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

Diabetes-related amputations in Germany: analysis of time trend from 2015 to 2022 and differences by area-level socioeconomic deprivation

Background

Diabetes-related amputations reduce health-related quality of life and are an indicator of the quality of care of diabetes.

Methods

Population-based age-standardized rates for diabetes-related cases of major and minor amputation were calculated and reported for the years 2015 - 2022 using the Diagnosis-related groups statistics. For 2022 these rates were also reported according to area-level socioeconomic deprivation.

Results

Diabetes-related major amputations decreased from 6.8 to 5.2 per 100,000 residents in women and from 18.6 to 17.5 per 100,000 residents in men between 2015 and 2022. In 2021 and 2022, there was no further decrease in men compared to the previous year. Diabetes-related minor amputations decreased in women between 2015 and 2022, but increased in men. Amputation rates were higher in regions with high deprivation than in regions with low deprivation.

Conclusions

Diabetes care should consider socioeconomic differences into account. The monitoring of the trends in amputations needs to be continued.

Eleven-year trends in socioeconomic inequalities in the prevalence and incidence of pharmacologically treated type 2 diabetes in France, 2010-2020

AIM

This study aimed to describe the association between socioeconomic inequalities and the prevalence and incidence of pharmacologically-treated type 2 diabetes in European France over the 2010-2020 period.

METHODS

Diabetes cases were identified using a validated algorithm from the French National Health Data System. Analysis was restricted to adults aged 45 years and older to focus on type 2 diabetes. Socioeconomic inequalities were measured for all years in European France using the French deprivation index (FDep, 2015 version), which is an area-based deprivation indicator using population-weighted quintiles (Q1 corresponds to the least deprived municipalities). The relative risks of diabetes prevalence and incidence associated with FDep quintiles (Q1 as the reference) were estimated by sex using a log-linear Poisson model adjusted for year, age and French department. The study population was the French health consumers aged 45 years and over (from 24,228,526 in 2010 to 29,772,928 in 2020).

RESULTS

A positive gradient was observed in the relative risks of type 2 diabetes prevalence and incidence by FDep quintiles over the study period. The strength of the estimated associations increased over the last decade for prevalence among men and women and for incidence among men in the two most deprived quintiles.

CONCLUSION

Thus, type 2 diabetes prevention should include a proportionate universalism approach, proposing actions of greater intensity in the most deprived areas.

A Scoping Review of Possible Solutions for Decreasing Socioeconomic Inequalities in Type 2 Diabetes Mellitus

Background

As socioeconomic inequalities are key factors in access and utilization of type 2 diabetes (T2D) services, the purpose of this scoping review was to identify solutions for decreasing socioeconomic inequalities in T2D.

Methods

A scoping review of scientific articles from 2000 and later was conducted using PubMed, Web of Science (WOS), Scopus, Embase, and ProQuest databases. Using the Arksey and O'Malley framework for scoping review, articles were extracted, meticulously read, and thematically analyzed.

Results

A total of 7204 articles were identified from the reviewed databases. After removing duplicate and nonrelevant articles, 117 articles were finally included and analyzed. A number of solutions and passways were extracted from the final articles. Solutions for decreasing socioeconomic inequalities in T2D were categorized into 12 main solutions and 63 passways.

Conclusions

Applying identified solutions in diabetes policies and interventions would be recommended for decreasing socioeconomic inequalities in T2D. Also, the passways could be addressed as entry points to help better implementation of diabetic policies.

Influence of social deprivation on morbidity and all-cause mortality of cardiometabolic multi-morbidity: a cohort analysis of the UK Biobank cohort

BACKGROUND

The relation of social deprivation with single cardiometabolic disease (CMD) was widely investigated, whereas the association with cardiometabolic multi-morbidity (CMM), defined as experiencing more than two CMDs during the lifetime, is poorly understood.

METHODS

We analyzed 345,417 UK Biobank participants without any CMDs at recruitment to study the relation between social deprivation and four CMDs including type II diabetes (T2D), coronary artery disease (CAD), stroke and hypertension. Social deprivation was measured by Townsend deprivation index (TDI), and CMM was defined as occurrence of two or more of the above four diseases. Multivariable Cox models were performed to estimate hazard ratios (HRs) per one standard deviation (SD) change and in quartile (Q1-Q4, with Q1 as reference), as well as 95% confidence intervals (95% CIs).

RESULTS

During the follow up, 68,338 participants developed at least one CMD (median follow up of 13.2 years), 16,225 further developed CMM (median follow up of 13.4 years), and 18,876 ultimately died from all causes (median follow up of 13.4 years). Compared to Q1 of TDI (lowest deprivation), the multivariable adjusted HR (95%CIs) of Q4 (highest deprivation) among participants free of any CMDs was 1.23 (1.20 ~ 1.26) for developing one CMD, 1.42 (1.35 ~ 1.48) for developing CMM, and 1.34 (1.27 ~ 1.41) for all-cause mortality. Among participants with one CMD, the adjusted HR (95%CIs) of Q4 was 1.30 (1.27 ~ 1.33) for developing CMM and 1.34 (1.27 ~ 1.41) for all-cause mortality, with HR (95%CIs) = 1.11 (1.06 ~ 1.16) for T2D patients, 1.07 (1.03 ~ 1.11) for CAD patients, 1.07 (1.00 ~ 1.15) for stroke patients, and 1.24 (1.21 ~ 1.28) for hypertension patients. Among participants with CMM, TDI was also related to the risk of all-cause mortality (HR of Q4 = 1.35, 95%CIs 1.28 ~ 1.43).

CONCLUSIONS

We revealed that people living with high deprived conditions would suffer from higher hazard of CMD, CMM and all-cause mortality.

Life Course Assessment of Area-Based Social Disadvantage: A Systematic Review

Area-based social disadvantage, which measures the income, employment, and housing quality in one's community, can impact an individual's health above person-level factors. A life course approach examines how exposure to disadvantage can affect health in later life. This systematic review aimed to summarize the approaches used to assess exposure to area-based disadvantage over a life course, specifically those that define the length and timing of exposure. We reviewed the abstracts of 831 articles based on the following criteria: (1) whether the abstract described original research; (2) whether the study was longitudinal; (3) whether area-based social disadvantage was an exposure variable; (4) whether area-based social disadvantage was assessed at multiple points; and (5) whether exposure was assessed from childhood to older adulthood. Zero articles met all the above criteria, so we relaxed the fifth criterion in a secondary review. Six studies met our secondary criteria and were eligible for data extraction. The included studies followed subjects from childhood into adulthood, but none assessed disadvantages in late life. The approaches used to assess exposure included creating a cumulative disadvantage score, conducting a comparison between life course periods, and modeling the trajectory of disadvantage over time. Additional research was needed to validate the methodologies described here, specifically in terms of measuring the impact of area-based social disadvantage on health.

Influence of neighborhood-level socioeconomic deprivation and individual socioeconomic position on risk of developing type 2 diabetes in older men: a longitudinal analysis in the British Regional Heart Study cohort

INTRODUCTION

Evidence from longitudinal studies on the influence of neighborhood socioeconomic deprivation in older age on the development of type 2 diabetes mellitus (T2DM) is limited. This study investigates the prospective associations of neighborhood-level deprivation and individual socioeconomic position (SEP) with T2DM incidence in older age.

RESEARCH DESIGN AND METHODS

The British Regional Heart Study studied 4252 men aged 60-79 years in 1998-2000. Neighborhood-level deprivation was based on the Index of Multiple Deprivation quintiles for participants' 1998-2000 residential postcode. Individual SEP was defined as social class based on longest-held occupation. A cumulative score of individual socioeconomic factors was derived. Incident T2DM cases were ascertained from primary care records; prevalent cases were excluded. Cox proportional hazard models were used to examine the associations.

RESULTS

Among 3706 men, 368 incident cases of T2DM were observed over 18 years. The age-adjusted T2DM risk increased from the least deprived quintile to the most deprived: HR per quintile increase 1.14 (95% CI 1.06 to 1.23) (p=0.0005). The age-adjusted T2DM HR in social class V (lowest) versus social class I (highest) was 2.45 (95% CI 1.36 to 4.42) (p=0.001). Both associations attenuated but remained significant on adjustment for other deprivation measures, becoming non-significant on adjustment for body mass index and T2DM family history. T2DM risk increased with cumulative individual adverse socioeconomic factors: HR per point increase 1.14 (95% CI 1.05 to 1.24).

CONCLUSIONS

Inequalities in T2DM risk persist in later life, both in relation to neighborhood-level and individual-level socioeconomic factors. Underlying modifiable risk factors continue to need to be addressed in deprived older age populations to reduce disease burden.

The influence of socioeconomic aspects and hospital case volume on survival in colorectal cancer in Saxony, Germany

BACKGROUND

Colorectal cancer (CRC) is one of the most common types of cancer in Western civilization and responsible for a high number of yearly deaths. Long-term outcome is influenced by many factors, potentially including socioeconomic aspects like income, education, and employment. Furthermore, annual surgical case volume plays a major role in achieving good oncological results. In our retrospective study, we evaluated the effect of socioeconomic deprivation and hospital volume on overall survival (OS) in the federal state of Saxony, Germany.

METHODS

All patients with CRC who underwent surgery in Saxony, Germany between 2010 and 2020 and were living in Saxony at the time of diagnosis were included in our retrospective analysis. Uni- and multivariate analyses were conducted considering age, sex, tumor localization, UICC tumor stage, surgical approach (open/laparoscopic), number of resected lymph nodes, adjuvant chemotherapy, year of surgery, and hospital case volume. In addition, our model was adjusted for social disparity using the German Index of Socioeconomic Deprivation (GISD).

RESULTS

A total of 24,085 patients were analyzed (15,883 with colon cancer and 8,202 with rectal cancer). Age, sex, UICC tumor stage and tumor localization were distributed as expected for CRC. Median overall survival time was 87.9 months for colon cancer and 110.0 months for rectal cancer. Univariate analysis revealed laparoscopic surgery (colon and rectum P < 0.001), high case volume (rectum: P = 0.002) and low levels of socioeconomic deprivation (colon and rectum P < 0.001) to be significantly associated with better survival. In multivariate analyses, the associations of laparoscopic surgery (colon: HR = 0.76, P < 0.001; rectum: HR = 0.87, P < 0.01), and mid-low to mid-high socioeconomic deprivation (colon: HR = 1.18-1.22, P < 0.001; rectum: HR = 1.18-1.36, P < 0.001-0.01) remained statistically significant. Higher hospital case volume was associated with better survival only in rectal cancer (HR = 0.89; P < 0.01).

CONCLUSION

In Saxony, Germany, better long-term survival after CRC surgery was associated with low socioeconomic deprivation, laparoscopic surgery and partly with high hospital case volume. Thus, there is a need to reduce social differences in access to high-quality treatment and prevention and increase hospital patient volume.

Characteristics of Composite Deprivation Indices Used in Public Health: A Scoping Review Protocol

Introduction: A deprivation index has become a more popular tool to rank levels of deprivation within different geographic areas. It is extensively used for monitoring health inequalities, evaluating health care services, developing and modifying health policies and programs, and allocating health resources equitably. Our objectives are (1) to explore the relevant literature to describe features of composite deprivation measures; (2) create a list and classification of original deprivation indices. We will develop the classification of indices to systematize knowledge and improve the functional utility of the information. Methods: Any original deprivation index mentioned in peer-reviewed or grey literature documents will be eligible for inclusion if it assesses deprivation at a population level and used in relation to health. The study area will be limited to the geographic areas of North America, Europe, Australia, and New Zealand. Tables and a narrative summary will be used to describe features of deprivation indices. Diagrammatic form will be used to create the classification of deprivation indices. Discussion: Practically, the results of this study could facilitate finding a common language among researchers and specialists who create and use deprivation indices, thus helping the development and implementation of appropriate deprivation indices for different countries.

Difference in the prevalence of hypertension and its risk factors depending on area-level deprivation in Japan

Objectives

Area-level deprivation is an important factor related to mortality or health behaviors; however, a study investigating differences in hypertension prevalence depending on area-level deprivation has not been conducted in Japan. We investigated differences in the prevalence of hypertension and its risk factors, i.e. obesity, smoking, alcohol consumption, and heavy alcohol drinking depending on area-level deprivation using nationwide health checkups data in 2018.

Results

Area-level deprivation was derived from census data. An analysis of the data by secondary medical areas revealed that the age-standardized proportions of individuals whose systolic blood pressure was ≥ 140 mmHg, those whose diastolic blood pressure was ≥ 90 mmHg, those whose body mass index was ≥ 25 or 30 kg/m², smokers, and heavy alcohol drinkers showed an increasing trend with an increase in the deprivation level. The relative index of inequality, which can be interpreted as the ratio of the age-standardized proportion for the most deprived area compared with that for the least deprived area, was significantly greater than 1 for all proportions, except for the proportion of drinkers in women. Overall, there was a disparity in the prevalence of hypertension and its risk factors depending on area-level deprivation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-05931-6.

Exercise facilities and the prevalence of obesity and type 2 diabetes in the city of Madrid

AIMS/HYPOTHESIS

We aimed to study the association between the availability of exercise facilities and the likelihood of obesity and type 2 diabetes in the adult population of Madrid, Spain.

METHODS

We analysed the electronic medical records of all 1,270,512 residents of Madrid aged 40-75 years in 2017. Exercise facility availability was defined as the count of exercise facilities in a 1000 m street network buffer around each residential building entrance. Poisson regression with standard errors clustered at census tract level was used to assess prevalence ratios of exercise facility availability tertiles and obesity and type 2 diabetes. We also examined stratified results by tertiles of area-level socioeconomic status (SES) and sex.

RESULTS

People living in areas with lower availability of exercise facilities had a higher prevalence of obesity (prevalence ratio [PR] 1.22 [95% CI 1.20, 1.25]) and diabetes (PR 1.38 [95% CI 1.34, 1.43]). We observed effect modification by area-level SES (p<0.001), with stronger associations for residents living in low-SES areas and no association for residents living in high-SES areas. Associations with type 2 diabetes were stronger among women compared with men, while associations with obesity were similar by sex.

CONCLUSIONS/INTERPRETATION

People living in areas with low availability of exercise facilities had a higher prevalence of obesity and type 2 diabetes, and this association was strongest in low-SES areas and for women. Understanding the potential role of exercise facilities in driving inequities in obesity and type 2 diabetes prevalence may inform interventions to reduce health inequities.

Area-level deprivation and geographic factors influencing utilisation of General Practitioner services

Inequities in access to General Practitioner (GP) services are a key policy concern given the role of GPs as gatekeepers to secondary care services. Geographic or area-level factors, including local deprivation and supply of healthcare providers, are important elements of access. In considering how area-level deprivation relates to GP utilisation, two potentially opposing factors may be important. The supply of healthcare services tends to be lower in areas of higher deprivation. However, poorer health status among individuals in deprived areas suggests greater need for healthcare. To explore the relationship of area-level deprivation to healthcare utilisation, we use data from the Healthy Ireland survey, which provided a sample of 6326 respondents to face-to-face interviews.

A u-shaped relationship between GP supply and area-level deprivation is observed in the data. Modelling reveals that residing in more deprived communities has a strong, statistically significant positive association with having seen a GP within the last four weeks, controlling for individual characteristics and GP supply. All else equal, residing in an area ranked in the most deprived quintile increases the odds of a respondent having visited the GP in four weeks by 1.43 (95% Confidence Interval: 1.15–1.78), compared to the least deprived quintile (p-value< 0.001). The findings indicate that the level of deprivation in an area may be relevant to decisions about how to allocate primary care resources.

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GP utilisation is higher amongst those in more deprived areas.

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GP supply is lower in middle income areas compared to deprived or affluent areas.

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Differences in GP supply and GP utilisation occur across deprivation quintiles.

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Other geographic factors are not found to be significant in determining GP utilisation.

Area Deprivation Index Score is Associated with Lower Rates of Long Term Follow-up after Upper Extremity Vascular Injuries

The Area Deprivation Index (ADI) has been shown to be a determinant of healthcare outcomes in both medical and surgical fields, and is a measure of the socioeconomic status of patients. We sought to analyze outcomes in patients with upper extremity vascular injuries that were admitted over a five-year period to a Level I trauma center sorted by ADI. All patients with upper extremity vascular injury presenting to a level one trauma center between January 2013 and January 2017 were retrospectively collected. The patients were divided into two groups based on their ADI with the first group representing the lowest quartile of patients and the second group the higher three quartiles. Patient's demographics were analyzed as well as modes of trauma, hospital transfer status prior to receiving care, type of intervention received, follow-up rates and outcomes including both complication and amputation rates. Over this time period, a total of 88 patients with traumatic upper extremity vascular injuries were identified. The majority of injuries were due to penetrating trauma (74/88, 84%) with 41% (10/24) of patients in the lower ADI being victims of gunshot wounds compared to 27% (17/64) of those in the higher ADI (P = 0.19). Patients in the lowest ADI quartile were more likely to be African Americans (P= 0.0001), and more likely to be transferred to our university hospital prior to receiving care (P= 0.007). Arrival Glasgow Coma Scale and Injury Severity Score were similar as was time spent in the emergency room. Length of stay trended longer in the lowest ADI quartile as compared to the higher ADI (7.5 vs. 11.8, P= 0.59). The rates of long term follow-up were significantly lower in patients with the lowest ADI scores as opposed to the higher ADI group (P= 0.0098), however, there was no statistically significant difference in outcomes between the two groups including both complication and amputation rates. The ADI is associated with lower rates of long term follow-up after upper extremity vascular injuries, despite patients in both the high and low ADI groups having similar outcomes in regards to complication and amputation rates. Further study is warranted to investigate the role of the socioeconomic status in outcomes following traumatic injury.

Neighborhood Deprivation, Obesity, and Diabetes in Residents of the US Gulf Coast

Socioeconomic status has been associated with cardiovascular disease risk factors. However, few studies have examined this relationship among populations in the US Gulf Coast region. We assessed neighborhood deprivation in relation to obesity and diabetes in 9,626 residents participating in the Gulf Long-Term Follow-Up Study (2011-present) who completed a home visit (2011-2013) with height, weight, waist, and hip measurements. Obesity was categorized as body mass index of at least 30, and diabetes was defined by doctor's diagnosis or prescription medication. Participant home addresses were linked to an established Area Deprivation Index and categorized into 4 levels (1 = least deprived). In adjusted, modified Poisson regression models, participants with greatest deprivation were more likely to have obesity compared with those with least deprivation (adjusted prevalence ratio (aPR) = 1.21, 95% confidence interval (CI): 1.08, 1.35), central obesity (aPR = 1.11, 95% CI: 1.04, 1.19), and diabetes (aPR = 1.49, 95% CI: 1.03, 2.14). Repeated analyses among a subgroup of participants (n = 3,016) whose hemoglobin A1C values were measured 3 years later indicated the association with diabetes (defined as diagnosis, medications, or hemoglobin A1C ≥ 6.5) was similar (aPR = 1.46, 95% CI: 1.14, 1.86). Results suggest neighborhood deprivation is associated with obesity and diabetes in a US region with high baseline prevalence.

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

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

Association between regional deprivation and type 2 diabetes incidence in Germany

Objective

The aim of this analysis was to estimate the association between regional deprivation and type 2 diabetes incidence and to investigate differences by age and sex for Germany.

Research design and methods

Type 2 diabetes incidence rate ratios comparing the most deprived fifth of the population to the remainder of the population (divided into quintiles) were estimated using the illness-death model, which describes the relationship between prevalence, mortality, and incidence. For the analysis, we used the type 2 diabetes prevalence and the general mortality rate according to deprivation quintiles, which we calculated based on valid estimates for Germany. Because mortality rate ratios for people with type 2 diabetes compared with people without type 2 diabetes are lacking for Germany, we used estimates from Scotland. Estimates were standardized to the German population in 2012 and stratified by sex.

Results

Incidence of type 2 diabetes was estimated to be over twice as high among people living in the most deprived regions of Germany compared with people living in the least deprived regions (men: 2.41, 95% CI 1.27 to 4.28; women: 2.40, 95% CI 1.25 to 4.29). The strength of the association increased with increasing age until the age of 75 years. No sex differences were present.

Conclusions

The study adds new evidence regarding the association between type 2 diabetes incidence and regional deprivation for Germany. The results underpin the importance to intensify public health actions to reduce social inequalities in Germany and whole Europe in the future.

Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Phenotypic characteristics and risk factors in a multi-ethnic cohort of young adults with type 2 diabetes

Background: Early onset of type 2 diabetes (T2DM) is associated with prolonged exposure to hyperglycaemia and increased propensity to chronic complications. The aim of this study was to characterize and compare the phenotypic characteristics and risk factors in a multi-ethnic cohort of young adults with type 2 diabetes (T2DMY). Methods: One hundred young adults (White European [WE], South Asian [SA] and African-Caribbean [AC]) diagnosed with T2DM before the age of 40 years were recruited. Demographics, family history, diabetes related complications, co-morbidities, anthropometry (body mass index [BMI], body composition), physical activity and biochemistry (HbA1c, lipid profile, liver and renal function) and autoantibodies (anti GAD, anti islet cell) were collected for all participants. Data were analysed for the most represented ethnic groups: (WE, N = 36 and SA, N = 53) using SPSS version 23. Results: Mean (± standard deviation) age at diagnosis was 32.5 ± 5.5 years and mean diabetes duration was 7.7 ± 3.8 years. Overweight/obesity was present in 95% of participants, history of maternal diabetes in 68%, deprivation 75%, low physical activity 40%, polycystic ovarian disease 29% (in females), acanthosis nigricans 12% and non-alcoholic fatty liver 11%. There was considerable clustering of risk factors within the cohort with over 75% of all subjects having three or more of the above risk factors and 52% required insulin within 3 years of diagnosis. Two-thirds of the patients had evidence of at least one diabetes related microvascular complication. Conclusion: T2DMY is characterized by a high burden of commonly associated risk factors for both the disease and its long-term complications.

Types of diabetes are not limited to age groups: type 1 diabetes in adults and type 2 diabetes in children and adolescents

Based on data from the national diabetes registry DPV (Diabetes patient documentation), the diabetes registry of North Rhine-Westphalia and surveys conducted at hospitals and practices in Baden-Württemberg and Saxony, this study estimates the incidence and prevalence of type 1 diabetes in over-18-year-old adults and type 2 diabetes in 11- to 18-year-old children and adolescents. The national incidence of type 1 diabetes in adults was 6.1 per 100,000 person-years from 2014 to 2016, with slightly lower figures for women compared to men. Annually, around 4,150 adults develop type 1 diabetes. In 2016, the prevalence of type 1 diabetes was estimated at 493 per 100,000 persons and was lower in women at 445 per 100,000 people than in men at 544 per 100,000. Based on this data, there were around 341,000 adults with type 1 diabetes in 2016. For 11- to 18-year-old children and adolescents, the national incidence of type 2 diabetes was 2.8 per 100,000 person-years between 2014 and 2016 and higher for girls than for boys. Annually, around 175 adolescents in this age group develop type 2 diabetes. The incidence estimates for Saxony were higher (4.3 per 100,000 person-years). The prevalence of type 2 diabetes between 2014 and 2016 for 11- to 18-year-old children and adolescents was estimated between 12 and 18 cases per 100,000 persons. During this period, there were about 950 children and adolescents of this age group with type 2 diabetes in Germany.

Type 2 diabetes mellitus and neighborhood deprivation index: A spatial analysis in Zhejiang, China

AIMS/INTRODUCTION

Many studies have reported that socioeconomically disadvantaged people or people who live in deprived areas are more vulnerable to diabetes complications. However, few such studies were carried out in China. The present study examined the spatial association between the incidence of type 2 diabetes mellitus and neighborhood deprivation in Zhejiang, China, from a spatial epidemiology perspective.

MATERIALS AND METHODS

Type 2 diabetes mellitus data (2012-2016) in the present study were derived from a population-based diabetes registry system maintained by Zhejiang Provincial Center for Disease Control and Prevention. Principal components analysis was used to combine different socioeconomic variables together into a composited Neighborhood Deprivation Index. We applied the global Moran's I and Anselin's local Moran's I statistics to explore the spatial patterns of type 2 diabetes mellitus incidence and Neighborhood Deprivation Index.

RESULTS

Type 2 diabetes mellitus incidence (Moran's I: 0.531, P < 0.001) and Neighborhood Deprivation Index (Moran's I: 0.772, P < 0.001) showed positive statistically significant global Moran's I index values, showing a tendency towards clustering. The local Moran's I analyses showed that type 2 diabetes mellitus incidence hot spots were mainly located in urban centers, and type 2 diabetes mellitus incidence cold spots appeared in the provincial capital area (Hangzhou city) and western and south-western regions of Zhejiang; the hot spots of the less deprived areas were concentrated in urban centers (except Lishui city), and the cold spots of the most deprived areas were clustered in western and south-western regions of Zhejiang.

CONCLUSIONS

The study showed that the incidence of type 2 diabetes mellitus was higher in affluent areas than the deprived areas across the study period. It will be significant to focus preventive efforts on the least deprived areas.

[Primary and secondary data on dementia care as an example of regional health planning]

BACKGROUND

Health service planning that takes into account as far as possible the regional needs and regional discrepancies is a controversial health issue in Germany.

OBJECTIVES

In a pilot scheme, we tested a planning process for regional healthcare services, based on the example of dementia care. The aim of this article is to present the strengths and limitations of this planning process.

MATERIALS AND METHODS

We developed an indicator set for dementia care based on routine regional data obtained from two German statutory health insurance companies. Additionally, primary data based on a questionnaire sent to all GPs in the area were evaluated. These data were expanded through the addition of official socio-demographic population data. Procedures and evaluation strategies, discussion of the results and the derivation of planning measures followed, in close agreement with a group of local experts.

RESULTS

Few epidemiological data on regional variations in health care planning are publicly available. Secondary data from statutory health insurance companies can be assessed to support the estimation of regional health care needs, but interpretation is difficult. The use of surveys to collect primary data, and the assessment of results by the local health board may facilitate interpretation and may contribute towards more valid statements regarding regional health planning.

CONCLUSIONS

Despite the limited availability of data and the considerable efforts involved in data analysis, the project demonstrates how needs-based health service planning can be carried out in a small region, taking into account the increasing demands of the local health care providers and the special local features.

[Indices of Multiple Deprivation for the analysis of regional health disparities in Germany : Experiences from epidemiology and healthcare research]

BACKGROUND

Deprivation indices allow material and social differences at the regional level to be described in a statistically efficient and concise manner and to use these in health analyses. Following the British example, Indices of Multiple Deprivation (IMDs) are now available for Germany, the German Index of Multiple Deprivation (GIMD) as well as its regional versions. In this study, empirical experiences based on the use of these indices in health studies will be presented.

METHOD

The German IMDs consist of seven deprivation domains, which represent single aspects of deprivation (income, employment, and educational deprivation, municipal revenue deprivation, social capital deprivation, environment and security deprivation). Specific indicators were generated from data of official statistics and assigned to the deprivation domains. The weighted single domains were finally combined to an overall index. The German IMDs are available at a municipal level and at a district level.

RESULTS

Analyses using the IMDs showed significant associations between regional deprivation and mortality, morbidity and aspects of health services research. Multilevel analyses showed significant associations with regional deprivation, independent of individual factors.

CONCLUSIONS

The German IMDs are valid and efficient tools for the use in epidemiology and health services research, but also for health policy. When constructing deprivation indices, several methodological challenges have to be considered.

Individual- and area-level socioeconomic inequalities in diabetes mellitus in Saskatchewan between 2007 and 2012: a cross-sectional analysis

BACKGROUND

Improving our understanding of social inequalities may improve prevention and treatment efforts for diabetes mellitus. We examined the association between individual- and area-level socioeconomic measures and physician-diagnosed diabetes in Saskatchewan over time.

METHODS

In this cross-sectional study, we linked health administrative data with individual-level socioeconomic data from the Canadian Community Health Survey and area-level data from the 2006 Canadian census. We used general linear mixed-models regression to analyze the effect of each factor, controlling for geographic and demographic measures.

RESULTS

Area-level deprivation was associated with medically diagnosed type 2 diabetes mellitus after adjustment for the individual-level factors of age, sex, household income and education. Individuals residing in areas ranked in the least deprived quintile had a lower likelihood of diabetes than those in the most deprived quintile (odds ratio 0.40, 95% confidence interval 0.18-0.88). However, this disparity existed only in urban areas. This result may reflect less pronounced health inequalities in rural areas, greater socioeconomic heterogeneity, larger geographic units or some combination of these factors.

INTERPRETATION

Individual- and area-level socioeconomic factors were associated with the likelihood of medically diagnosed diabetes; however, the strength of this association varied between urban and rural communities. Acknowledgement of area-level deprivation as a modifiable risk factor related to the prevalence of diabetes is important in the development of effective interventions for urban, but not rural, areas.

Social disparities in the prevalence of diabetes in Australia and in the development of end stage renal disease due to diabetes for Aboriginal and Torres Strait Islanders in Australia and Maori and Pacific Islanders in New Zealand

BACKGROUND

Disparities in health status occur between people with differing socioeconomic status and disadvantaged groups usually have the highest risk exposure and the worst health outcome. We sought to examine the social disparities in the population prevalence of diabetes and in the development of treated end stage renal disease due to type 1 diabetes which has not previously been studied in Australia and New Zealand in isolation from type 2 diabetes.

METHODS

This observational study examined the population prevalence of diabetes in a sample of the Australian population (7,434,492) using data from the National Diabetes Services Scheme and of treated end stage renal disease due to diabetes using data from the Australian and New Zealand Dialysis and Transplant Registry. The data were then correlated with the Australian Bureau of Statistics Socioeconomic Indexes for Areas for an examination of socioeconomic disparities.

RESULTS

There is a social gradient in the prevalence of diabetes in Australia with disease incidence decreasing incrementally with increasing affluence (Spearman's rho = .765 p < 0.001). There is a higher risk of developing end stage renal disease due to type 1 diabetes for males with low socioeconomic status (RR 1.20; CI 1.002-1.459) in comparison to females with low socioeconomic status. In Australia and New Zealand Aboriginal and Torres Strait Islanders, Maori and Pacific Islanders appear to have a low risk of end stage renal disease due to type 1 diabetes but continue to carry a vastly disproportionate burden of end stage renal disease due to type 2 diabetes (RR 6.57 CI 6.04-7.14 & 6.48 CI 6.02-6.97 respectively p < 0.001) in comparison to other Australian and New Zealanders.

CONCLUSION

Whilst low socioeconomic status is associated with a higher prevalence of diabetes the inverse social gradient seen in this study has not previously been reported. The social disparity seen in relation to treated end stage renal disease due to type 2 diabetes for Aboriginal and Torres Strait Islanders, Maori and Pacific Islanders has changed very little in the past 20 years. Addressing the increasing incidence of diabetes in Australia requires consideration of the underlying social determinants of health.

Predictors of non-drug psychiatric/psychotherapeutic treatment in children and adolescents with mental or behavioural disorders

Children and adolescents with mental health problems need effective and safe therapies to support their emotional and social development and to avoid functional impairment and progress of social deficits. Though psychotropic drugs seem to be the preferential treatment, psychotherapy and psychosocial interventions are essential in mental health care. For Germany, current data on the utilization of psychotherapy and psychosocial interventions in children with mental health problems is lacking. To analyse why certain children and adolescents with mental or behavioural disorders do and others do not receive non-drug treatment, we assessed predictors associated with specific non-drug psychiatric/psychotherapeutic treatment including psychosocial interventions, psychotherapy and other non-drug treatments. The study is based on data of two large German health insurance funds, AOK and TK, comprising 30 % of the German child and adolescent population. Predictors of non-drug psychiatric/psychotherapeutic treatment were analysed for 23,795 cases and two controls for every case of the same age and sex in children aged 0-17 years following a new diagnosis of mental or behavioural disorder in 2010. Predictors were divided according to Andersen's behavioural model into predisposing, need and enabling factors. The most prominent and significant predictors positively associated with non-drug psychiatric/psychotherapeutic treatment were the residential region as predisposing factor; specific, both ex- and internalizing, mental and behavioural disorders, psychiatric co-morbidity and psychotropic drug use as need factors; and low area deprivation and high accessibility to outpatient physicians and inpatient institutions with non-drug psychiatric/psychotherapeutic department as enabling factors. In conclusion, the present study suggests that the residential region as proxy for supply of therapist and socioeconomic situation is an influencing factor for the use of psychotherapy. The analysis sheds further light on predisposing, need and enabling factors as predictors of non-drug psychotherapeutic/psychiatric treatment in children and adolescents with mental or behavioural health disorders in Germany. More research is needed to further understand the factors promoting the gap between the need and utilization of mental health care.

Impact of UK NICE Clinical Guidelines 168 and social deprivation on access to interventional treatment for symptomatic varicose vein and specialist referral for leg ulceration

Background UK National Institute for Health and Care Excellence (NICE) clinical guidelines (CG) 168, published in July 2013, aimed to improve the management of lower limb venous disease by newly recommending interventional treatment for all people affected by symptomatic varicose veins (VV) and specialist vascular referral for all people suffering from a leg ulcer (LU) that had been present for ≥2 weeks. This study aims to determine if CG168 has increased access to vascular services, particularly for the socially deprived, who might be expected to have greater need for such services. Methods The study was performed in a highly multi-cultural, socio-economically diverse, mixed urban/suburban population of approximately 1.2 million people living in and around East Birmingham, UK. Index of multiple deprivation quintile (IMD-Q) was used as a measure of social deprivation to compare levels of social deprivation of people undergoing interventions for symptomatic VV or referred with an LU during 18-month periods before and after the publication of CG168. The referring general practitioner practices (GPPs) were also recorded. Results There was no change in overall IMD-Q distribution before and after CG168 in terms of VV interventions. However, there was a non-significant increase in proportions of people classified as IMD-Q5 (the most deprived quintile). After CG168, fewer IMD-Q5 people with LU were referred, with a shift in referrals towards those from less socially deprived areas. More GPP referred people with both VV and LU after CG168, and those that referred patients before and after CG168 tended to refer more after CG168. Conclusions CG168 has increased VV interventions as well as the number referred with LU. However, this improvement in access to treatment and referral may have disproportionately favoured the more socio-economic privileged. Professional and public education is required to ensure that the beneficial impact of the CG168 recommendations are maximised and that those with the greatest health needs have equal access to evidence-based management of their venous disease.

Do the risk factors for type 2 diabetes mellitus vary by location? A spatial analysis of health insurance claims in Northeastern Germany using kernel density estimation and geographically weighted regression

BACKGROUND

The provision of general practitioners (GPs) in Germany still relies mainly on the ratio of inhabitants to GPs at relatively large scales and barely accounts for an increased prevalence of chronic diseases among the elderly and socially underprivileged populations. Type 2 Diabetes Mellitus (T2DM) is one of the major cost-intensive diseases with high rates of potentially preventable complications. Provision of healthcare and access to preventive measures is necessary to reduce the burden of T2DM. However, current studies on the spatial variation of T2DM in Germany are mostly based on survey data, which do not only underestimate the true prevalence of T2DM, but are also only available on large spatial scales. The aim of this study is therefore to analyse the spatial distribution of T2DM at fine geographic scales and to assess location-specific risk factors based on data of the AOK health insurance.

METHODS

To display the spatial heterogeneity of T2DM, a bivariate, adaptive kernel density estimation (KDE) was applied. The spatial scan statistic (SaTScan) was used to detect areas of high risk. Global and local spatial regression models were then constructed to analyze socio-demographic risk factors of T2DM.

RESULTS

T2DM is especially concentrated in rural areas surrounding Berlin. The risk factors for T2DM consist of proportions of 65-79 year olds, 80 + year olds, unemployment rate among the 55-65 year olds, proportion of employees covered by mandatory social security insurance, mean income tax, and proportion of non-married couples. However, the strength of the association between T2DM and the examined socio-demographic variables displayed strong regional variations.

CONCLUSION

The prevalence of T2DM varies at the very local level. Analyzing point data on T2DM of northeastern Germany's largest health insurance provider thus allows very detailed, location-specific knowledge about increased medical needs. Risk factors associated with T2DM depend largely on the place of residence of the respective person. Future allocation of GPs and current prevention strategies should therefore reflect the location-specific higher healthcare demand among the elderly and socially underprivileged populations.

Does charge-free screening improve detection of gestational diabetes in women from deprived areas: a cross-sectional study

Background

Gestational diabetes mellitus (GDM) occurs in 2–6 % of all pregnancies. We investigated whether area level deprivation is associated with a higher risk for GDM and whether GDM detection rates in deprived regions changed after the introduction of charge-free GDM screening in Germany in 2012.

Methods

We analyzed population-based data from Bavaria, Germany, comprising n = 587,621 deliveries in obstetric units between 2008 and 2014. Area level deprivation was assessed municipality-based using the Bavarian Index of Multiple Deprivation (BIMD), divided into quintiles and assigned to each mother based on her residential address. We estimated annual odds ratios (ORs) for GDM diagnosis by BIMD quintile with adjustment for maternal obesity, maternal age, migration background and single mother status.

Results

Women from the most deprived regions were less likely to be diagnosed with GDM before introduction of charge-free GDM screening (OR = 0.76 [95 % confidence interval: 0.66, 0.86] compared to least deprived areas), in 2008. In contrast, high area level deprivation was associated with significantly increased risk of GDM diagnosis in 2013 (OR [95 % confidence interval] = 1.15 [1.02, 1.29]). The OR was also elevated, although not significantly, in 2014 (OR [95 % confidence interval] = 1.05 [0.93, 1.18]).

Conclusions

The prevalence of GDM seems to have been underreported in women from highly deprived areas before introduction of the charge-free GDM screening in Germany. In fact, women living in deprived regions seem to have an increased risk for GDM and may profit from access to charge-free GDM screening.

Incorporating Environmental Justice into Second Generation Indices of Multiple Deprivation: Lessons from the UK and Progress Internationally

Second generation area-based indices of multiple deprivation have been extensively used in the UK over the last 15 years. They resulted from significant developments in political, technical, and conceptual spheres for deprivation data. We review the parallel development of environmental justice research and how and when environmental data was incorporated into these indices. We explain the transfer of these methods from the UK to Germany and assess the progress internationally in developing such indices. Finally, we illustrate how billions of pounds in the UK was allocated by using these tools to tackle neighbourhood deprivation and environmental justice to address the determinants of health.

Regional Variability of Lifestyle Factors and Hypertension with Prediabetes and Newly Diagnosed Type 2 Diabetes Mellitus: The Population-Based KORA-F4 and SHIP-TREND Studies in Germany

Objective

Type 2 diabetes mellitus (T2D) shows regional differences in Germany. The purpose of the project was to compare the prevalence of prediabetes and undiagnosed T2D in two regions in Germany, the Northeast and the South, and to evaluate their associations with regional variations in lifestyle factors and hypertension.

Methods

Data from the KORA-F4 study (South Germany, 2006–2008) and the SHIP-TREND study (Northeast Germany, 2008–2012) were used. Participants aged 35–79 years without T2D with an overnight fasting of more than 8 hours and an oral glucose tolerance test were included: KORA-F4: n = 2,616 and SHIP-TREND: n = 1,968.

Results

The prevalence of prediabetes/newly diagnosed T2D was especially high in men (about 60%) and women (about 50%) in the Northeast, followed by men (about 50%) and women (about 30%) in the South. Lifestyle factors associated with T2D varied between the regions: more participants in the Northeast were active smokers and the percentages of people with overweight or obesity were greater than in their southern counterparts. However, these differences could not explain the striking disparity in prediabetes/newly diagnosed T2D. The frequency of hypertension was also distinctly higher in the Northeast than in the South and clearly associated with prediabetes/newly diagnosed T2D. Especially in men living in the Northeast, screening individuals with blood pressure ≥ 140/90mmHg might reveal up to 70% of those with prediabetes/newly diagnosed T2D.

Conclusions

Knowledge about regional variability in T2D and related risk factors is important for the planning of diabetes prevention programs. In our analyses, common lifestyle factors did not nearly explain these variations between the northern SHIP-TREND and the southern KORA-F4 studies. Further examinations of regional socioeconomic, political, environmental and other aspects are needed. Meanwhile, targeted diabetes prevention strategies with a special focus on men living in the northern parts of Germany are reasonable.

Development of a cross-cultural deprivation index in five European countries

BACKGROUND

Despite a concerted policy effort in Europe, social inequalities in health are a persistent problem. Developing a standardised measure of socioeconomic level across Europe will improve the understanding of the underlying mechanisms and causes of inequalities. This will facilitate developing, implementing and assessing new and more effective policies, and will improve the comparability and reproducibility of health inequality studies among countries. This paper presents the extension of the European Deprivation Index (EDI), a standardised measure first developed in France, to four other European countries-Italy, Portugal, Spain and England, using available 2001 and 1999 national census data.

METHODS AND RESULTS

The method previously tested and validated to construct the French EDI was used: first, an individual indicator for relative deprivation was constructed, defined by the minimal number of unmet fundamental needs associated with both objective (income) poverty and subjective poverty. Second, variables available at both individual (European survey) and aggregate (census) levels were identified. Third, an ecological deprivation index was constructed by selecting the set of weighted variables from the second step that best correlated with the individual deprivation indicator.

CONCLUSIONS

For each country, the EDI is a weighted combination of aggregated variables from the national census that are most highly correlated with a country-specific individual deprivation indicator. This tool will improve both the historical and international comparability of studies, our understanding of the mechanisms underlying social inequalities in health and implementation of intervention to tackle social inequalities in health.