Challenges in diabetes management in Indonesia: a literature review

Real-world smartphone-based point-of-care diagnostics in primary health care to monitor HbA1c levels in people with diabetes

BACKGROUND

The lack of accurate and affordable monitoring of glycated hemoglobin (HbA1c) is a common issue among patients with diabetes in low- and middle-income countries. We aimed to test a tablet- and smartphone-based point-of-care (TSB POC) device against a local laboratory-based measure of HbA1c for monitoring diabetes under real-world conditions.

METHODS

For this cross-sectional clinical method applicability study, capillary and venous blood was collected in duplicate and analyzed at local primary health care centers. For a heterogeneity test, the tests were performed by an expert, and by a team of local nurses. The study was conducted in a multicenter design in rural and urban Aceh, Indonesia in 2019, and included a total of 533 adults. We mainly used Bland-Altman plots to assess the number of readings within the 95%-limits of agreement (LoA) and Deming regressions.

RESULTS

The results show a mean difference between capillary HbA1c on the test device and the reference method of -0.54 [CI0.95 = -1.6933; 0.6048] with 5.21% of measurements outside the LoA and a Pearson's r = 0.91 in the Deming Regression. There is no significant difference in test concordance between local nurses and the expert (4.23% versus 5.13% results outside the LoA [CI0.95 = -0.0331; 0.0511]).

CONCLUSIONS

TSB POC for analysis of HbA1c is an acceptable alternative for accessible monitoring of diabetes patients under these conditions. This method could provide access to high-quality diagnostic decisions through regular and cost-effective HbA1c monitoring directly in healthcare facilities, thus providing better access to essential health services.

A Randomized Clinical Trial Study on the Prevention Strategy and Early Detection of Ulcer Recurrence in Patients with Type 2 Diabetes Mellitus Using the Risk of Recurrence Ulcer Tool

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifies: NCT06434922.

Effects of family support system on the self-management behaviour of patients with T2DM: a multi-centre cross-sectional study in community settings

BACKGROUND

The burden of type 2 diabetes mellitus (T2DM) in China continues to escalate.

OBJECTIVE

To investigate the impact of family support system on the self-management behaviour of patients with T2DM.

METHODS

In this cross-sectional study, 1,042 participants were sampled using a multistage stratified probability-proportionate-to-size method. On-site interviews were conducted using a structured questionnaire administered by 122 family doctors from 13 community health service centres in 8 administrative districts. A structural equation model was established to investigate the impact of individual factors and family support system on the self-management behaviour of T2DM patients. Statistical analysis was performed using the SPSS 25.0 software.

RESULTS

The self-management behaviour pass rate among individuals with T2DM was 40.9%. In terms of individual factors, those with a high school education level or above demonstrated higher self-management behaviour scores than those with a junior high school education level or lower. The structural equation model revealed a path of interactions among individual factors, family support system-related factors, and the self-management behaviour of patients with T2DM: Family function → Family support → Patients' self-management behaviour → Quality of life. The coefficient of the direct path from family function to family support was 0.74 (P < 0.001), while the coefficient of the direct path from family support to self-management behaviour was 0.68 (P = 0.001).

CONCLUSION

There is significant room for improvement in the self-management behaviour of T2DM patients in China. Family function can enhance the self-management behaviour of T2DM patients by promoting family support.

Body mass index as a dominant risk factor for metabolic syndrome among indonesian adults: a 6-year prospective cohort study of non-communicable diseases

BACKGROUND

Non-communicable diseases (NCDs), notably cardiovascular disease and type 2 diabetes mellitus, are largely driven by metabolic syndrome (MetS), a cluster of critical risk factors. Despite extensive research, the progression of MetS, especially in Indonesia, has received limited attention. This research tracks adult MetS risk dynamics in a populous Bogor District cohort, providing crucial insights into its evolving nature.

METHODS

This prospective open cohort study analysed secondary data from the Special Research - Cohort Study of Non-Communicable Diseases by the Ministry of Health, Republic of Indonesia from 2011 to 2018. The final sample was 1,376 Indonesian adult participants, all residents of Bogor District. MetS outcome, dietary assessment, physical activity, and biomarkers were analysed every two consecutive years.

RESULTS

The risk of overweight and obese participants developing MetS was 2.4 and 4.4 times higher, respectively (95% CI: 1.176-3.320 and 3.345-5.740) than those with body mass index (BMI) in the normal range. Participants who reported less intentional physical exercise had a MetS risk 1.5 times higher (95% CI: 1.034-2.109) than those with more intentional physical exercise. The role of diet is also significant, evidenced by a 30% reduction in MetS risk for people with fat intakes in the 2nd quartile compared to the 1st quartile (95% CI: 0.505-0.972). Meanwhile, a carbohydrate intake in the 2nd quartile increased the risk of MetS 1.5 times (95% CI: 1.063-2.241) in comparison with the 1st quartile.

CONCLUSIONS

Notably, participants with underweight BMI exhibited the highest cumulative survival of MetS, while those with obese BMI recorded the lowest cumulative survival. There is an urgent need for strategic interventions to enhance the existing early detection and NCD monitoring program. This involves a targeted focus on promoting a community-based healthy lifestyle in the Bogor District. The study emphasizes the importance of tailored public health measures to address specific risk factors identified in the local context, aiming to mitigate the prevalence and impact of MetS in the population.

Vasculitis-panniculitis mimicking unresolved diabetic foot ulcer

Summary

Diabetes foot ulcer (DFU) is a common long-term complication of diabetes. Intractable chronic wounds to standard care of diabetic foot raise the question of whether other factors intervene in disease development. We report a case of a 54-year-old male patient who came to Sardjito General Hospital with leg pain and previous history of multiple debridement and amputation for DFU referred from a remote hospital yet no improvement was evident in the surrounding lesion following treatment. Consequently, a histopathological examination was carried out proving the presence of other aetiologic factors, vasculitis and panniculitis existing in the lesion. In this case, we report a rare type of causative factor of foot ulcers among diabetic patients. Vasculitis suspected for polyarteritis nodosa accompanied by panniculitis is considered in this patient. The treatment of choice is corticosteroids or immunosuppressants based on the clinical condition, contrary to usual wound care in DFU. Based on the evidence, clinicians need to consider other causes than only macrovascular complications in a diabetic patient with DFU that is intractable to standard wound care. In this patient, vasculitis may be considered in forming diabetic foot ulcers alongside macrovascular complications.

Learning points

A thorough examination is essential to rule out other processes in intractable DFU patients. Prompt management based on proper diagnosis is crucial to prevent peripheral arterial disease complications. Vasculitis and macrovascular complication are inseparable processes forming DFU in this patient.

Validity and Reliability of a Vibration-Based Cell Phone in Detecting Peripheral Neuropathy among Patients with a Risk of Diabetic Foot Ulcer

The aim of this study was to determine the validity and reliability of a vibration-based cell phone in detecting peripheral neuropathy among individuals with a risk of diabetic foot ulcer (DFU). The current study consisted of 3 phases: a pilot study, concurrent validity study, and interreliability study. A 128 Hz tuning fork and vibration-based cell phone using the Vibrations-Test app was compared in the primary care setting. The pilot study confirmed that the vibration-based cell phone has an adequate reliability (r > 0.70, P < .001). The concurrent validity test involved 96 participants (aged 55.78 ± 8.32 years). The Pearson correlation test found the highest correlation in the fifth metatarsal heads (r = 0.741, right feet; 0.772, left feet; P < .001). In the 4 primary care settings, the interrater reliability between nurses of the vibration-based cell phone were k = 1.000, 1.000, 1.000, and 0.720. The concurrent validity test found moderate to strong correlation results and that the interrater reliability had a strong agreement that was almost perfect. Thus, vibration-based cell phone applications can be used as screening tools for detecting neuropathy among individuals with a risk of DFU.

Prevalence and determinants of obesity among individuals with diabetes in Indonesia

Background: Obesity and diabetes mellitus (DM), both individually or simultaneously, increase the risk of morbidity and mortality. The present study aimed to determine the prevalence and determinants of obesity among diabetic individuals in Indonesia. Methods: Data were extracted based on 2018 Indonesian Basic Health Survey (Riset Kesehatan Dasar=RISKESDAS). This study involved all individuals with DM and categorized obesity based on body mass index. After data clearing, this study analyzed 3911 DM subjects of the 33.905 subjects acquired from the 2018 RISKESDAS. The study also observed demographic data, diabetes control parameters, history of hypertension, lipid profiles, and food consumption patterns. These variables were involved in a Chi-square test, and related variables were then involved in the Binary logistic regression to define the independent determinants of obesity among DM subjects. Results: Of the 3911 DM subjects included, the study found an obesity prevalence of 32.9%. This study found that female (prevalence odds ratio [POR]=2.15; 95% CI: 1.76-2.62), age 15-44 years (POR=2.46; 95% CI: 1.83-3.33), urban residence (POR=1.49; 95% CI: 1.25-1.77), history of hypertension (POR=1.25; 95% CI: 1.04-1.51), high diastolic blood pressure (POR=1.90; 95% CI: 1.58-2.29), high LDL (POR=1.44; 95% CI: 1.13-1.84), high HDL (POR=0.60; 95% CI: 0.46-0.78, and high triglycerides (POR=1.27; 95% CI: 1.07-1.50) were the risk factor of obesity  among DM subjects; while higher education (POR=0.64; 95% CI: 0.53-0.78) and married (POR=0.73; 95% CI: 0.59-0.90) were protective factors of obesity among DM subjects. Conclusions: The study concluded that almost one-third of DM subjects in Indonesia were obese. Female, age, urban residence, education level, history of hypertension, diastolic blood pressure, and lipid profiles were all associated with obesity among DM subjects in Indonesia. These findings suggest that monitoring and controlling of related determinants is needed to prevent complications caused by the doubled burden of diabetes and obesity.

Validation of EuroSCORE II Scoring System on Isolated CABG Patient in Indonesia

BACKGROUND

Coronary Artery Bypass Graft (CABG) is one solution to overcome cardiovascular problems. EuroSCORE II is a scoring system to predict mortality risk in patients undergoing cardiac surgery including CABG. Unfortunately, there's still much debate about the benefits of EuroSCORE II in Asia, including Indonesia. This study aims to validates EuroSCORE II in predicting the outcomes in patients underwent CABG without any other procedure.

RESULTS

A total of 2628 patients were included. The mean age was 59 years, mostly male (84.97%; n = 2233). Most patients underwent elective surgery (93.07%; n = 2446) and only 1.67% (n = 44) of the patients has high EuroSCORE category. Death was found in 4.22% (n-111) patients. EuroSCORE II had fair discriminant power (AUC 0.72), but a lower mortality predicted value for each group.

CONCLUSION

The parameters in EuroSCORE II are related with mortality in isolated CABG patients, but they cannot be used as mortality predictors in Indonesia.

The effectiveness of a thermography-driven preventive foot care protocol on the recurrence of diabetic foot ulcers in low-medical resource settings: An open-labeled randomized controlled trial

BACKGROUND

Plantar temperature monitoring, along with a comprehensive preventive foot care approach, is utilized to prevent recurrence of diabetic foot ulcers. However, there is a lack of standardized protocols for individuals with diabetic foot ulcer history in low-medical resource countries.

OBJECTIVE

This study investigated the efficacy of nurse-led, thermographic-evaluation-guided foot care in preventing diabetic foot ulcer recurrence in a low-medical resource country.

DESIGN

Single-blind, 1:1 allocation randomized controlled trial.

SETTINGS

Two wound care facilities with wound care nurse specialists in Indonesia.

PARTICIPANTS

120 patients with a diabetic foot ulcer history.

INTERVENTION

In the intervention group, baseline risk assessment including smartphone thermography evaluation was performed. Personalized foot care and education were conducted monthly for participants whose thermographs showed increased foot lesion temperature at baseline risk assessment. The control group received usual care and education using a booklet at baseline. The follow-up period was six months.

MAIN OUTCOME

Time to recurrence was evaluated using Kaplan-Meier survival analysis, and between-group comparisons were performed using the log-rank test. Potential risk factors were incorporated into the multivariate Cox regression model. Secondary outcomes included quality of life (European Quality of Life 5 Dimensions 3 Level Version) and foot care behavior, were analyzed using Mixed Models for Repeated Measures at baseline, third, and sixth follow-up (3 and 6 months from baseline).

RESULTS

120 participants (intervention 60, control 60) were randomized. The intervention group had a significantly lower recurrence rate than the control group (15% vs. 35%, p = 0.011) and a significant difference in time to ulceration (log-rank test, p = 0.009) after a 6-month follow-up period. Intervention care reduced the risk of diabetic foot ulcer recurrence by 59% (Hazard ratio 0.41, 95% confidence interval 0.18, 0.96, p = 0.039) in multivariate Cox regression analysis. On the third follow-up, total diabetic foot care behavior score (p < 0.001) was significantly improved by the intervention. On the sixth follow-up, mobility (p = 0.020), self-care (p = 0.023), pain/discomfort (p < 0.001), anxiety/depression (p = 0.016), EuroQol Visual Analogue Scale score (p = 0.002), and total diabetic foot care behavior score (p < 0.001) showed significant improvements in the intervention group.

CONCLUSIONS

Foot care and personalized education delivered at a frequency based on the risk level assessed by thermography effectively reduced diabetic foot ulcer recurrence, and improved quality of life and foot care behaviors.

REGISTRATION NUMBER

UMIN000039012.

TWEETABLE ABSTRACT

Nurse-led diabetic foot care and education reduced diabetic foot ulcer recurrence in Indonesia.

Risk factors of severe hypoglycemia among patients with type 2 diabetes mellitus in outpatient clinic of tertiary hospital in Indonesia

This study aimed to describe risk factors of severe hypoglycemia in type 2 diabetes mellitus (T2DM) patients in a tertiary care hospital in Indonesia. This study was a retrospective cohort study in the Endocrinology Outpatient Clinic of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia. All subjects more than 18 years old who had been visiting the clinic for at least a year were included. Subjects were interviewed whether they had any severe hypoglycemia events within the past year, while data on risk factor variables of severe hypoglycemia was taken from medical records one year before data collection. We recruited 291 subjects, among whom 25.4% suffered at least one episode of severe hypoglycemia within one year. History of severe hypoglycemia (OR 5.864, p ≤ 0.001), eGFR less than 60 mL/min/1.73m2 (OR 1.976, p = 0.028), and insulin use (OR 2.257, p = 0.021) were associated with increased risk of severe hypoglycemia. In conclusion, history of previous severe hypoglycemia, eGFR less than 60 mL/min/1.73m2, and insulin use were associated with severe hypoglycemia.

Development of the information quality scale for health information supply chain type 2 diabetes mellitus management using exploratory factor analysis

Background

Research on the quality scale of the healthcare supply chain is still limited. This study aimed to assess the information quality of the supply chain model with a focus on construct validity. Studies related to information quality measurement generally focus on measuring the dimensions of the completeness of medical records and consumer perspectives. We intended to assess the scale based on doctors needed as care coordinators on type 2 diabetes mellitus or the Non-Insulin-Dependent-Diabetes-Mellitus (NIDDM) program in primary healthcare.

Methods

Sixty-four primary healthcare doctors with an age range of 24-51 years were involved in this research. The scale obtained was formed from the assessment of the point of view of a panel of experts through the content validity index (CVI). The exploratory factor analysis (EFA) method was used to explore the scale of information quality in the information supply chain model for the NIDDM chronic disease management program.

Result

The data analysis results indicated three main factors that affected the quality of the information supply chain model of NIDDM, namely accessibility, safety, and efficiency of information related to NIDDM. The results of the validity and reliability of the data showed that the scale used in this research was valid and reliable with a Cronbach alpha coefficient of 0.861.

Conclusion

The scale developed in this research could be used to explore the quality of the information supply chain of NIDDM management in primary healthcare. Each item on the scale could explain the variables according to their respective groups.

Developing non-exercise activity thermogenesis (NEAT) through building design

Purpose

Physical inactivity has a considerable negative impact on health. Physical activity has reduced partly due to workplace and lifestyle changes, causing people to spend more time in buildings and increasing sedentary behaviour. The purpose of this paper is to address a largely untapped opportunity for designers and managers to improve building users’ health by designing buildings that raise users’ Non-Exercise Activity Thermogenesis (NEAT) levels. In this research a conceptual model was developed to assess buildings’ performance in providing NEAT-promoting opportunities through building design features and management, in relation to building users’ propensity for NEAT behaviours.

Design/methodology/approach

The conceptual model was developed by a multi-disciplinary team of researchers and data to populate the model was obtained through a survey of 75 buildings in Jakarta (Indonesia).

Findings

The presented proof-of-concept shows that the model’s “meso-scale” approach to study physical activity and building design can lead to potential improvements of NEAT levels and physical activity in buildings.

Originality/value

The review of precedent models shows that this subject has been researched at micro-scale (i.e. detailed monitoring of individuals’ movement) and macro-scale (i.e. epidemiological studies of populations’ health). The presented model is original, as it explores a “meso-scale”(i.e. building scale) that is unique.

Effect of Drug Information Service on Clinical Outcome of Patients with Type 2 Diabetes Mellitus in Padang, Indonesia

Type 2 diabetes mellitus (T2DM) has been a health burden worldwide, including Indonesia. However, T2DM therapy needs a long and complex process, which patients often do not favor, thus making them does not take medications as instructed and negatively affecting clinical outcomes. This study aimed to understand the effect of Drug Information Service provision on the clinical outcome of T2DM patients. This quasi-experimental study was conducted using one group pre-post-test design. As the clinical outcome, the fasting blood glucose levels were measured before and after the intervention. A drug information service was provided through direct explanation to the patients. Sociodemographic data were analyzed descriptively. The difference in fasting blood glucose before and after the intervention was assessed using Wilcoxon signed-rank test. Forty patients participated in this study. Most participants are female (N=34; 85%) and receive two-drugs combination therapy of metformin and sulfonylureas (N=32; 77.5%). Although there is a decrease in mean fasting blood glucose level after intervention (174.92±59.561 vs. 184.20±49.768), there is no significant difference between fasting blood glucose levels pre-intervention and post-intervention (p>0.05). It is concluded that despite the noticeable decline of blood glucose level after drug information service, its effect on blood glucose control is not significant.

The cultural beliefs and practices of diabetes self-management in Javanese diabetic patients: An ethnographic study

BACKGROUND

It is important to assess the cultural beliefs and practices of diabetic patients since such beliefs and practices greatly influence how patients self-manage the disease. However, how cultural beliefs and practices affect self-management in Javanese diabetic patients in Indonesia is still unclear since research about it is very limited. Therefore, the purpose of this study was to explore the cultural beliefs and practices of diabetes self-management in Javanese diabetic patients.

METHODS

An ethnographic study was conducted between July 2020 and March 2021 in Banyumas Regency, Indonesia. Forty-seven participants were included, consisting of 36 type 2 diabetes mellitus (T2DM) patients as key informants and 11 family members and health providers as general informants. Purposive and snowball sampling methods were used, and data was collected through in-depth interviews, observations, and the writing of field notes. The data were analyzed by thematic analyses using NVivo 12 software.

RESULTS

Four themes emerged from the data analysis: (1) misconception about diabetes and management, such as the belief of there being dry sugar and wet sugar types of diabetes; the belief that consuming a lot of cold rice does not increase blood glucose; the belief that insulin causes organ damage; the belief that diabetes can be completely cured; and the belief that walking barefoot is good for the body; (2) cultural beliefs and practices regarding treatment regimen, such as use of medicinal plants to lower blood glucose and home remedies to treat foot ulcers; (3) coping influenced by a blend of culture and religion, such as managing stress by submitting to God and being patients in dealing with their disease; (4) cultural influence on diet management, such as facing difficulties managing their diets at cultural events and difficulties managing the habit of eating sweet-tasting food.

CONCLUSION

This is the first study to show that Javanese culture strongly influences how diabetic patients in Java self-manage their disease. Various aspects of Javanese culture were found to have either beneficial or detrimental effects on diabetic patients' health status. This study provides new insights for nurses in Indonesia and will help them design a culturally sensitive education program for their diabetic patients.

The early detection of type 1 diabetes mellitus and latent autoimmune diabetes in adults (LADA) through rapid test reverse-flow immunochromatography for glutamic acid decarboxylase 65 kDa (GAD65)

Background

Diabetes mellitus (DM) is a chronic and costly disease that has become a primary concern worldwide. Type 1 diabetes mellitus is categorized as an autoimmune disease, which results in islet cell apoptosis and insulin-dependent. GAD₆₅ is known as a potential marker of impaired pancreatic β cell function that appears in the initial phase of type 1 DM and latent autoimmune diabetes in adults (LADA). This study aimed to develop a novel rapid test of anti-GAD₆₅ autoantibodies in human serum samples.

Methods

We have developed a rapid test for anti-GAD65 autoantibodies in this assay based on the reverse-flow immunochromatography method. Human recombinant-protein antigen for GAD₆₅ was attached as the control line over the nitrocellulose membrane. On the other side, the goat anti-mouse immunoglobulin G (IgG) was coated on the same membrane as a control line. The positive result for GAD₆₅ was confirmed by a colloidal gold signal on the strip. Our novel assay analyzed 276 healthy subjects and 51 type 1 diabetes individuals serum samples from several ethnicities in Indonesia for this study.

Results

Among the 276 healthy samples, 225 samples were identified as positive for anti-GAD₆₅ autoantibodies, while 51 samples were negative. Interestingly, the positive results for anti-GAD₆₅ autoantibodies were linear to the decreasing of high-density lipoprotein (HDL) levels and inversely associated with triglyceride levels. A significant correlation with age was observed in all groups. The sensitivity and specificity test proved that this kit has higher accuracy (AUC value = 0.960).

Conclusion

The significant advantages of our rapid test for anti-GAD₆₅ autoantibodies provide higher sensitivity, specificity, and stability compared to previous commercial kits. Therefore, it could be proposed as the future clinical diagnostic kit for patient management of type 1 DM.

Undiagnosed diabetes mellitus and associated factors among adults in Ethiopia: a systematic review and meta-analysis

Diabetes has become a major public health problem, with 4.6 million deaths annually. The number of people living with undiagnosed diabetes is on the rise and has a diverse prevalence. Thus, this systematic review and meta-analysis was aimed to synthesize the pooled estimate prevalence of undiagnosed diabetes mellitus, impaired fasting glucose and its associated factors in Ethiopia. The databases Medline, Hinari, Google Scholar, and Google search were used to find potential studies published from January 2013 until January 2021. Extracted data were entered into the excel spreadsheet. The random effects model with Der Simonian-Laird weights was used to assess the pooled estimate of prevalence of undiagnosed diabetes, impaired fasting glucose, and its associated factors. The Cochrane Q-test and I² statistics were used to screen for statistical heterogeneity. A funnel plot and Egger's statistical test were also used to search for any publication bias (small study effect). After extensive searching of articles on different databases, a total of nine studies were included for this systematic review and meta-analysis. In random effects model, the pooled prevalence of undiagnosed diabetes mellitus and impaired fasting glucose was 5.75%, 95% CI (3.90-7.59%), and 8.94%, 95% CI (2.60-15.28%), respectively. Regarding the associated factors, participants family history of diabetes was significantly associated with diabetes status. The pooled odds of developing diabetes mellitus among participants with a family history of diabetes mellitus were about 3.56 times higher than those without a family history of diabetes mellitus (OR = 3.56, 95% CI (2.23, 5.68)). In this review, the higher prevalence of undiagnosed diabetes mellitus and impaired fasting glucose was observed among adults in Ethiopia. Family history of diabetes was found to have an association with increased risk of diabetes mellitus. Our finding highlights the need of screening at the community level, with special focus on adults with family history of diabetes mellitus.

Impact of diabetes mellitus on COVID-19 clinical symptoms and mortality: Jakarta's COVID-19 epidemiological registry

Background and aims

While the higher prevalence of diabetes mellitus (DM) at younger age in Indonesia might contribute to the relatively higher COVID-19 mortality rate in Indonesia, there were currently no available evidence nor specific policy in terms of COVID-19 prevention and management among DM patients. We aimed to find out the association between diagnosed diabetes mellitus (DM) with COVID-19 mortality in Indonesia.

Methods

We performed a retrospective cohort study using Jakarta Province’s COVID-19 epidemiological registry within the first 6 months of the pandemic. All COVID-19 confirmed patients, aged >15 years with known DM status were included. Patients were assessed for their clinical symptoms and mortality outcome based on their DM status. A multivariate Cox-regression test was performed to obtain the relative risk (RR) of COVID-19 mortality in the diagnosed DM group.

Results

Of 20,481 patients with COVID-19, 705 (3.4%) had DM. COVID-19 mortality rate in DM group was 21.28%, significantly higher compared to 2.77% mortality in the non-DM group [adjusted RR 1.98 (CI 95% 1.57–2.51), p < 0.001]. In addition, COVID-19 patients with DM generally developed more symptoms.

Conclusions

DM is associated not only with development of more COVID-19 clinical symptoms, but also with a higher risk of COVID-19 mortality. This finding may provide a basis for future policy regarding COVID-19 prevention and management among diabetes patients in Indonesia.

Towards a Parsimonious Pathway Model of Modifiable and Mediating Risk Factors Leading to Diabetes Risk

Modifiable risk factors are of interest for chronic disease prevention. Few studies have assessed the system of modifiable and mediating pathways leading to diabetes mellitus. We aimed to develop a pathway model for Diabetes Risk with modifiable Lifestyle Risk factors as the start point and Physiological Load as the mediator. As there are no standardised risk thresholds for lifestyle behaviour, we derived a weighted composite for Lifestyle Risk. Physiological Load was based on an index using clinical thresholds. Sociodemographics are non-modifiable risk factors and were specified as covariates. We used structural equation modeling to test the model, first using 2014/2015 data from the Indonesian Family Life Survey. Next, we fitted a smaller model with longitudinal data (2007/2008 to 2014/2015), given limited earlier data. Both models showed the indirect effects of Lifestyle Risk on Diabetes Risk via the mediator of Physiological Load, whereas the direct effect was only supported in the cross-sectional analysis. Specifying Lifestyle Risk as an observable, composite variable incorporates the cumulative effect of risk behaviour and differentiates this study from previous studies assessing it as a latent construct. The parsimonious model groups the multifarious risk factors and illustrates modifiable pathways that could be applied in chronic disease prevention efforts.

The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study

Background: Despite the known importance of breastfeeding for women's and children's health, global exclusive prevalence among infants under 6 months old is estimated at only 41%. In 2018, Indonesia had a lower exclusive breastfeeding rate of 37% at 6 months postpartum; ranging from 20% to 56%, showing unequal breastfeeding support throughout the country. The World Health Organization (WHO) launched the Ten Steps to Successful Breastfeeding (Ten Steps) in 1989, later embedded in UNICEF's Baby-Friendly Hospital Initiative (BFHI) program in 1991. The BFHI aims to encourage maternity facilities worldwide to ensure adequate education and support for breastfeeding mothers by adhering to the Ten Steps and complying with the International Code of Marketing of Breastmilk Substitutes. An Indonesian survey in 2011 found that less than one in 10 government hospitals implemented the Ten Steps. It has been common for Indonesian health services to collaborate with infant formula companies. While no Indonesian hospitals are currently BFHI-accredited, the WHO/UNICEF Ten Steps (updated in 2018) have been adopted in Indonesia's national regulation of maternity facilities since 2012. Internationally, implementation of the Ten Steps individually and as a package has been associated with benefits to breastfeeding rates and maternal and infant health. However, to date, few studies have examined the impact of implementing the Ten Steps in economic terms. This study aims to measure the economic benefit of Ten Steps implementation in an Indonesian hospital. Methods: The study was conducted in January 2020 in Airlangga University Hospital, Surabaya, Indonesia, which has implemented the Ten Steps since it was established in 2012. To understand and generate evidence on the social value of the Ten Steps, we conducted a "Social Return on Investment (SROI)" study of implementing the Ten Steps in this maternity facility. To estimate the costs relating to the Ten Steps we interviewed the financial and nursing managers, a senior pediatrician, and senior midwife due to their detailed understanding of the implementation of the Ten Steps in the hospital. The interview was guided by a questionnaire which we developed based on the 2018 WHO/UNICEF Ten Steps to Successful Breastfeeding. The analysis was supported with peer-reviewed literature on the benefits of Ten Steps breastfeeding outcomes. Results: The total per annum value of investment (cost) required to implement Ten Steps in Airlangga University Hospital was US$ 972,303. The estimate yearly benefit was US$ 22,642,661. The social return on the investment in implementing Ten Steps in this facility was calculated to be US$ 49 (sensitivity analysis: US$ 18-65). Thus, for every US$ 1 invested in Ten Steps implementation by Airlangga Hospital could be expected to generate approximately US$ 49 of benefit. Conclusions: Investment in the Ten Steps implementation in this Surabaya maternity facility produced a social value 49 times greater than the cost of investment. This provides novel evidence of breastfeeding as a public health tool, demonstrating the value of the investment, in terms of social impact for mothers, babies, families, communities, and countries. Breastfeeding has the potential to help address inequity throughout the lifetime by providing the equal best start to all infants regardless of their background. Indonesia's initial moves towards implementing the WHO/UNICEF Ten Steps can be strengthened by integrating all elements into the national regulation and health care system.

The Impact of COVID-19 Lockdown on Diabetes Complication and Diabetes Management in People With Diabetes in Indonesia

Aims: As the country with the seventh largest number of People with Diabetes (PWD) in the world, the Coronavirus disease 2019 (COVID-19) pandemic, and the Large Social Scale Restriction (LSSR) policy taken by the Indonesian government to reduce the number of COVID-19 transmissions is estimated to interfere diabetes management and will increase the incidence of diabetes complications. This study aims to determine the difficulties of diabetes management and its impact on diabetes morbidity during the COVID-19 pandemic in Indonesia. Methods: This study is a cross-sectional study using a national scale web survey. This research was conducted in Indonesia enrolling 1124 PWD aged 18 years or older. Diabetes complications are defined as self-assessed incidence of hypoglycemia, or Diabetic Foot Ulcer (DFU), or hospital admission experienced by PWD in Indonesia during the COVID-19 pandemic. The correlation between diabetes management difficulties and diabetes-related complications was measured using a modified cox regression test. Results: Diabetes management difficulties were experienced by 69.8% of PWD in Indonesia. The difficulties include attending diabetes consultation 30.1%, access to diabetes medication 12.4%, checking blood glucose levels 9.5%, controlling diet 23.8%, and performing regular exercise 36.5%. Diabetes-related complications occurred in 24.6% of subjects. Those who had diabetes management difficulties during the COVID-19 pandemic are prone to have diabetes complications by 1.4 times greater (PR: 1.41, 95% CI: 1.09-1.83) than those who did not. Conclusion: The COVID-19 pandemic and LSSR have impact on diabetes management and diabetes-related complications as assessed by PWD in Indonesia.

The barriers and facilitators of foot care practices in diabetic patients in Indonesia: A qualitative study

AIM

To investigate the barriers and facilitators of foot care practice in diabetic patients in Indonesia.

DESIGN

A qualitative content analysis with an inductive approach.

METHOD

Semi-structured interviews were conducted on 34 type 2 diabetes mellitus (T2DM) patients, health providers and family members in Purwokerto, Indonesia, between July 2020 and December 2020. The interview transcripts were coded using NVivo 12.

RESULTS

Four themes emerged from data analysis, including personal barriers (low susceptibility of developing foot ulcer, limited knowledge about foot care, fatalistic practices, financial problems, glucose control taking priority over foot care, lack of motivation, lack of confidence, fear of being labelled), environmental barriers (lack of knowledge and time of health providers, lack of family support and climate conditions), perceived foot health benefits (intention to feel better and desire to stay socially active) and religious practices (foot washing as part of religious practice and intention to feel clean before praying).

Modulatory effect of Artocarpus camansi on ILP-2, InR, and Imp-L2 genes of sucrose -induced diabetes mellitus in Drosophila melanogaster

Diabetes mellitus continues to be a menace, being one of the five major causes of death in the world. In this study, the common fruit fly, Drosophila melanogaster, a well-studied genetic model organism for understanding molecular mechanisms of human diseases, and Artocarpus camansi (breadnut), an underutilized fruit, was used. This study was aimed at investigating the antihyperglycemic potentials of Artocarpus camansi fruit in sucrose-induced diabetic Drosophila melanogaster. Phytochemical screening was carried out after the fruit has been pulverized and freeze-dried. Total phenol content and total flavonoid content were carried out in vitro on the aqueous extract of Artocarpus camansi, and the result obtained showed that its phenol content is low, and its flavonoid content increases at increasing concentrations. Alpha-amylase inhibitory activity was carried out in vivo on sucrose-induced diabetic Drosophila melanogaster tissue. Gene expression profiling of Insulin-like peptide-2 (ILP-2), Insulin-like receptor (InR) and Ecdysone inducible gene L2 (Imp-L2) was carried out on trizol homogenate of Drosophila melanogaster tissue. In this study, Drosophila melanogaster was divided into nine groups. Group1 served as the basal control as they were fed with normal basal diet, group II served as the negative control which were fed with basal diet and 0.5 mL sucrose/100 mL distilled water, group III served as the positive control which were fed with basal diet 0.5 mL sucrose/100 mL distilled water and metformin, groups IV and V which were fed with basal diet and 0.1 and 1% Artocarpus camansi respectively, groups VI and VII were fed with basal diet, sucrose and 0.1 and 1% Artocarpus camansi respectively, groups VIII and IX served the purpose of the synergistic effect which were fed with basal diet, sucrose, metformin and 0.1 and 1% Artocarpus camansi respectively. All the groups were left for seven days. The experiment was conducted for 3 months and the fruit fly meals were changed every 5 days. Gene expression profiling results showed that the dietary inclusion of fruit downregulated the expression of ILP-2 and InR and upregulated the expression of Imp-L2 when the diabetic group were compared with the normal control. The results suggest that Artocarpus camansi fruit could possess antihyperglycemic properties and its use as a nutraceutical in the alleviation of diabetes should be encouraged.

Antihyperglycemic, Endothelial protection and Toxicity study of Basil Leaves Extract on Diabetic Rats

BACKGROUND: Diabetes Mellitus (DM) remains a serious debilitating global health problem in low- and middle-income countries with rising incidence of DM-related complications due to ineffective Diabetic control. Herbs of the Ocimum family, especially Ocimum basilicum or basil leaves, have been investigated for their antihyperglycemic properties. AIM: This study aimed to demonstrate the antihyperglycemic effect, endothelial protection, and toxicity of basil leaves on Diabetes-induced Wistar rats in vivo. METHODS: Streptozosin injections were used to induced diabetes in male Wistar rats. Basil leaves extracts 100, 300, and 1000 mg/kg BW were introduced to diabetic rats. Blood glucose levels (BGL), soluble Advanced Glycation End, tumor necrosis factor-α, interleukin (IL)-6, IL-2 were measured using enzyme-linked immunosorbent assay. Kidney and liver functions together with the histopathology reports were reported for acute, subacute, and chronic toxicity studies. RESULTS: Basil leaves exposure significantly lowers BGL (p < 0.00), but yielded no statistically significant difference between extract doses. Hemostatic parametersshowed significantly reduced endothelial dysfunction markers for all doses compared to control. Toxicity study yielded no differences between control and any doses of basil leaves in all acute, subacute, and chronic toxicity studies. Histopathological findings exhibited no evidence of tissue damage on the liver, kidney, heart, pancreas, lung, and lymph tissues in either control or experiment rats. CONCLUSIONS: Basil leaves exposure were positively associated with lower glucose level, lower endothelial activation markers on Diabetic rats. The toxicity and histopathological results of the extract are on par with control.

Screening diabetes mellitus patients for pulmonary tuberculosis: a multisite study in Indonesia, Peru, Romania and South Africa

BACKGROUND

Diabetes mellitus (DM) patients are three times more likely to develop tuberculosis (TB) than the general population. Active TB screening in people with DM is part of a bidirectional approach. The aim of this study was to conduct pragmatic active TB screening among DM patients in four countries to inform policy.

METHODS

DM patients were recruited in Indonesia (n=809), Peru (n=600), Romania (n=603) and South Africa (n=51). TB cases were diagnosed using an algorithm including clinical symptoms and chest X-ray. Presumptive TB patients were examined with sputum smear and culture.

RESULTS

A total of 171 (8.3%) individuals reported ever having had TB (South Africa, 26%; Indonesia, 12%; Peru, 7%; Romania, 4%), 15 of whom were already on TB treatment. Overall, 14 (0.73% [95% confidence interval 0.40 to 1.23]) TB cases were identified from screening. Poor glucose control, smoking, lower body mass index, education and socio-economic status were associated with newly diagnosed/current TB. Thirteen of the 14 TB cases diagnosed from this screening would have been found using a symptom-based approach.

CONCLUSIONS

These data support the World Health Organization recommendation for routine symptom-based screening for TB in known DM patients in high TB-burden countries. DM patients with any symptoms consistent with TB should be investigated and diagnostic tools should be easily accessible.

Challenges of Shifting Diabetes Mellitus Care From Secondary- to Primary-Level Care in Urban and Rural Districts: A Qualitative Inquiry Among Health Providers

Objectives: The study aims to understand the acceptability of Prolanis, a program that shifts the diabetes mellitus type 2 (T2DM) patient management from secondary to primary care, among Indonesian primary health care providers. Method: We completed face-to-face semistructured interviews with 14 health professionals from 3 urban and 4 rural government-owned primary health care clinics (Puskesmas) in 4 districts. We performed content analysis using the theoretical framework of acceptability (TFA) to understand which factors could facilitate or reduce acceptability. Results: Our study identifies that lack of health care providers’ acceptability to Prolanis was attributable to the negative affective attitude, low perceived effectiveness, poor self-efficacy, and work burden. The use of Prolanis output as one of the pay-for-performance indicators was deemed unsuitable because it could demotivate health providers to capture more undetected T2DM cases. This, compounded by lacking perceived benefit for the health care providers, leading to negative attitudes. Participants believed that the program improved patients’ adherence to visiting clinics routinely; however, the absence of a formal evaluation of reductions of key T2DM indicators—blood glucose level and HbA1c—causing the health providers to doubt the program effectiveness. Availability of or access to adequate blood glucose testing equipment is also of paramount importance to improve acceptability. Although the significant increase in patient load only occurred to Puskesmas with lacking doctors, an increased workload burden due to clerical works was experienced by the nonmedical workforce. The program appears to be more acceptable for health care providers in urban Puskesmas compared with their rural counterparts, attributable to better geographical accessibility and care-seeking behavior among people living in urban locations. Conclusions: This study highlights critical issues that should be addressed to improve the acceptability of Prolanis among health care professionals. Government or stakeholders play a critical role in improving program acceptability. More study is needed to capture wider variety of health care facilities’ characteristics.

The Pattern of Peroxisome Proliferator-activated Receptor Gamma Coactivator 1-alpha Gene Expression in Type-2 Diabetes Mellitus Rat Model Liver: Focus on Exercise

BACKGROUND: Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) has an important role in mitochondria biogenesis which generated cellular metabolism. Carbohydrate metabolism in the liver is crucial to maintain plasma blood glucose. AIM: This research aimed to determine the expression of PGC-1α gene in the liver type-2 diabetes mellitus (T2DM) rat model, after treatment with a focus on exercise. METHODS: We used 25 healthy male Wistar rats as subjects. Rats were modified to T2DM models by feeding a high-fat diet and low-dose streptozotocin injection. We divided the rats into five groups, that is, sedentary group as a control and four others as treatment groups. The exercise was assigned for treatment groups by a run on the treadmill as moderate intensity continuous (MIC), highintensity continuous (HIC), slow interval (SI), and fast interval (FI). The treatment groups were exercise throughout 8 weeks with a frequency of 3 times a week. RESULTS: The results showed that expression of PGC-1α gene was lower in all treatment groups compared to controls (p < 0.05). Expression in HIC was higher than MIC (p < 0.05), so was the expression in FI more than SI (p < 0.05). CONCLUSIONS: Exercise affected PGC-1α gene expression in the liver of the T2DM rat model. The expression of PGC-1α was linear with exercise intensity.

Non-vascular contributing factors of diabetic foot ulcer severity in national referral hospital of Indonesia

PURPOSE

Diabetic foot ulcer (DFU) is a common chronic complication of type 2 diabetes mellitus (T2DM) in Indonesia, with a prevalence of 7.3%. However, the characteristics of these patients remain unclear. We investigated the characteristics of patients with DFU without peripheral arterial disease (PAD) and analyzed non-vascular factors related to severity of DFU in a tertiary care national referral hospital in Indonesia.

METHODS

This was a cross-sectional study including 123 hemodynamically stable DFU patients without PAD recruited from Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia from 2010-2015.

RESULTS

DFU patients were predominantly over 50 years old (75.6%) and diagnosed with T2DM for 5 years with poor glycemic control (82.7%) and peripheral neuropathy (91.3%). Most patients had anemia (86.7%), leukocytosis (84.6%), and were undernourished, as characterized by a low lipid profile (90.8%) and hypoalbuminemia (83.7%). Most had extensive size of ulcer at the initial visit, with a median size of 16.23 (2.92-60.16) cm2. Ulcers were mostly located of the forefoot (62.5%) and were caused by mechanical trauma (46.2%). Bivariate analysis revealed that significant factors for the development of DFU were related to DFU size, including duration of T2DM (p = 0.04), leukocyte levels (p =  < 0.01), and thrombocyte levels (p =  < 0.01). Multivariate analysis showed leucocyte (p = 0.03) and thrombocyte (p = 0.023) had significantly correlated with DFU severity.

CONCLUSION

Leucocyte and thrombocyte may be the greatest contributing non-vascular factors for severity of DFU in Indonesia.

Incidence of concomitant illnesses in pregnancy in Indonesia: Estimates from 1990-2019, with projections to 2030

Background

‘Indirect’ causes of maternal death including concomitant illnesses such as infectious and non-communicable diseases (NCDs), accounted for 23% of maternal deaths in Indonesia in 2010. Reproductive-age women in Indonesia face a “double burden” of disease with increasing rates of NCDs and persisting rates of infectious disease. However, there is a lack of data on the burden of these diseases in pregnancy. The aim of this study was to estimate incidence of concomitant illnesses among pregnant women in Indonesia from 1990–2030.

Methods

Publicly available data was accessed including incidence of concomitant illnesses in Indonesian reproductive-age women, population data and crude birth rate data from 1990–2019, and formed basis for projections to 2030. A dataset of estimates for all variables was generated for each year and sampled from a binomial distribution. Using these estimates, pregnancy estimates and incidence in pregnant women were calculated. A cubic splines model was fitted to generate estimates of incidence of concomitant illnesses in pregnancy.

Findings

Past trends to 2019 show a decline in incident cases of infectious diseases except for HIV/AIDs, and an increase in most NCDs. In 2019, the most common disease was sexually transmitted infections. From 2020–2030, incidences of diabetes and lower respiratory infections are estimated to continue to increase.

Interpretation

With an increasing incidence of NCDs and high-incidence of infectious diseases in pregnancy, Indonesian policymakers and stakeholders should consider what evidence-based strategies and interventions are best to reduce potential impacts of concomitant illnesses on pregnancy outcomes.

Funding

Australian Government Research Training Program Scholarship.

Rural-Urban Differences in Adult Life Expectancy in Indonesia: A Parametric g-formula-based Decomposition Approach

BACKGROUND

Evidence on rural-urban differences in adult mortality in low- and middle-income countries (LMICs) is limited and mixed. We examined the size of and factors contributing to rural-urban life expectancy differences among adults in Indonesia, the third most populous LMIC.

METHODS

Data come from the 2000, 2007, and 2014/2015 waves of the Indonesian Family Life Survey, a population-representative longitudinal study with mortality follow-up. We used Poisson regression and life tables to estimate rural-urban differences in life expectancy among 18,867 adult respondents ≥30 years. We then used a novel g-formula-based decomposition to quantify the contribution of rural-urban differences in blood pressure (BP), body mass index (BMI), and smoking to life expectancy differences.

RESULTS

Compared with urban adults, life expectancy at age 30 was 2.2 (95% confidence interval [CI] = 0.4, 3.9) years higher for rural men and 1.2 (95% CI = -0.4, 2.7) years higher for rural women. Setting the BMI and systolic BP distribution equal in urban and rural adults reduced the urban mortality penalty by 22% for men and 78% for women, with the majority of this reduction coming from the contribution of rural-urban differences in BMI. Smoking did not contribute to the urban mortality penalty for either men or women.

CONCLUSIONS

Adult life expectancy is lower in urban than in rural areas in Indonesia and we estimate that this difference is partly related to differences in BMI and systolic BP.

Cost-Effectiveness Analysis of Type 2 Diabetes Mellitus (T2DM) Treatment in Patients with Complications of Kidney and Peripheral Vascular Diseases in Indonesia

Type 2 diabetes mellitus (T2DM) is a chronic disease with high-cost treatment. This study aimed to analyze the cost-effectiveness of T2DM treatment in hospitalized patients with complications of kidney and peripheral vascular disease (PVD) in Indonesia by focusing on patients of Health Social Security Agency (BPJS Kesehatan). An observational study was applied by collecting data retrospectively from patients’ medical record at the biggest public hospital in West Java Province, Indonesia. Two perspectives of payer and healthcare provider were applied to estimate the treatment cost. We considered following inclusion criteria: (i) Hospitalized T2DM patients without complication, with complications of kidney and PVD during 2014–2017; (ii) member of BPJS Kesehatan; (iii) >18 years old patients; and (iv) patients with complete medical record data. The results showed that the majority patients were female (56.72%), 45–64 years old (69.40%), and had a length of stay at 4–10 days (54.48%). The greatest contributions in the total treatment cost were found to be hospital room, medical services and medicines for the treatment of T2DM without complications, with complications of kidney and PVD, respectively. From the perspective of payer, the incremental cost-effectiveness ratios (ICERs) of T2DM treatment with complications of kidney and PVD would be IDR 215,723 and IDR 234,591 per 1 mg/dL blood glucose reduction, respectively. From the perspective of healthcare provider, the ICERs of T2DM treatment with complications of kidney and PVD would be IDR 166,289 and IDR 681,853 per 1 mg/dL blood glucose reduction in both perspectives (1 US$ = IDR 13,451). In a comparison with T2DM without complication, reducing 1 mg/dL blood glucose in T2DM treatment with complication of PVD would require higher cost than in T2DM treatment with complication of kidney from both perspectives.

Type 1 diabetes mellitus in children: experience in Indonesia

The prevalence of type 1 diabetes mellitus (T1DM) in children in Indonesia is increasing although the real number is unknown due to high rate of misdiagnosis. Public and healthcare awareness on T1DM in children is still low, reflected by the high number of children diagnosed with diabetic ketoacidosis (DKA). The Indonesian Pediatric Society (IPS) had published a guideline on T1DM management, which consists of insulin injection, daily monitoring of blood glucose, nutrition, physical activity, and education. Aside from low awareness, current challenges on T1DM management in Indonesia are funding by the national health insurance, fasting during Ramadan, and inequities on DM care. The involvement of society, healthcare workers, stakeholders, and the government is of importance to ensure optimal management for children with diabetes.

The nursing outlook of the self- and family management support programs among Indonesian with diabetes: An umbrella review

BACKGROUND AND AIMS

Diabetes is one of the most critical diseases particularly in developing countries such as Indonesia. Various diabetes approaches have been well conducted to prevent complications. However, little has been discussed in association with the achievement of self- and family management support programs in Indonesia. Thus, the objective of the umbrella review is to evaluate the implementation of the self- and family management support programs among Indonesian with diabetes.

METHOD

To guide this review, the revised self- and family management framework developed by Grey, Schulman-Green, Knafl, and Reynolds (2015) was used. A literature search was conducted via online databases including Cochrane, Scopus, ProQuest, SAGE, EBSCO, and PubMed. The inclusion criteria were diabetes studies related to self- and family management in Indonesia; articles published from 2000 to 2019; quantitative, qualitative, and review studies; used humans as research subjects; and English articles were prioritized. Meanwhile, the exclusion criteria were studies not addressing the nature of self- and family management in Indonesia, laboratory-based research using human cell and study protocol.

RESULTS

A total of 78 studies were involved in the final analysis. The facilitators and barriers, process, and outcomes (distal and proximal) were presented. The results indicated that the implementation of the self- and family management process generated favorable outcomes for the diabetes population in Indonesia.

CONCLUSIONS

The self- and family management support program is a promising strategy to improve the facilitators and overcome the barriers to diabetes care. Patients, families, diabetes nurses, and health policymakers are recommended to work in tandem to achieve successful diabetes care, particularly in the community.

The Impact of the Indonesian Chronic Disease Management Program (PROLANIS) on Metabolic Control and Renal Function of Type 2 Diabetes Mellitus Patients in Primary Care Setting

BACKGROUND

Indonesia through its government National Health Insurance System has launched a non-communicable and chronic disease management program named Indonesian Chronic Disease Management Program (PROLANIS), with Type 2 Diabetes Mellitus (T2DM) and hypertension as the main focus. However, study that evaluates the clinical impact of PROLANIS in patients with T2DM is still scarce to this date. This study aims to evaluate the metabolic control and renal function of PROLANIS participants with T2DM every six month within the first 18-months of implementation.

METHODS

This study was a retrospective cohort study conducted at Wates sub-district, East Java using secondary data from PROLANIS group report from April 2018 to October 2019. The study population was T2DM patients who voluntarily joined the PROLANIS group in April 2018. The six-month-evaluation included metabolic parameters [body mass index (BMI), blood pressure, hemoglobin A1C, total cholesterol, high-density lipid, low-density lipid, and triglyceride (TG)] and renal parameters [blood urea nitrogen (BUN), creatinine serum, and urinary microalbumin]. Paired t-test and wilcoxon signed-rank test was used for the analysis, and the P-value was adjusted using Bonferroni correction. A P-value < .0015 was considered statistically significant, while a P-value between .0015 and .003 was considered as marginally significant.

RESULTS

A total of 30 participants were included in the analysis. Following the PROLANIS implementation, the only parameter of metabolic control that showed significant improvement was TG serum level (P < .001). Despite the worsening status of other metabolic parameters, the changes were not statistically significant except for BMI that was marginally significant (P = .002). From renal function, only BUN serum level was significantly deteriorated (P < .001), while the others did not significantly change.

CONCLUSION

PROLANIS implementation in our study population seems to be ineffective. Future study with more primary healthcare centers needs to be done to scrutinize the clinical impact of this program nationwide.

Burden of metabolic diseases in Indonesia: an even more critical issue during COVID-19 pandemic

[No abstract available]

Assessing the prospect of a common health-related stigma reduction response: Cross-perspectives of people living with stigmatised health conditions in Indonesia

ABSTRACTThis study explored the possibility of a common health-related stigma reduction intervention among people living with HIV, leprosy, schizophrenia and diabetes in Indonesia by assessing their perspectives towards others with the same (within group) and different health conditions (across groups), and willingness to participate in such a program. This mixed-methods study was conducted in West Java, Indonesia between March and June 2018. Eighty participants completed a survey with social distance scale (SDS), while 12 focus group discussion were conducted. Participants with HIV, leprosy and diabetes reported lower within-group SDS scores (4.14 ± 3.65; 4.25 ± 3.95; 7.23 ± 5.31, respectively) while those with schizophrenia reported the highest within-group SDS score (7.76 ± 4.63). Participants with diabetes reported a twofold higher across-group SDS score towards people with the other three health conditions (p < 0.05). The qualitative findings showed that the perception of participants towards one another was shaped by knowledge, understanding and relatedness to the experience of living with health-related stigma. Overall, participants supported the idea of a common stigma reduction intervention for different health conditions, but recommended step-wise implementation of such interventions. Accordingly, this study recommends piloting a common stigma reduction intervention with special focus on fostering understanding, awareness and empathy between people living with different health conditions.

Interaction between the genetic risk score and dietary protein intake on cardiometabolic traits in Southeast Asian

Background

Cardiometabolic diseases are complex traits which are influenced by several single nucleotide polymorphisms (SNPs). Thus, analysing the combined effects of multiple gene variants might provide a better understanding of disease risk than using a single gene variant approach. Furthermore, studies have found that the effect of SNPs on cardiometabolic traits can be influenced by lifestyle factors, highlighting the importance of analysing gene-lifestyle interactions.

Aims

In the present study, we investigated the association of 15 gene variants with cardiometabolic traits and examined whether these associations were modified by lifestyle factors such as dietary intake and physical activity.

Methods

The study included 110 Minangkabau women [aged 25–60 years and body mass index (BMI) 25.13 ± 4.2 kg/m²] from Padang, Indonesia. All participants underwent a physical examination followed by anthropometric, biochemical and dietary assessments and genetic tests. A genetic risk score (GRS) was developed based on 15 cardiometabolic disease-related SNPs. The effect of GRS on cardiometabolic traits was analysed using general linear models. GRS-lifestyle interactions on continuous outcomes were tested by including the interaction term (e.g. lifestyle factor*GRS) in the regression model. Models were adjusted for age, BMI and location (rural or urban), wherever appropriate.

Results

There was a significant association between GRS and BMI, where individuals carrying 6 or more risk alleles had higher BMI compared to those carrying 5 or less risk alleles (P = 0.018). Furthermore, there were significant interactions of GRS with protein intake on waist circumference (WC) and triglyceride concentrations (P_interaction = 0.002 and 0.003, respectively). Among women who had a lower protein intake (13.51 ± 1.18% of the total daily energy intake), carriers of six or more risk alleles had significantly lower WC and triglyceride concentrations compared with carriers of five or less risk alleles (P = 0.0118 and 0.002, respectively).

Conclusions

Our study confirmed the association of GRS with higher BMI and further showed a significant effect of the GRS on WC and triglyceride levels through the influence of a low-protein diet. These findings suggest that following a lower protein diet, particularly in genetically predisposed individuals, might be an effective approach for addressing cardiometabolic diseases among Southeast Asian women.

Improving clinical outcomes of diabetic foot ulcers by the 3-month self- and family management support programs in Indonesia: A randomized controlled trial study

BACKGROUND AND AIMS

Diabetic foot ulcers are the leading cause of lower extremity amputations, which require more effective prevention. Even though previous nursing studies on diabetic foot ulcers have been well performed, programs implementing self- and family management are limited and even underexplored. Therefore, the purpose of the study was to investigate the effect of 3-month self- and family management support programs on clinical outcomes among Indonesians with diabetic foot ulcers.

METHOD

The randomized controlled trial design was used to answer the research question of the study. A total of 56 eligible participants were enrolled, with 27 in the experimental group and 29 in the control group. The experimental group received self- and family management support programs for three months. Meanwhile, the control group received usual care. Descriptive statistics, multivariate analysis of variance, and Generalized Estimating Equations were used to analyze the data. The significance level was considered at .05 for hypothesis testing.

RESULTS

The study showed that there were statistically significant improvements in self-management, family supports, hemoglobin A1c, and wound size after implemented the programs for three months (p < .05).

CONCLUSIONS

With regard to the result of the study, implementing the 3-month self- and family management support programs improves the patients' and families' abilities to perform diabetic foot ulcer care at home.

Topical ozonated virgin coconut oil improves wound healing and increases HSP90α, VEGF-A, EGF, bFGF and CD34 in diabetic ulcer mouse model of wound healing

Background: Diabetes is a disease that affects people worldwide, including in Indonesia. The prevalence of diabetes in Indonesia is increasing from year to year. One of the most devastating complications of diabetes mellitus is diabetic ulcers, which is a limb-threatening complication. Over the past few decades, ozone generated using plasma medical technology has been investigated as an agent that helps wound healing. This study aims to evaluate the effects of topical ozonated virgin coconut oil (VCO) in a diabetic wound mouse model. Methods: This study was an experimental study with a post-test control design. An ulcer wound model was made in 50 diabetic male Wistar mice, divided into five groups, and a control group of 10 non-diabetic mice. The control groups were given conventional therapy only and the treatment groups were also given topical ozonated VCO with different flow durations (0 min, 90 min, 7 h, 14 h). Macroscopic appearance and wound contraction were observed. HSP90β, VEGF-A, EGF, bFGF and CD34 levels were measured from the immunostained slices of wound margins. Results: The reduction of wound length was proportionally related to the duration of ozone flow. Ozonated VCO with a longer duration of ozone flow healed the wound more quickly and had the shortest wound length. VCO with ozone flow for 14 hours (16837.10 µm) had the biggest reduction in wound length compared to other groups. The wounds treated with ozonated VCO showed an increase in HSP90β, VEGF-A, EGF, bFGF and CD34 levels that correlated to improved wound healing. A longer period of treatment resulted in higher levels of wound healing biomarkers compared to shorter therapeutic durations. Conclusions: Topical ozonated VCO improved the wound healing process in a diabetic ulcer mouse model by improving macroscopic wound appearance and increasing levels of wound healing biomarkers.

A nutrigenetics approach to study the impact of genetic and lifestyle factors on cardiometabolic traits in various ethnic groups: findings from the GeNuIne Collaboration

Several studies on gene-diet interactions (nutrigenetics) have been performed in western populations; however, there are only a few studies to date in lower middle-income countries (LMIC). A large-scale collaborative project called gene-nutrient interactions (GeNuIne) Collaboration, the main objective of which is to investigate the effect of GeNuIne on cardiometabolic traits using population-based studies from various ethnic groups, has been initiated at the University of Reading, UK. While South Asians with higher genetic risk score (GRS) showed a higher risk of obesity in response to a high-carbohydrate diet, South East and Western Asian populations with higher GRS showed an increased risk of central obesity in response to a high-protein diet. The paper also provides a summary of other gene-diet interaction analyses that were performed in LMIC as part of this collaborative project and gives an overview of how these nutrigenetic findings can be translated to personalised and public health approaches for the prevention of cardiometabolic diseases such as obesity, type 2 diabetes and CVD.

Predicting Healthy Lifestyle Behaviours Among Patients With Type 2 Diabetes in Rural Bali, Indonesia

Background

Type 2 diabetes is a lifelong metabolic disease closely related to unhealthy lifestyle behaviours. This study aimed to identify factors explaining the healthy lifestyle behaviours of patients with type 2 diabetes in rural Indonesia. The extended health belief model, demographic characteristics, clinical lifestyle factors and diabetes knowledge were investigated to provide a complete description of these behaviours.

Method

A sample of 203 patients with type 2 diabetes representing a cross-section of the population were recruited from community health centres in the rural areas of Bali province. The data were collected through questionnaires. Descriptive statistics and a hierarchical regression test were employed.

Results

This study showed demographic characteristics, clinical and lifestyle factors, diabetes knowledge and the extended health belief model accounted for 71.8% of the variance in healthy lifestyle behaviours of patients with type 2 diabetes in rural Indonesia. The significant demographic factors were age, education level, employment status and traditional beliefs. The significant clinical and lifestyle factors were alcohol use, diabetic medicine and duration of symptoms. Finally, the significant extended health belief model factors were perceived severity, susceptibility, barriers, family support, bonding social capital and chance locus of control.

Conclusions

The extended health belief model forms an adequate model for predicting healthy lifestyle behaviours among patients with diabetes in rural Indonesia. The contribution of this model should be strengthened in developing the diabetes management.

Projected burden of type 2 diabetes mellitus-related complications in Singapore until 2050: a Bayesian evidence synthesis

OBJECTIVE

We examined the effects of age, gender, and ethnicity on the risk of acute myocardial infarction, stroke, and end-stage renal disease according to type 2 diabetes mellitus status among adults aged 40-79 in Singapore.

METHODS

A Bayesian inference framework was used to derive age-specific, gender-specific and ethnicity-specific prevalence of type 2 diabetes mellitus from the 2010 Singapore National Health Survey, and age-standardized gender and ethnicity-specific incidence rates of acute myocardial infarction, stroke and end-stage renal disease from the National Registry of Diseases Office. Population forecasts were used in tandem with incidence rates to project the future chronic disease burden until 2050.

RESULTS

The highest relative risk of acute myocardial infarction was observed in the youngest age group (aged 40-44), with higher relative risk for women (men: 4.3 (2.7-6.4); women: 16.9 (9.3-28.3)). A similar trend was observed for stroke (men: 6.5 (4.2-9.7); women: 10.7 (6.0-17.4)). For end-stage renal disease, the highest relative risk was for men aged 45-50 (11.8 (8.0-16.9)) and women aged 55-60 (16.4 (10.7-24.0)). The annual incidence of acute myocardial infarction is projected to rise from 9300 (in 2019) to 16 400 (in 2050), the number of strokes from 7300 to 12 800, and the number of end-stage renal disease cases from 1700 to 2700.

CONCLUSIONS

Type 2 diabetes mellitus was associated with an increased risk of complications and is modulated by age and gender. Prevention and early detection of type 2 diabetes mellitus can reduce the increasing burden of secondary complications.

The prevalence of metabolic syndrome and its association with body fat distribution in middle-aged individuals from Indonesia and the Netherlands: a cross-sectional analysis of two population-based studies

BACKGROUND

The prevalence of metabolic syndrome varies among populations with different ethnicities. Asian populations develop metabolic complications at lower amounts of adiposity than western populations. The role of abdominal obesity in the metabolic differences between the two populations is poorly understood.

OBJECTIVES

Our objectives were to estimate the prevalence of metabolic syndrome and the relative contribution of its components in the Indonesian and the Dutch population, as well as to examine the associations of overall and abdominal obesity with metabolic syndrome.

METHODS

In this cross-sectional study of middle-aged adults in the Netherlands Epidemiology of Obesity Study (n = 6602) and the Indonesian National Health Surveillance (n = 10,575), metabolic syndrome was defined by the unified IDF and AHA/NHLBI criteria. We performed logistic and linear regressions to examine associations of BMI and waist circumference with the metabolic syndrome, mutually adjusted for waist circumference and BMI.

RESULTS

The prevalence of metabolic syndrome was 28% and 46% in Indonesian men and women, and 36% and 24% in Dutch men and women. The most prominent components were hypertension (61%) and hyperglycemia (51%) in the Indonesian, and hypertension (62%) and abdominal obesity (40%) in the Dutch population. Per SD in BMI and waist circumference, odds ratios (ORs, 95% CI) of metabolic syndrome were 1.5 (1.3-1.8) and 2.3 (1.9-2.7) in Indonesian men and 1.7 (1.2-2.5) and 2.9 (2.1-4.1) in Dutch men. The ORs of metabolic syndrome were 1.4 (1.2-1.6) and 2.3 (2.0-2.7) in Indonesian women and 1.0 (0.8-1.3) and 4.2 (3.2-5.4) in Dutch women.

CONCLUSION

More Indonesian women than men have metabolic syndrome, whereas the opposite is true for the Dutch population. In both the Indonesian and the Dutch populations, hypertension is the primary contributor to the prevalence of metabolic syndrome. In both populations, abdominal adiposity was more strongly associated with metabolic syndrome than overall adiposity.

Performance of Point-of-Care Testing Compared with the Standard Laboratory Diagnostic Test in the Measurement of HbA1c in Indonesian Diabetic and Nondiabetic Subjects

OBJECTIVE

This study is aimed at investigating if point-of-care testing for HbA1c (POCT-HbA1c) using the HemoCue® HbA1c 501 system could be an alternative method for diabetes screening and monitoring to replace the HbA1c measurement in a standard diagnostic laboratory.

DESIGN

This was a cross-sectional study to assess the agreement between POCT and a standard laboratory measurement method for determining the level of HbA1c. Setting and Participants. In total, 108 participants were recruited to participate in this study, consisting of 61 diabetics and 47 nondiabetics. The diabetic group comprised 37 females and 24 males, diagnosed with type 2 diabetes mellitus (DM) and undergoing diabetes treatment at several community health care centres in Bandung, West Java. The nondiabetic group consisted of 15 female and 32 male patients of several community health care centres and healthy volunteers. Sample Collection and Analysis. A venous blood sample was taken for routine HbA1c analysis by the diagnostic laboratory method. For the POCT-HbA1c, a blood sample was taken from the fingertip at the same time and analysed with the HemoCue® HbA1c 501 system. Outcome Measures. The HbA1c results of both methods were compared and analysed with a Bland-Altman agreement plot. The sensitivity and specificity of the POCT-HbA1c data were also compared with those of the standard diagnostic results.

RESULTS

Based on the Bland-Altman plot, the HbA1c level for 100 out of 108 (92.59%) subjects analysed by the POCT-HbA1c was within the range of the 95% limit of agreement. Compared with the standard diagnostic assay, the sensitivity of the POCT-HbA1c was 97.83% and its specificity was 77.42%.

CONCLUSIONS

The high sensitivity and accuracy of POCT-HbA1c indicate that it is a potential method for diabetes screening and monitoring to replace the routine diagnostic laboratory HbA1c measurement, especially when a rapid result is required.

The Influence of Health Education on Diabetes Mellitus on Knowledge Improvement of Diabetes Mellitus Cadres in the Working Area of Medokan Ayu Health Center, Surabaya, Indonesia

This study aimed to analyze the influence of health education on improcing health cadres' knowledge about Diabetes Melitus (DM) at Ayu Medokan Health Center, Surabaya, Indonesia. The type and design of this study was non-randomized pretest-posttest design, with samples of DM cadres in the working area of Medokan Ayu Health Center, Surabaya, Indonesia. Sample size was 24 persons. The treatment variable was health education, while the dependent variable was the increase of the cadres' knowledge about DM. Normality test was performed with Kolmogorov Smirnov (a=0.05) and data analysis with Paired t-test (a=0.05). This study found that DM cadres were mostly female (23 people), with the youngest age 24 years, and the oldest 61 years. The highest age group (45.80%) was 40-49 years with a mean age of 44.37 + 9.27 years. Most of DM cadres' education (62.5%) was senior high school, then junior high school (25%). Most (58.3%) of the DM cadres did not work or as housewives. Besides being a DM cadre, most of them also posyandu and bumantik cadres, 2) There was a significant difference (p<0,0001) between the level of knowledge before and after health education. In conclusion, cadres' knowledge about DM can be improved, among others, by providing health education.

Using peer education to improve diabetes management and outcomes in a low-income setting: a randomized controlled trial

BACKGROUND

Diabetes is an important health burden in Indonesia. However, diabetes management and treatment remain poor, with most people with diabetes in Indonesia not achieving the recommended blood glucose levels. Peer education may have particular potential in low-income settings in complementing diabetes care without being a large additional strain on the health system.

METHODS/DESIGN

This cluster randomized controlled trial aims to identify the effect of the implementation of peer education for patients with type 2 diabetes on diabetes-related outcomes in Aceh, Indonesia, which will complement the diabetes treatment provided at primary-care health posts (puskesmas). Altogether, 29 puskesmas were recruited in Banda Aceh and Aceh Besar, each of which was randomly assigned to either the control or the intervention group. Then, 534 people with diabetes were identified and recruited through their respective puskesmas. The intervention consists of up to two peer education groups per puskesmas, which are led by previously trained people with diabetes. Peer education sessions are held every month for 18 months, with follow-up data being collected 9 and 18 months after the first peer education session. The main objective is to improve diabetes management and the health behavior of participants receiving peer education to reduce their average blood glucose levels as measured by glycated hemoglobin (HbA1c) levels. Secondary outcomes are the effects of peer education on lipid levels, waist circumference, blood pressure, quality of life, treatment adherence, diabetes knowledge, physical activity, and dietary diversity. Data sources for the measurement of outcomes include patient and health facility surveys and biomarker measurements. An economic evaluation will be conducted to assess the cost-effectiveness of the intervention.

DISCUSSION

This trial will contribute to the evidence on the effectiveness and cost-effectiveness of peer education in improving diabetes management in a low-income setting in Indonesia and in other comparable contexts.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN68253014 . Registered on 18 February 2019.

Risk factors for nutrition-related chronic disease among adults in Indonesia

OBJECTIVE

To conduct a secondary data analysis detailing the associations between sociodemographic and behavioral factors and nutrition-related chronic disease.

METHODS

These analyses utilized 2014 data from the Indonesian Family Life Survey, a home-based survey that collected socioeconomic, dietary intake, physical activity, and biological data among adults. We explored four outcomes in relation to sociodemographic and behavioral determinants: 1) hypertension, 2) elevated high-sensitivity c-reactive protein (hs-CRP), and 3) central obesity, as these are critical metabolic determinants in the progression to cardiovascular disease, and 4) type 2 diabetes. Hypertension was defined as systolic blood pressure ≥140 mm or diastolic blood pressure ≥ 90mm or current use of antihypertensive medication. Elevated hs-CRP was defined as hs-CRP >3 mg/dL. Central obesity was defined as waist circumference ≥ 90 cm if male and waist circumference ≥ 80 cm if female, which are specific to South Asia. Type 2 diabetes was defined as glycated hemoglobin ≥ 6.5%. We employed separate gender-stratified multivariate logistic regression models to test the associations between sociodemographic and behavioral determinants and each nutrition-related chronic disease outcome. All analyses employed sampling weights, which account for the survey design.

RESULTS

In 2014, about 30% of adults were hypertensive and one-fifth had elevated hs-CRP. Approximately 70% of women had central obesity and 11.6% of women and 8.9% of men had diabetes. Older-age was consistently associated with nutrition-related chronic disease and being overweight was associated with hypertension, elevated hs-CRP, and type 2 diabetes. Regularly consuming instant noodles (women) and soda (men) were associated with elevated hs-CRP and soda consumption was associated with central obesity among men.

CONCLUSIONS

Large segments of the adult population in Indonesia now have or are at risk for non-communicable disease. Our analyses provide preliminary empirical evidence that interventions that target healthful food intake (e.g. reduce the intake of ultra-processed foods) should be considered and that the reduction of overweight is critical for preventing chronic diseases in Indonesia.

Moderate-Vigorous Physical Activity and Clinical Parameters in Adults with Type 2 Diabetes Mellitus: A Report from the Walking with Diabetes Study

Background and aims: This study investigate the effects of increases in moderate-vigorous physical activity (MVPA) on several clinical parameters in Indonesian type 2 diabetes mellitus (T2DM) patients.

Material and methods: This study used clinical and physical activity data of forty-two T2DM patients who completed a 6 month-free-living physical activity program, the Walking with Diabetes Study. Upon completion of the program, participants were categorised into a group with increases in MVPA (the MVPA+ group, n=24) or a group with steady/decreases in MVPA (the control group, n=18). High density lipoprotein, triglyceride, routine hematology profiles, blood pressure, body mass index, weight/hip ratio and self-reported MVPA, at baseline, 3 and 6 months were retrospectively analysed. Generalized estimating equation adjusted for age and sex were conducted to assess group and time effects on the clinical parameters.

Results: Hemoglobin (p <0.01), erythrocytes (p<0.05), hematocrits (p<0.001) and thrombocytes (p<0.05) were higher in the MVPA+ group. The 1h and 2h-erythrocyte sedimentation rate (ESR) increased in both groups across time (p<0.001). No changes between groups across time were found for other parameters.

Conclusions: Increases in MVPA improve several hematology parameters in T2DM patients, but it does not have protective effects in controlling systemic inflammation in T2DM patients.