions were the largest for diabetes and for the Asian Surinamese population.

CONCLUSIONS

A substantial part of the well-known ethnic inequalities in incidence of diabetes, IHD, and stroke can be attributed to OWOB. Interventions aimed at reducing OWOB have clear potential to reduce the health inequalities in these outcomes, especially for diabetes, in particular when they have an impact across the lifespan.

[Chronic communicable and non-communicable pathology and skin pathology of the migrant patient]

The care of migrant patients includes initial screening and lifelong monitoring, highlighting the importance of preventing and tracking chronic, communicable and non-communicable diseases. The prevalence of hypertension, diabetes mellitus, dyslipidemia, and obesity varies by ethnicity, influenced by genetic factors, lifestyle, and socio-economic status. Preventive measures, health promotion, and risk factor identification are crucial. Chronic communicable diseases may manifest years after transmission, underscoring the necessity of primary care screening, especially for populations from endemic or high-risk areas. Imported skin lesions are a common reason for consultation among migrant and traveller patients. Their ethiology is varied, ranging from common conditions such as scabies, mycoses, and urticaria to tropical dermatoses like filariasis and leprosy.

Parental status and markers of brain and cellular age: A 3D convolutional network and classification study

Recent research shows prominent effects of pregnancy and the parenthood transition on structural brain characteristics in humans. Here, we present a comprehensive study of how parental status and number of children born/fathered links to markers of brain and cellular ageing in 36,323 UK Biobank participants (age range 44.57-82.06 years; 52% female). To assess global effects of parenting on the brain, we trained a 3D convolutional neural network on T1-weighted magnetic resonance images, and estimated brain age in a held-out test set. To investigate regional specificity, we extracted cortical and subcortical volumes using FreeSurfer, and ran hierarchical clustering to group regional volumes based on covariance. Leukocyte telomere length (LTL) derived from DNA was used as a marker of cellular ageing. We employed linear regression models to assess relationships between number of children, brain age, regional brain volumes, and LTL, and included interaction terms to probe sex differences in associations. Lastly, we used the brain measures and LTL as features in binary classification models, to determine if markers of brain and cellular ageing could predict parental status. The results showed associations between a greater number of children born/fathered and younger brain age in both females and males, with stronger effects observed in females. Volume-based analyses showed maternal effects in striatal and limbic regions, which were not evident in fathers. We found no evidence for associations between number of children and LTL. Classification of parental status showed an Area under the ROC Curve (AUC) of 0.57 for the brain age model, while the models using regional brain volumes and LTL as predictors showed AUCs of 0.52. Our findings align with previous population-based studies of middle- and older-aged parents, revealing subtle but significant associations between parental experience and neuroimaging-based surrogate markers of brain health. The findings further corroborate results from longitudinal cohort studies following parents across pregnancy and postpartum, potentially indicating that the parenthood transition is associated with long-term influences on brain health.

A Qualitative evaluation in community settings in England exploring the experiences of coaches delivering the NHS Low Calorie Diet programme pilot to ethnically diverse participants

BACKGROUND

The management of type 2 diabetes (T2D) within diverse ethnic populations requires a culturally tailored approach. However, little is known about the experiences of coaches delivering interventions for T2D, such as the National Health Service (NHS) Low Calorie Diet (LCD) programme, to people from diverse ethnic backgrounds.

OBJECTIVE

To explore the experiences of coaches delivering an NHS programme using total diet replacement approaches to individuals from diverse ethnic backgrounds, to inform the effective tailoring and equitable delivery of future interventions.

DESIGN

Qualitative study.

SETTING

Individuals delivering the NHS LCD programme.

PARTICIPANTS

One-to-one semistructured interviews were conducted with seven health coaches delivering the NHS LCD programme. Inclusion criteria included participants delivering the NHS LCD programme either from a minoritised ethnic background or delivering the programme to those from ethnic minority and white British backgrounds.

MAIN OUTCOME MEASURES

Qualitative semistructured interviews conducted through different stages of the programme. Reflexive thematic analysis was used to analyse the transcripts.

RESULTS

Key themes highlighted the following experiences of delivering the LCD programme: (1) training and support needs; (2) needing to understand culture and ethnicity; (3) the impact of language; (4) the use of resources in providing dietary advice and (5) experiences of cultural tailoring. The themes highlight the need to prioritise person-centred care, to integrate culturally tailored approaches and for provision of education and training to those delivering health programmes.

CONCLUSION

These findings describe the experiences of health coaches in tailoring delivery and emphasise the role of cultural competence in ensuring equitable and effective healthcare interventions for diverse populations. This learning can inform future programmes and policies aimed at promoting inclusive healthcare practices.

Assessment of the impact of a personalised nutrition intervention in impaired glucose regulation over 26 weeks: a randomised controlled trial

Dietary interventions can reduce progression to type 2 diabetes mellitus (T2DM) in people with non-diabetic hyperglycaemia. In this study we aimed to determine the impact of a DNA-personalised nutrition intervention in people with non-diabetic hyperglycaemia over 26 weeks. ASPIRE-DNA was a pilot study. Participants were randomised into three arms to receive either (i) Control arm: standard care (NICE guidelines) (n = 51), (ii) Intervention arm: DNA-personalised dietary advice (n = 50), or (iii) Exploratory arm: DNA-personalised dietary advice via a self-guided app and wearable device (n = 46). The primary outcome was the difference in fasting plasma glucose (FPG) between the Control and Intervention arms after 6 weeks. 180 people were recruited, of whom 148 people were randomised, mean age of 59 years (SD = 11), 69% of whom were female. There was no significant difference in the FPG change between the Control and Intervention arms at 6 weeks (- 0.13 mmol/L (95% CI [- 0.37, 0.11]), p = 0.29), however, we found that a DNA-personalised dietary intervention led to a significant reduction of FPG at 26 weeks in the Intervention arm when compared to standard care (- 0.019 (SD = 0.008), p = 0.01), as did the Exploratory arm (- 0.021 (SD = 0.008), p = 0.006). HbA1c at 26 weeks was significantly reduced in the Intervention arm when compared to standard care (- 0.038 (SD = 0.018), p = 0.04). There was some evidence suggesting prevention of progression to T2DM across the groups that received a DNA-based intervention (p = 0.06). Personalisation of dietary advice based on DNA did not result in glucose changes within the first 6 weeks but was associated with significant reduction of FPG and HbA1c at 26 weeks when compared to standard care. The DNA-based diet was effective regardless of intervention type, though results should be interpreted with caution due to the low sample size. These findings suggest that DNA-based dietary guidance is an effective intervention compared to standard care, but there is still a minimum timeframe of adherence to the intervention before changes in clinical outcomes become apparent.Trial Registration: www.clinicaltrials.gov.uk Ref: NCT03702465.

Intersectional analysis of social disparities in type 2 diabetes risk among adults in Germany: results from a nationwide population-based survey

BACKGROUND

Differences in type 2 diabetes risk have been reported for several sociodemographic determinants including sex/gender or socioeconomic status. From an intersectional perspective, it is important to not only consider the role of social dimensions individually, but also their intersections. This allows for a deeper understanding of diabetes risk and preventive needs among diverse population groups.

METHODS

As an intersectionality-informed approach, multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was used in a population-based sample of adults without known diabetes in Germany from the cross-sectional survey "Disease knowledge and information needs- Diabetes mellitus (2017)". Diabetes risk was assessed by the German Diabetes Risk Score (GDRS, range 0-122 points), estimating the individual risk of developing type 2 diabetes within the next 5 years based on established self-reported risk factors. Nesting individuals in 12 intersectional strata defined by combining sex/gender, educational level, and history of migration, we calculated measures to quantify the extent to which individual differences in diabetes risk were explained at strata level, and how much this was due to additive or multiplicative intersectional effects of social determinants.

RESULTS

Drawing on data of 2,253 participants, we found good discriminatory accuracy of intersectional strata (variance partition coefficient = 14.00% in the simple intersectional model). Model-predicted GDRS means varied between 29.97 (corresponding to a "low risk" of < 2%) in women with high educational level and a history of migration, and 52.73 ("still low risk" of 2-5%) in men with low educational level without a history of migration. Variance in GDRS between strata was mainly explained by additive effects of social determinants (proportional change in variance to intersectional interaction model = 77.95%) with being male and having low educational level being associated with higher GDRS. There was no evidence of multiplicative effects in individual strata.

CONCLUSIONS

Type 2 diabetes risk differed between intersectional strata and can to some extent be explained at strata level. The role of intersectional effects was minor and needs to be further investigated. Findings suggest a need for specific preventive measures targeted at large groups with increased diabetes risk, such as men and persons with low educational level.

Multi-Centre UK Analysis of Simultaneous Pancreas and Kidney (SPK) Transplant in Recipients With Type 2 Diabetes Mellitus

90% of the UK diabetic population are classified as T2DM. This study aims to compare outcomes after SPK transplant between recipients with T1DM or T2DM. Data on all UK SPK transplants from 2003-2019 were obtained from the NHSBT Registry (n = 2,236). Current SPK transplant selection criteria for T2DM requires insulin treatment and recipient BMI < 30 kg/m2. After exclusions (re-transplants/ambiguous type of diabetes) we had a cohort of n = 2,154. Graft (GS) and patient (PS) survival analyses were conducted using Kaplan-Meier plots and Cox-regression models. Complications were compared using chi-squared analyses. 95.6% of SPK transplants were performed in recipients with T1DM (n = 2,060). Univariate analysis showed comparable outcomes for pancreas GS at 1 year (p = 0.120), 3 years (p = 0.237), and 10 years (p = 0.196) and kidney GS at 1 year (p = 0.438), 3 years (p = 0.548), and 10 years (p = 0.947). PS was comparable at 1 year (p = 0.886) and 3 years (p = 0.237) and at 10 years (p = 0.161). Multi-variate analysis showed comparable outcomes in pancreas GS (p = 0.564, HR 1.221, 95% CI 0.619, 2.406) and PS(p = 0.556, HR 1.280, 95% CI 0.563, 2.911). Comparable rates of common complications were demonstrated. This is the largest series outside of the US evaluating outcomes after SPK transplants and shows similar outcomes between T1DM and T2DM recipients. It is hoped dissemination of this data will lead to increased referral rates and assessment of T2DM patients who could benefit from SPK transplantation.

Call to action on diabetes care: reaching communities facing health inequalities, health inequities and deprivation

This article presents evidence and policy on the importance of reaching out into local communities with inclusive approaches to try to reduce and prevent inequities and inequalities in diabetes care. The global emergency diabetes is causing and the risks and disproportionately high ethnic disparities are investigated. The article includes some suggestions on changing approaches to reduce health inequalities to enable diabetes care to become more accessible for those who need it the most.

Prevalence of prediabetes in patients with idiopathic frozen shoulder: a prospective study

Background

The association between diabetes and frozen shoulder is well established. However, the data regarding prediabetes and primary frozen shoulder (PFS) are still lacking.

Methods

In a prospective study, 158 patients with PFS were included. The prediabetes status was ascertained by estimating serum hemoglobin A1c (HbA1c) levels in patients with PFS. According to the level of HbA1c, patients were classified into normoglycemic, prediabetic, and diabetic. In addition, random blood sugar (RBS) was also performed.

Results

Out of 158 participants, 84 (53.2%) were male and 74 (46.8%) were female. Nine patients had bilateral shoulder involvement, and all were diabetics; 47.5% (n = 75) of the patients were in the age group of 51-60 years, 16.5% (n = 26) of the participants were normoglycemic, 37.3% (n = 59) were prediabetics, and 46.2% (n = 73) were diabetics. The difference in mean HbA1c values between the 3 groups was statistically significant (P < .001). However, there was no statistical difference in various age groups (P = .86) or gender (P = .68) between normoglycemics, prediabetics, and diabetics. The difference in mean RBS values between diabetic-nondiabetic and diabetic-prediabetic groups were statistically significant (P < .001), whereas no significant difference was detected between nondiabetic and prediabetic (P = .355).

Conclusion

The prevalence of prediabetes is 37.5% in patients with PFS. Single-point HbA1c estimation is an acceptable tool to detect prediabetes, whereas RBS estimation should not be used to detect prediabetes.

Missed Opportunities in Type 2 Diabetes Mellitus: A Narrative Review

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a significant health problem around the world.

OBJECTIVE

This review aims to define missed opportunities and how they apply to patients with T2DM.

METHOD

This narrative review describes the natural history of T2DM and also describes where missed opportunities may arise.

RESULTS

Missed opportunities may relate to prevention, early detection, diagnosis, and treatment of diabetes. The cornerstone of T2DM prevention is the control of modifiable risk factors and lifestyle changes to potentially prevent diabetes. Early detection of T2DM is important as it is a chronic condition that can progress rapidly if untreated. Missed opportunities related to the diagnosis of T2DM draw attention to the heterogeneous presentation of diabetes. The condition can be incidentally identified in asymptomatic patients, so all healthcare professionals should be aware of the disease. Furthermore, it is not unexpected that patients with atypical symptoms may have a delay in diagnosis. The treatment-related missed opportunities in T2DM are broad and include self-care, education, remission of T2DM, risk factor management, prevention of complications, medication therapy and compliance, as well as individualized care. Considering patient pathways is a useful approach to evaluate missed opportunities in patient care.

CONCLUSION

Missed opportunities are a concept that is not often considered in diabetes care, which calls upon reflection of real-world activities and consideration of whether patient outcomes could have been improved with changes in decision-making. Future studies that aim to improve patient care should consider this concept.

Sick individuals, sick populations revisited: a test of the Rose hypothesis for type 2 diabetes disparities

Introduction

The Rose hypothesis predicts that since genetic variation is greater within than between populations, genetic risk factors will be associated with individuals' risk of disease but not population disparities, and since socioenvironmental variation is greater between than within populations, socioenvironmental risk factors will be associated with population disparities but not individuals' disease risk.

Methods

We used the UK Biobank to test the Rose hypothesis for type 2 diabetes (T2D) ethnic disparities in the UK. Our cohort consists of 26 912 participants from Asian, black and white ethnic groups. Participants were characterised as T2D cases or controls based on the presence or absence of T2D diagnosis codes in electronic health records. T2D genetic risk was measured using a polygenic risk score (PRS), and socioeconomic deprivation was measured with the Townsend Index (TI). The variation of genetic (PRS) and socioeconomic (TI) risk factors within and between ethnic groups was calculated using analysis of variance. Multivariable logistic regression was used to associate PRS and TI with T2D cases, and mediation analysis was used to analyse the effect of PRS and TI on T2D ethnic group disparities.

Results

T2D prevalence differs for Asian 23.34% (OR=5.14, CI=4.68 to 5.65), black 16.64% (OR=3.81, CI=3.44 to 4.22) and white 7.35% (reference) ethnic groups in the UK. Both genetic and socioenvironmental T2D risk factors show greater within (w) than between (b) ethnic group variation: PRS w=64.60%, b=35.40%; TI w=71.18%, b=28.19%. Nevertheless, both genetic risk (PRS OR=1.96, CI=1.87 to 2.07) and socioeconomic deprivation (TI OR=1.09, CI=1.08 to 1.10) are associated with T2D individual risk and mediate T2D ethnic disparities (Asian PRS=22.5%, TI=9.8%; black PRS=32.0%, TI=25.3%).

Conclusion

A relative excess of within-group versus between-group variation does not preclude T2D risk factors from contributing to T2D ethnic disparities. Our results support an integrative approach to health disparities research that includes both genetic and socioenvironmental risk factors.

Cardiometabolic health across menopausal years is linked to white matter hyperintensities up to a decade later

Introduction

The menopause transition is associated with several cardiometabolic risk factors. Poor cardiometabolic health is further linked to microvascular brain lesions, which can be detected as white matter hyperintensities (WMHs) using T2-FLAIR magnetic resonance imaging (MRI) scans. Females show higher risk for WMHs post-menopause, but it remains unclear whether changes in cardiometabolic risk factors underlie menopause-related increase in brain pathology.

Methods

In this study, we assessed whether cross-sectional measures of cardiometabolic health, including body mass index (BMI) and waist-to-hip ratio (WHR), blood lipids, blood pressure, and long-term blood glucose (HbA1c), as well as longitudinal changes in BMI and WHR, differed according to menopausal status at baseline in 9,882 UK Biobank females (age range 40-70 years, n premenopausal = 3,529, n postmenopausal = 6,353). Furthermore, we examined whether these cardiometabolic factors were associated with WMH outcomes at the follow-up assessment, on average 8.78 years after baseline.

Results

Postmenopausal females showed higher levels of baseline blood lipids (HDL β  = 0.14, p < 0.001, LDL β  = 0.20, p < 0.001, triglycerides β  = 0.12, p < 0.001) and HbA1c (β  = 0.24, p < 0.001) compared to premenopausal women, beyond the effects of age. Over time, BMI increased more in the premenopausal compared to the postmenopausal group (β  = -0.08, p < 0.001), while WHR increased to a similar extent in both groups (β  = -0.03, p = 0.102). The change in WHR was however driven by increased waist circumference only in the premenopausal group. While the group level changes in BMI and WHR were in general small, these findings point to distinct anthropometric changes in pre- and postmenopausal females over time. Higher baseline measures of BMI, WHR, triglycerides, blood pressure, and HbA1c, as well as longitudinal increases in BMI and WHR, were associated with larger WMH volumes (β range = 0.03-0.13, p ≤ 0.002). HDL showed a significant inverse relationship with WMH volume (β  = -0.27, p < 0.001).

Discussion

Our findings emphasise the importance of monitoring cardiometabolic risk factors in females from midlife through the menopause transition and into the postmenopausal phase, to ensure improved cerebrovascular outcomes in later years.

Investigating inequalities in men's health: a literature review

As part of a project to review the delivery of healthcare services in Torbay and South Devon, England, the author undertook a literature review focusing on the specialty of men's health. Men have a shorter life expectancy than women and this discrepancy is particularly pronounced in areas of social deprivation such as those found in the coastal and rural communities of the author's locality. The concept of men's health is complex, and this literature review identified five main themes that can have a significant influence on the delivery of healthcare services for men: masculinity, ethnicity, mental health, relevance of place, and access to services. In this article, the author discusses these themes and considers approaches that could be used to improve the provision of men's healthcare.

Beta cell lipotoxicity in the development of type 2 diabetes: the need for species-specific understanding

The propensity to develop type 2 diabetes (T2D) is known to have both environmental and hereditary components. In those with a genetic predisposition to T2D, it is widely believed that elevated concentrations of circulatory long-chain fatty acids (LC-FFA) significantly contribute towards the demise of insulin-producing pancreatic β-cells - the fundamental feature of the development of T2D. Over 25 years of research support that LC-FFA are deleterious to β-cells, through a process termed lipotoxicity. However, the work underpinning the theory of β-cell lipotoxicity is mostly based on rodent studies. Doubts have been raised as to whether lipotoxicity also occurs in humans. In this review, we examine the evidence, both in vivo and in vitro, for the pathogenic effects of LC-FFA on β-cell viability and function in humans, highlighting key species differences. In this way, we aim to uncover the role of lipotoxicity in the human pathogenesis of T2D and motivate the need for species-specific understanding.

Two-year recall for people with no diabetic retinopathy: a multi-ethnic population-based retrospective cohort study using real-world data to quantify the effect

BACKGROUND/AIMS

The English Diabetic Eye Screening Programme (DESP) offers people living with diabetes (PLD) annual screening. Less frequent screening has been advocated among PLD without diabetic retinopathy (DR), but evidence for each ethnic group is limited. We examined the potential effect of biennial versus annual screening on the detection of sight-threatening diabetic retinopathy (STDR) and proliferative diabetic retinopathy (PDR) among PLD without DR from a large urban multi-ethnic English DESP.

METHODS

PLD in North-East London DESP (January 2012 to December 2021) with no DR on two prior consecutive screening visits with up to 8 years of follow-up were examined. Annual STDR and PDR incidence rates, overall and by ethnicity, were quantified. Delays in identification of STDR and PDR events had 2-year screening intervals been used were determined.

FINDINGS

Among 82 782 PLD (37% white, 36% South Asian, and 16% black people), there were 1788 incident STDR cases over mean (SD) 4.3 (2.4) years (STDR rate 0.51, 95% CI 0.47 to 0.55 per 100-person-years). STDR incidence rates per 100-person-years by ethnicity were 0.55 (95% CI 0.48 to 0.62) for South Asian, 0.34 (95% CI 0.29 to 0.40) for white, and 0.77 (95% CI 0.65 to 0.90) for black people. Biennial screening would have delayed diagnosis by 1 year for 56.3% (1007/1788) with STDR and 43.6% (45/103) with PDR. Standardised cumulative rates of delayed STDR per 100 000 persons for each ethnic group were 1904 (95% CI 1683 to 2154) for black people, 1276 (95% CI 1153 to 1412) for South Asian people, and 844 (95% CI 745 to 955) for white people.

INTERPRETATION

Biennial screening would have delayed detection of some STDR and PDR by 1 year, especially among those of black ethnic origin, leading to healthcare inequalities.

Developing a Culturally Appropriate Tool to Support Self-Care in Migrants with Type 2 Diabetes - A Co-Design Study

Introduction

Migrants, especially from the Middle East, experience poorer health outcomes and face greater difficulties in accessing healthcare compared to native populations and there is a need for culturally appropriate education for this vulnerable group. The purpose of this study is to describe the process of developing a culturally appropriate tool to support self-care in migrants with type 2 diabetes.

Methods

In this Co-design study, a tool for supporting self-care in migrants with type 2 diabetes was developed. Migrant patients with type 2 diabetes, healthcare providers and researchers participated in the process, which was based on six elements; engage, plan, explore, develop, decide and change. From February 2021 to December 2022, idea groups were conducted, and a tool was developed through brainstorming, prioritizing and prototyping.

Results

In total, 14 migrant patients, ten health care providers and four researchers participated in the Co-design process. The patients wished to receive information about type 2 diabetes self-care behaviour in their own languages. The healthcare providers asked for clear instructions on where to guide their patients regarding reliable information about diabetes in the patient's own language. All participants agreed that information can be presented in different formats, either: text (paper or online), audio-visual via recorded videos and/or lectures and pictures.

Discussion

The Co-design process led to several important insights and experiences related to the importance of diverse cultural backgrounds. When conducting a Co-design study with end-users as stakeholders, it is significant that the stakeholders have a diverse background in experiences, both as patients as well as those who deliver or implement the health service. In this study it was of great importance to include patients with diverse backgrounds regarding; gender, age, health literacy, occupation, years living in Sweden and duration of diabetes.

Understanding the influence of ethnicity on adherence to antidiabetic medication: Meta-ethnography and systematic review

INTRODUCTION

A high prevalence of diabetes and diabetes-related complications in people from minority ethnic communities in high income countries is of significant concern. Several studies have indicated low adherence rates to antidiabetic medication in ethnic minority groups. Poor adherence to antidiabetic medication leads to a higher risk of complications and potential mortality. This review aims to qualitatively explore the barriers to and facilitators of adherence to antidiabetic medication among ethnic minority groups in high-income countries.

METHODS

A comprehensive search of MEDLINE, Embase, CINAHL, PsycINFO, and Global Health databases for qualitative studies exploring the barriers to or facilitators of adherence to antidiabetic medication in minority ethnic groups was conducted from database inception to March 2023 (PROSPERO CRD42022320681). A quality assessment of the included studies was conducted using the Critical Appraisal Skills Programme (CASP) tool. Key concepts and themes from relevant studies were synthesised using a meta-ethnographic approach. The Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach was used to assess the Confidence in the review findings.

RESULT

Of 13,994 citations screened, 21 studies that included primary qualitative studies were selected, each of which involved people from minority ethnic communities from eight high income countries. This qualitative evidence synthesis has identified three overarching themes around the barriers to and facilitators of adherence to antidiabetic medication among ethnic minority groups.: 1) cultural underpinnings, 2) communication and building relationships, and 3) managing diabetes during visiting home countries. Based on the GRADE-CERQual assessment, we had mainly moderate- and high-confidence findings.

CONCLUSION

Multiple barriers and facilitators of adherence to antidiabetic medication among people from minority ethnic communities in high-income countries have been identified. A medication adherence intervention focusing on identified barriers to adherence to antidiabetic medication in these communities may help in improving diabetes outcomes in these groups.

Influence of autozygosity on common disease risk across the phenotypic spectrum

Autozygosity is associated with rare Mendelian disorders and clinically relevant quantitative traits. We investigated associations between the fraction of the genome in runs of homozygosity (FROH) and common diseases in Genes & Health (n = 23,978 British South Asians), UK Biobank (n = 397,184), and 23andMe. We show that restricting analysis to offspring of first cousins is an effective way of reducing confounding due to social/environmental correlates of FROH. Within this group in G&H+UK Biobank, we found experiment-wide significant associations between FROH and twelve common diseases. We replicated associations with type 2 diabetes (T2D) and post-traumatic stress disorder via within-sibling analysis in 23andMe (median n = 480,282). We estimated that autozygosity due to consanguinity accounts for 5%-18% of T2D cases among British Pakistanis. Our work highlights the possibility of widespread non-additive genetic effects on common diseases and has important implications for global populations with high rates of consanguinity.

Causal relationship between type 2 diabetes mellitus and bone mineral density: a Mendelian randomization study in an East Asian population

It remains unclear whether the relationship between type 2 diabetes mellitus (T2DM) and bone mineral density (BMD) reflects causality in East Asian populations. Herein, a Mendelian randomization study conducted in East Asian population enhances the current clinical cognition that T2DM is not associated with reduction in BMD.

PURPOSE

A Mendelian randomization (MR) approach was utilized to investigate the relationship between type 2 diabetes mellitus (T2DM) and bone mineral density (BMD) in East Asian populations.

METHODS

Genome-wide association study summary data from BioBank Japan were used to identify genetic variants strongly related to T2DM risk (36,614 cases and 155,150 controls) and osteoporosis (7788 cases and 204,665 controls). Heel BMD GWAS data of 1260 East Asian people from ieu open gwas project was considered as a second outcome. Inverse variance-weighted (IVW) analysis was mainly applied; MR-Egger and the weighted median were also used to obtain robust estimates. A series of sensitivity analyses including Cochran's Q test, MR-Egger regression, and leave-one-out analysis were used to detect pleiotropy or heterogeneity.

RESULTS

In the main analysis, IVW estimates indicated that T2DM significantly associated with the risk of osteoporosis (odds ratio = 0.92, 95% CI: 0.86-0.99, p = 0.016) and with higher BMD (OR: 1.25, 95% CI: 1.06-1.46, p = 6.49 × 10-3). Results of comprehensive sensitivity analysis were consistent with the main causality estimate. Horizontal pleiotropy and heterogeneity were absent in our MR study.

CONCLUSIONS

T2DM is not associated with reduction in BMD in terms of genetic polymorphism in East Asian populations.

A Culturally Adapted Diet and Physical Activity Text Message Intervention to Prevent Type 2 Diabetes Mellitus for Women of Pakistani Origin Living in Scotland: Formative Study

BACKGROUND

Individuals of South Asian origin are at an increased risk of developing type 2 diabetes mellitus (T2DM) compared with other ethnic minority groups. Therefore, there is a need to develop interventions to address, and reduce, this heightened risk.

OBJECTIVE

We undertook formative work to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland.

METHODS

We used a stepwise approach that was informed by the Six Steps in Quality Intervention Development framework, which consisted of gathering evidence through literature review and focus groups (step 1), developing a program theory for the intervention (step 2), and finally developing the content of the text messages and an accompanying delivery plan (step 3).

RESULTS

In step 1, we reviewed 12 articles and identified 3 key themes describing factors impacting on diet and physical activity in the context of T2DM prevention: knowledge on ways to prevent T2DM through diet and physical activity; cultural, social, and gender norms; and perceived level of control and sense of inevitability over developing T2DM. The key themes that emerged from the 3 focus groups with a total of 25 women were the need for interventions to provide "friendly encouragement," "companionship," and a "focus on the individual" and also for the text messages to "set achievable goals" and include "information on cooking healthy meals." We combined the findings of the focus groups and literature review to create 13 guiding principles for culturally adapting the text messages. In step 2, we developed a program theory, which specified the main determinants of change that our text messages should aim to enhance: knowledge and skills, sense of control, goal setting and planning behavior, peer support, and norms and beliefs guiding behavior. In step 3, we used both the intervention program theory and guiding principles to develop a set of 73 text messages aimed at supporting a healthy diet and 65 text messages supporting increasing physical activity.

CONCLUSIONS

We present a theory-based approach to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. This study outlines an approach that may also be applicable to the development of interventions for other ethnic minority populations in diverse settings. There is now a need to build on this formative work and undertake a feasibility trial of a text message-based diet and physical activity intervention to prevent T2DM for women of Pakistani origin living in Scotland.

Dietary management of type 2 diabetes mellitus among South Asian immigrants: A mixed-methods study

AIMS

There is a high prevalence of South Asian immigrants in Australia living with type 2 diabetes mellitus, with the dietary management of the condition presenting as a key challenge. However, their current dietary patterns and barriers to diabetes self-management are unclear. Therefore, this study aims to (i) investigate current dietary patterns and (ii) explore barriers and facilitators to dietary management in this population.

METHODS

A concurrent mixed-methods study comprising three 24-h dietary recalls and a semi-structured interview for each self-identified South Asian immigrant adult with diabetes recruited across Victorian primary care clinics and social media to address the aforementioned two aims. Dietary recall data were converted into food groups using Foodworks, and data analysed in SPSS. Qualitative data were thematically analysed using NVivo.

RESULTS

Among 18 participants recruited, 14, 16 and 17 participants had grain, fruit and dairy intake lower than daily Australian recommendations, respectively. These findings echoed qualitative data that participants viewed diabetes management as reducing carbohydrate intake. Participants reported difficulties incorporating diabetes-related dietary and lifestyle recommendations into their routine and a lack of knowledge about available organisational support. They mentioned challenges in receiving social support from families and friends and relied on support from health professionals. Facilitators included proficiency in nutrition information label reading and self-blood glucose monitoring skills.

CONCLUSION

Enhancing the accessibility to organisational support, facilitating the adaption of dietary recommendations into individuals' routines, and strengthening support from health professionals are essential components in intervention development to improve diabetes management for South Asians.

Type 1 diabetes in North East England and North Cumbria: patterns and time trends in 0-14-year-olds from 2012 to 2020

Introduction

It is important to understand patterns in the epidemiology of type 1 diabetes because they may provide insight into its etiology. We examined the incidence of type 1 diabetes in children aged 0-14 years, and patient demographics and clinical parameters at presentation, over the period 2012-2020 using the North East and North Cumbria Young Persons diabetes register.

Methods

Patients up to the age of 14 years with type 1 diabetes, and their families- managed in a total of 18 young persons diabetes clinics-were approached in person at the time of clinic appointments or in the days following diagnosis and they consented to their data being included in the register. Data were submitted regionally to a central unit. Descriptive statistics including crude and age-specific incidence rates were calculated. Temporal trends were analyzed using Joinpoint regression. Comparisons in incidence rates were made between age, sex and areas of higher and lower affluence as measured by the Index of Multiple Deprivation (IMD).

Results

A total of 943 cases were recorded between January 2012 and December 2020. Median age at diagnosis was 8.8 years (Q1: 5.3, Q3: 11.7). There were more males than females (54% male). The median HbA1c at diagnosis was 100 mmoL/L (IQR: 39) and over one third (35%) were in ketoacidosis (pH < 7.3). Crude incidence decreased from 25.5 (95% confidence interval [CI] 20.9, 29.9) in 2012 to 16.6 (95% CI: 13.0, 20.2) per 100,000 in 2020 (5.1% per annum, 95% CI 1.1, 8.8%). During the period of the study there was no evidence of any trends in median age, HbA1c, BMI or birthweight (p = 0.18, 0.80, 0.69, 0.32) at diagnosis. Higher rates were observed in males aged 10-14 years, but similar rates were found for both sexes aged 0-9 years and there was no difference between areas of higher or lower deprivation (p = 0.22).

Conclusion

The incidence of diabetes in the young may be falling in the North East of England and North Cumbria. The reasons are unclear as there were no associations identified between levels of deprivation or anthropometric measurements. Potential mechanisms include alterations in socioeconomic background or growth pattern. Further research is needed to understand the reasons behind this finding.

Decisional Needs of People From Minority Ethnic Groups Around Living Donor Kidney Transplantation: A UK Healthcare Professionals' Perspective

Despite improved patient and clinical outcomes, living donor kidney transplantation is underutilized in the United Kingdom, particularly among minority ethnic groups, compared to deceased donor kidney transplantation. This may in part be due to the way in which kidney services present information about treatment options. With a focus on ethnicity, semi structured interviews captured the views of 19 kidney healthcare professionals from two renal centres in West Yorkshire, about the decisional needs and context within which people with advanced kidney disease make transplant decisions. Data were analysed using thematic analysis. Themes were categorized into three groups: 1) Kidney healthcare professionals: language, cultural awareness, trusted personnel, and staff diversity, 2) Patient information resources: timing and setting of education and suitability of patient-facing information and, 3) People with advanced kidney disease: knowledge, risk perception, and cultural/religious beliefs. To our knowledge, this is the first study in the United Kingdom to investigate in depth, healthcare professionals' views on living donor kidney transplantation decision making. Six recommendations for service improvement/delivery to support decision making around living donor kidney transplantation among minority ethnic groups are described.

Examining the Role of the Health Belief Model Framework in Achieving Diversity and Equity in Organ Donation Among South Asians in the United Kingdom

Organ donation continues to be low among ethnic minorities in the United Kingdom (UK), especially within the South Asian community, with a disproportionate number of patients of South Asian ethnicity awaiting organ transplants. In 2020/21, Minority Ethnic (ME) patients comprised almost a third of the national transplant waiting list, highlighting the continued imbalance between the need for transplants in South Asian communities and the availability of suitable organs. Median waiting times for transplants show that, generally, white patients wait less time than ME patients; Only 39.5% of ME families consented to proceed with deceased organ donation when approached compared to 69% of white families. How to increase awareness among the South Asian community on the scarcity of organ donors continues to be a growing challenge facing the healthcare system in the UK and globally. This article reflects on the education strategy implemented using the Health Belief Model. It provides a detailed framework with which to consider the rationale that led to a specific behaviour, in this case organ donation among the three major ethnicities (i.e., Indian, Pakistani, Bangladeshi) within the South Asian community as part of a single study.

Implementation of a diabetes prevention programme in a multi-ethnic community in primary care in England: An evaluation using constructs from the RE-AIM Framework

AIMS

To implement a diabetes prevention programme in primary care METHODS: The programme was implemented for 12 months in two neighbouring towns, served by eight general practices. Practices requested a referral pathway involving an external administrator running electronic searches and sending postal invitations. If interested, people called and booked a place on the programme. Practices were also provided with resources to refer people directly. Six Educators were trained to deliver the programme. The RE-AIM constructs "Adoption", "Reach" and "Uptake" were assessed.

RESULTS

All practices engaged in the searches and postal invitations. Overall, 3.9 % of those aged ≥ 25 years had an HbA1c level indicative of non-diabetic hyperglycaemia (NDH) and were invited. Overall uptake (attended as percentage of invited) was 16 % (practice range 10.5-26.6 %) and was highest in two practices where the invitation was followed by a telephone call. Four people were referred directly by their practice. Groups at risk of being excluded were the Bengali population and those unable to attend because of issues such as health, mobility and frailty.

CONCLUSIONS

Comprehensive electronic searches meant everyone previously diagnosed with NDH was invited to attend. Follow-up telephone call improved uptake and providing practices with resources to make these calls themselves would likely increase uptake further.

"We Eat Without Thinking: We Just Eat, Eat, Eat" - A Thematic Exploration of Cultural Practices of Ethnically Diverse Youth and Their Parents Who Are at Risk for Prediabetes and Type 2 Diabetes

PURPOSE

Cultural beliefs and practices influence management of type 2 diabetes (T2D) in youth and their parents, and have been minimally explored, limiting our understanding and implementation of preventative healthcare. An enhanced evidence base may inform comprehensive, effective community health nursing (CHN). Thus, the purpose of this research was to explore the influence of youths' and their parents' understandings of cultural practices on risk for prediabetes and T2D.

DESIGN

A secondary thematic analysis was conducted. Qualitative data were obtained from semi-structured interviews with 24 participants who were purposefully recruited from two mid-western Canadian high schools.

FINDINGS

Three themes and one subtheme were developed including: 1) Food Culture and related subtheme, Acculturation to New Food Choices; 2) Exercise Culture: Adapting Physical Activity in a New Country; and, 3) Risk Perception of the Effects of T2D on Loved Ones: Behavior Modifications and Motivation. Cultural practices and acculturation to food such as dietary choices, preparation, large portions, different dietary staples, food availability, and food gathering patterns influenced health behaviors. Similarly, changes in exercise patterns including adapting to Western video game culture, weather in Canada, and the new way of life emerged as important factors that impacted health. Participants who perceived a familial risk of diabetes identified behavior modifications such as regular diabetes screening, nutrition counseling, healthier food choices, smaller food portions, and an increase in physical activity as strategies to reduce risk of prediabetes and diabetes.

CONCLUSIONS

There is a critical need for research aimed at prediabetes and T2D prevention, and intervention programs targeting ethnically diverse groups where prediabetes and T2D is most prevalent.

CLINICAL EVIDENCE

Community health nurses are at the core of implementing and supporting disease prevention and, therefore, may consider the findings from this research to develop family-focused, intergenerational, and culturally-based interventions.

Variations in all-cause mortality, premature mortality and cause-specific mortality among persons with diabetes in Ontario, Canada

INTRODUCTION

Patients with diabetes have a higher risk of mortality compared with the general population. Large population-based studies that quantify variations in mortality risk for patients with diabetes among subgroups in the population are lacking. This study aimed to examine the sociodemographic differences in the risk of all-cause mortality, premature mortality, and cause-specific mortality in persons diagnosed with diabetes.

RESEARCH DESIGN AND METHODS

We conducted a population-based cohort study of 1 741 098 adults diagnosed with diabetes between 1994 and 2017 in Ontario, Canada using linked population files, Canadian census, health administrative and death registry databases. We analyzed the association between sociodemographics and other covariates on all-cause mortality and premature mortality using Cox proportional hazards models. A competing risk analysis using Fine-Gray subdistribution hazards models was used to analyze cardiovascular and circular mortality, cancer mortality, respiratory mortality, and mortality from external causes of injury and poisoning.

RESULTS

After full adjustment, individuals with diabetes who lived in the lowest income neighborhoods had a 26% (HR 1.26, 95% CI 1.25 to 1.27) increased hazard of all-cause mortality and 44% (HR 1.44, 95% CI 1.42 to 1.46) increased risk of premature mortality, compared with individuals with diabetes living in the highest income neighborhoods. In fully adjusted models, immigrants with diabetes had reduced risk of all-cause mortality (HR 0.46, 95% CI 0.46 to 0.47) and premature mortality (HR 0.40, 95% CI 0.40 to 0.41), compared with long-term residents with diabetes. Similar HRs associated with income and immigrant status were observed for cause-specific mortality, except for cancer mortality, where we observed attenuation in the income gradient among persons with diabetes.

CONCLUSIONS

The observed mortality variations suggest a need to address inequality gaps in diabetes care for persons with diabetes living in the lowest income areas.

Effect of lifestyle intervention on HbA1c levels in overweight and obese adults with type 2 diabetes across ethnicities: A systematic review and meta-analysis of randomized controlled trials

AIMS

Weight reduction is fundamental for the management and remission of diabetes. We aimed to assess ethnic differences in the effects of lifestyle weight-loss interventions on HbA1c levels in overweight or obese adults with type 2 diabetes mellitus (T2DM).

METHODS

We systematically searched PubMed/MEDLINE and Web of Science online databases up to 31 Dec 2022. Randomized controlled trials using lifestyle weight-loss interventions in overweight or obese adults with T2DM were selected. We performed subgroup analyses to explore the heterogeneity across different ethnicities (Asians, White/Caucasians, Black/Africans and Hispanics). A random effects model was applied to calculate weighted mean difference (WMD) with 95% confidence interval (CI).

RESULTS

Thirty studies including 7580 subjects from different ethnicities were identified according to the predefined inclusion and exclusion criteria. HbA1c levels were significantly reduced by lifestyle weight-loss intervention. Notably, a significantly beneficial effect on HbA1c was observed in White/Caucasians (WMD = -0.59, 95% CI: -0.90, -0.28, P < 0.001) and Asians (WMD = -0.48, 95% CI: -0.63, -0.33, P < 0.001), but not in the Black/African or Hispanic group (both P > 0.05). The findings remained essentially unchanged in the sensitivity analysis.

CONCLUSIONS

Lifestyle weight-loss interventions had distinct beneficial effects on HbA1c levels in different ethnic groups with T2DM, especially in Caucasians and Asians.

HbA1c screening for diabetes mellitus and to evaluate diabetic control in people of African ancestry with HIV in South London

We evaluated glycaemic status in 948 Black adults with HIV and report a high prevalence of dysglycaemia (37.2%). HbA1c testing identified 38 (4.0%) individuals not previously known to have diabetes mellitus (DM) and showed suboptimal or poor glycaemic control in more than half of those with a prior DM diagnosis despite high levels of HIV control.

Exercise in the Prevention and Treatment of Type 2 Diabetes

Type 2 diabetes is a systemic, multifactorial disease that is a leading cause of morbidity and mortality globally. Despite a rise in the number of available medications and treatments available for management, exercise remains a first-line prevention and intervention strategy due to established safety, efficacy, and tolerability in the general population. Herein we review the predisposing risk factors for, prevention, pathophysiology, and treatment of type 2 diabetes. We emphasize key cellular and molecular adaptive processes that provide insight into our evolving understanding of how, when, and what types of exercise may improve glycemic control. © 2023 American Physiological Society. Compr Physiol 13:1-27, 2023.

Ethnic disparities in medication adherence? A systematic review examining the association between ethnicity and antidiabetic medication adherence

OBJECTIVES

Adherence to prescribed medication is an essential component of diabetes management to obtain optimal outcomes. Understanding the relationship between medication adherence and ethnicity is key to optimising treatment for all people with different chronic illnesses, including those with diabetes. The aim of this review is to examine whether the adherence to antidiabetic medications differed by ethnicity among people with diabetes.

METHODS

A systematic review was conducted of studies reporting adherence to antidiabetic medication amongst people from different ethnic groups. MEDLINE, Embase, CINAHL, and PsycINFO were searched from their inception to June 2022 for quantitative studies with a specific focus on studies assessing adherence to antidiabetic medications (PROSPERO: CRD42021278392). The Joanna Briggs Institute critical appraisal checklist and a second checklist designed for studies using retrospective databases were used to assess study quality. A narrative synthesis approach was used to summarize the results based on the medication adherence measures.

RESULTS

Of 17,410 citations screened, 41 studies that included observational retrospective database research and cross-sectional studies were selected, each of which involved diverse ethnic groups from different settings. This review identified a difference in the adherence to antidiabetic medications by ethnicity in 38 studies, despite adjustment for several confounding variables that may otherwise explain these differences.

CONCLUSION

This review revealed that adherence to antidiabetic medication differed by ethnicity. Further research is needed to explore the ethnicity-related factors that may provide an explanation for these disparities.

Obesity, diabetes mellitus, and pancreatic carcinogenesis: Correlations, prevention, and diagnostic implications

The prevalence of obesity, diabetes mellitus (DM), and pancreatic cancer (PC) has been consistently increasing in the last two decades worldwide. Sharing various influential risk factors in genetics and environmental inducers in pathogenesis, the close correlations of these three diseases have been demonstrated in plenty of clinical studies using multiple parameters among different populations. On the contrary, most measures aimed to manage and treat obesity and DM effectively reduce the risk and prevent PC occurrence, yet certain drugs can inversely promote pancreatic carcinogenesis instead. Most importantly, an elevation of blood glucose with or without a reduction in body weight, along with other potential tools, may provide valuable clues for detecting PC at an early stage in patients with obesity and DM, favoring a timely intervention and prolonging survival. Herein, the epidemiological and etiological correlations among these three diseases and the supporting clinical evidence of their connections are first summarized to favor a better and more thorough understanding of obesity- and DM-related pancreatic carcinogenesis. After comparing the distinct impacts of different weight-lowering and anti-diabetic treatments on the risk of PC, the possible diagnostic implications of hyperglycemia and weight loss in PC screening are also addressed in detail.

Ethnic differences in risk factors and prevalence of type 2 diabetes in the adult population of the Russian Federation

BACKGROUND: Russia is one of the most multinational states in the world. Identification of ethnic groups with a higher risk of developing DM2, analysis of risk factors for the development of DM2 will allow developing personalized approaches to the prevention and treatment of DM2.

AIMS: To reveal ethnic features of the prevalence of carbohydrate metabolism disorders and risk factors for the development of DM2 in the adult population of the Russian Federation.

MATERIALS AND METHODS. A retrospective analysis of the database of the national epidemiological cross-sectional study NATION was carried out. Depending on the self-specified nationality, on the basis of anthropological characteristics, the following ethnic groups were identified: “Mongoloid population”, “Peoples of the Volga region”, “Peoples of the North Caucasus”, “Peoples of Transcaucasia”, “Russians”. The analysis consisted of several stages and included: analysis of the anthropometric features of the selected groups, taking into account the presence of carbohydrate metabolism disorders (MO); study of the prevalence of violations of the MA in the selected ethnic groups; analysis of ethnic characteristics of risk factors for the development of type 2 diabetes; analysis of the frequency of violations of the MA in various ethnic groups, taking into account the territory of residence. MR disorders were defined as the presence of DM and/or prediabetes. In accordance with the WHO criteria, HbA1c≥6.5% corresponded to the diagnosis of DM, HbA1c values in the range of 5.7%≤HbA1c<6.5% to the diagnosis of prediabetes.

RESULTS: The highest frequency of violations of the MA was observed in the group «Peoples of the Volga region» (31.2%), the lowest in the «Peoples of the North Caucasus» (15.6%). BMI in the group “Peoples of the Volga region” was significantly lower than in the group “Peoples of the North Caucasus. Violations of MR were more often observed in the abdominal nature of obesity, obesity of the 1st stage, age over 45 years in the groups «Mongoloid population» and «Peoples of the Volga region» than in the peoples of the «Northern Caucasus» and «Transcaucasia». The frequency of occurrence of SR violations among representatives of the Volga Peoples group living in their historical territories was higher than among Russians living in the same regions: 32.5% and 24.3% (p<0.001 χ2 criterion), and also higher than in the Russian CFD: 32.5% and 27.4%, respectively, p=0.001 (χ2 test). The prevalence of violations of the MA among the peoples of the North Caucasus was less than among the Russians of the Central Federal District — 13.9% and 27.36%, respectively (p<0.001 χ2 criterion). The prevalence of MR violations among representatives of the “Peoples of the North Caucasus” group living in their historical territories (n=598) was less than among those living in other regions of the Russian Federation (n=164) (13.9% and 21.95%, p= 0.012 criterion χ2).

CONCLUSION: In the present work, for the first time, we analyzed the prevalence of MR disorders in various ethnic groups of the population of the Russian Federation, identified certain ethnic characteristics of DM2 risk factors and their contribution to the development of the disease. The obtained results should be used for planning preventive programs in various regions of the Russian Federation.

Type 2 diabetes

Type 2 diabetes accounts for nearly 90% of the approximately 537 million cases of diabetes worldwide. The number affected is increasing rapidly with alarming trends in children and young adults (up to age 40 years). Early detection and proactive management are crucial for prevention and mitigation of microvascular and macrovascular complications and mortality burden. Access to novel therapies improves person-centred outcomes beyond glycaemic control. Precision medicine, including multiomics and pharmacogenomics, hold promise to enhance understanding of disease heterogeneity, leading to targeted therapies. Technology might improve outcomes, but its potential is yet to be realised. Despite advances, substantial barriers to changing the course of the epidemic remain. This Seminar offers a clinically focused review of the recent developments in type 2 diabetes care including controversies and future directions.

Comparison of Beliefs about Health in Migrants and Swedish-Born Persons with Type 2 Diabetes

BACKGROUND

Based on findings from previous qualitative studies comparing migrants and Swedish-born persons with diabetes mellitus type 2, it was hypothesized that dissimilarities exist in beliefs about health, including factors of importance for health between groups.

METHODS

A survey in a diabetes clinic in a migrant-dense area in Sweden.

RESULTS

Migrants generally perceived their health as poorer than Swedes, although it was not significantly different. Health mainly meant feeling well, being alert, and healthy and learning to live with disease despite of person's origin. Studying factors of importance for health, migrants perceived knowledge about the body and treatment to influence health to a lower extent (p 0.009) and use of nature cure remedies to a higher extent (p 0.029) than Swedish-born persons.

CONCLUSIONS

The findings partly supported the hypothesis that dissimilarities in factors of importance for health exist between migrants and Swedish-born persons, and need to be assessed.

Comorbidities and ethnic health disparities in the UK biobank

Objective

The goal of this study was to investigate the relationship between comorbidities and ethnic health disparities in a diverse, cosmopolitan population.

Materials and Methods

We used the UK Biobank (UKB), a large progressive cohort study of the UK population. Study participants self-identified with 1 of 5 ethnic groups and participant comorbidities were characterized using the 31 disease categories captured by the Elixhauser Comorbidity Index. Ethnic disparities in comorbidities were quantified as the extent to which disease prevalence within categories varies across ethnic groups and the extent to which pairs of comorbidities co-occur within ethnic groups. Disease-risk factor comorbidity pairs were identified where one comorbidity is known to be a risk factor for a co-occurring comorbidity.

Results

The Asian ethnic group shows the greatest average number of comorbidities, followed by the Black and then White groups. The Chinese group shows the lowest average number of comorbidities. Comorbidity prevalence varies significantly among the ethnic groups for almost all disease categories, with diabetes and hypertension showing the largest differences across groups. Diabetes and hypertension both show ethnic-specific comorbidities that may contribute to the observed disease prevalence disparities.

Discussion

These results underscore the extent to which comorbidities vary among ethnic groups and reveal group-specific disease comorbidities that may underlie ethnic health disparities.

Conclusion

The study of comorbidity distributions across ethnic groups can be used to inform targeted group-specific interventions to reduce ethnic health disparities.

Real-World Data of a Group-Based Formula Low Energy Diet Programme in Achieving Type 2 Diabetes Remission and Weight Loss in an Ethnically Diverse Population in the UK: A Service Evaluation

(1) Background: Formula low energy diets (LED) are effective at inducing weight loss and type 2 diabetes (T2DM) remission. However, the effect of LED programmes in ethnic minority groups in the UK is unknown. (2) Methods: A service-evaluation was undertaken of a group-based LED, total diet replacement (TDR) programme in London, UK. The programme included: a 12-week TDR phase, 9-week food reintroduction and a 31-week weight maintenance phase and was delivered by a diabetes multi-disciplinary team. (3) Results: Between November 2018 and March 2020, 216 individuals were referred, 37 commenced the programme, with 29 completing (78%). The majority were of Black British (20%) ethnicity with a mean (SD) age of 50.4 (10.5) years, a body mass index of 34.4 (4.4) kg/m² and a T2DM duration of 4.2 (3.6) years. At 12 months, 65.7% achieved T2DM remission, with a mean bodyweight loss of 11.6 (8.9) kg. Completers lost 15.8 (5.3) kg, with 31.4% of participants achieving ≥15 kg weight loss. Quality of life measures showed significant improvements. (4) Conclusions: This service evaluation shows for the first time in the UK that a group-based formula LED programme can be effective in achieving T2DM remission and weight loss in an ethnical diverse population.

Ethnicity and prognosis following a cardiovascular event in people with and without type 2 diabetes: Observational analysis in over 5 million subjects in England

AIMS

To quantify ethnic differences in the risk of all-cause mortality and cardiovascular disease (CVD) events following a first CVD event in people with and without type 2 diabetes.

METHODS

We identified 5,349,271 subjects with a first CVD between 1 January 2002 and 31 May 2020 in England; CVD included aortic aneurism, cerebrovascular accident, heart failure, myocardial infarction, peripheral vascular disease, and other cardiovascular diseases. We estimated adjusted hazard ratios (HRs) for type 2 diabetes and ethnicity of three outcomes: fatal and nonfatal second CVD event (different phenotype compared to the first) and all-cause mortality.

RESULTS

Relative to White, HRs indicated lower rates in all ethnicities and for all outcomes in both men (from 0.64 to 0.79 for all-cause death; 0.78-0.79 for CVD-related death; and 0.85-0.98 for a second CVD event) and women (0.69-0.77; 0.77-0.83; 0.83-0.95, respectively). Irrespective of ethnicity and sex, type 2 diabetes increased rates of all outcomes by around a third.

CONCLUSIONS

Prognosis following a CVD event was consistently worse in subjects with type 2 diabetes while varied across ethnicities, suggesting the implementation of different strategies for the secondary prevention of CVD in different ethnic groups.

Greater ectopic fat deposition and liver fibroinflammation and lower skeletal muscle mass in people with type 2 diabetes

OBJECTIVE

Type 2 diabetes (T2D) is associated with significant end-organ damage and ectopic fat accumulation. Multiparametric magnetic resonance imaging (MRI) can provide a rapid, noninvasive assessment of multiorgan and body composition. The primary objective of this study was to investigate differences in visceral adiposity, ectopic fat accumulation, body composition, and relevant biomarkers between people with and without T2D.

METHODS

Participant demographics, routine biochemistry, and multiparametric MRI scans of the liver, pancreas, visceral and subcutaneous adipose tissue, and skeletal muscle were analyzed from 266 participants (131 with T2D and 135 without T2D) who were matched for age, gender, and BMI. Wilcoxon and χ² tests were performed to calculate differences between groups.

RESULTS

Participants with T2D had significantly elevated liver fat (7.4% vs. 5.3%, p = 0.011) and fibroinflammation (as assessed by corrected T1 [cT1]; 730 milliseconds vs. 709 milliseconds, p = 0.019), despite there being no differences in liver biochemistry, serum aspartate aminotransferase (p = 0.35), or alanine transaminase concentration (p = 0.11). Significantly lower measures of skeletal muscle index (45.2 cm² /m² vs. 50.6 cm² /m² , p = 0.003) and high-density lipoprotein cholesterol (1.1 mmol/L vs. 1.3 mmol/L, p < 0.0001) were observed in participants with T2D.

CONCLUSIONS

Multiparametric MRI revealed significantly elevated liver fat and fibroinflammation in participants with T2D, despite normal liver biochemistry. This study corroborates findings of significantly lower measures of skeletal muscle and high-density lipoprotein cholesterol in participants with T2D versus those without T2D.

The effectiveness of a structured group education programme for people with established type 2 diabetes in a multi-ethnic population in primary care: A cluster randomised trial

BACKGROUND AND AIMS

Structured self-management education has been shown to be effective in type 2 diabetes (T2DM) but more research is needed to look at culturally appropriate programmes in ethnic minority groups, where prevalence of T2DM is higher and diagnosis earlier. The study tested the effectiveness of a group education programme for people with established T2DM in a multi-ethnic primary care population.

METHODS AND RESULTS

Cluster randomised trial conducted in two multi-ethnic UK sites. Practices were randomised (1:1) to a structured T2DM group education programme or to continue with routine care. A culturally-adapted version was offered to South Asians, who formed the majority of ethnic minority participants. Other ethnic minority groups were invited to attend the standard programme. Primary outcome was change in HbA1c at 12 months. All analyses accounted for clustering and baseline value.367 participants (64(SD 10.8) years, 36% women, 34% from minority ethnic groups) were recruited from 31 clusters. At 12 months, there was no difference in mean change in HbA1c between the two groups (-0.10%; (95% CI: -0.37, 0.17). Subgroup analyses suggested the intervention was effective at lowering HbA1c in White European compared with ethnic minority groups. The intervention group lost more body weight than the control group (-0.82 kg at 6 months and -1.06 kg at 12 months; both p = 0.03).

CONCLUSION

Overall, the programme did not result in HbA1c improvement but in subgroup analysis, a beneficial effect occurred in White Europeans. Findings emphasise a need to develop and evaluate culturally-relevant programmes for ethnic minority groups.