Inequalities in the prevalence of diabetes mellitus and its risk factors in Sri Lanka: a lower middle income country

Health disparities and inequalities in prevalence of diabetes in the Kingdom of Saudi Arabia

BACKGROUND

Over time, global health systems have witnessed significant improvements in the delivery and coverage of healthcare services. Nevertheless, the increasing prominence of non-communicable diseases remains a persistent challenge. Diabetes is one such non-communicable chronic disease that poses a threat with respect to both mortality and morbidity. This study investigated the socio-economic determinants and inequalities in the prevalence of diabetes in the Kingdom of Saudi Arabia according to data collected from the 2018 Saudi Family Health Survey conducted by the General Authority for Statistics.

METHODS

The analysis was limited to a sample of 11,528 respondents aged ≥ 18 years, selected across all 13 regions of Saudi Arabia, with complete responses for all variables of interest. Socio-economic determinants in diabetes prevalence were explored with univariate, bivariate, and multivariate logistic regression analyses. Furthermore, inequalities were visualised and quantitatively estimated according to construction of a concentration curve and calculation of the concentration index.

RESULTS

The prevalence of diabetes among the 11,528 respondents was 11.20%. Age, education, income, and residence area were significant determinants of diabetes prevalence, with a greater risk of diabetes found in older participants (odds ratio [OR]: 12.262, 95% confidence interval [CI]: 9.820-15.313, p < 0.01) compared to younger participants. Inequality analysis showed a negative education-based concentration index (-0.235, p < 0.01), indicating that diabetes prevalence is concentrated among people with relatively less formal education. For males, the income-based concentration index was significantly positive, whereas the education-based concentration index was significantly negative, indicating a greater concentration of diabetes among Saudi men with higher incomes and less education.

CONCLUSION

These findings emphasize the need to prioritize policies and strategies for diabetes prevention and control with considerations of the socio-economic inequalities in prevalence. Key areas of focus should include improving education levels across all regions, raising awareness about diabetes and implementing nutritional interventions.

Pyroptosis in Diabetic Peripheral Neuropathy and its Therapeutic Regulation

Pyroptosis is a pro-inflammatory form of cell death resulting from the activation of gasdermins (GSDMs) pore-forming proteins and the release of several pro-inflammatory factors. However, inflammasomes are the intracellular protein complexes that cleave gasdermin D (GSDMD), leading to the formation of robust cell membrane pores and the initiation of pyroptosis. Inflammasome activation and gasdermin-mediated membrane pore formation are the important intrinsic processes in the classical pyroptotic signaling pathway. Overactivation of the NOD-like receptor thermal protein domain associated protein 3 (NLRP3) inflammasome triggers pyroptosis and amplifies inflammation. Current evidence suggests that the overactivation of inflammasomes and pyroptosis may further induce the progression of cancers, nerve injury, inflammatory disorders and metabolic dysfunctions. Current evidence also indicates that pyroptosis-dependent cell death accelerates the progression of diabetes and its frequent consequences including diabetic peripheral neuropathy (DPN). Pyroptosis-mediated inflammatory reaction further exacerbates DPN-mediated CNS injury. Accumulating evidence shows that several molecular signaling mechanisms trigger pyroptosis in insulin-producing cells, further leading to the development of DPN. Numerous studies have suggested that certain natural compounds or drugs may possess promising pharmacological properties by modulating inflammasomes and pyroptosis, thereby offering potential preventive and practical therapeutic approaches for the treatment and management of DPN. This review elaborates on the underlying molecular mechanisms of pyroptosis and explores possible therapeutic strategies for regulating pyroptosis-regulated cell death in the pharmacological treatment of DPN.

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.

Prevalence of type 2 diabetes and pre-diabetes in Sri Lanka: a systematic review and meta-analysis

OBJECTIVE

The purpose of this research was to determine the prevalence of diabetes and pre-diabetes in Sri Lanka.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (via PubMed), Web of Science, Sri Lankan Journals online and Google Scholar were searched for relevant articles published between January 1990 and June 2022 investigating the prevalence of pre-diabetes and diabetes in Sri Lanka.

METHODS

Random effect meta-analyses were conducted to derive the pooled prevalence of pre-diabetes and diabetes and their 95% CIs. Heterogeneity was explored by subgroup and meta-regression analyses. Sensitivity analyses were used to evaluate the impact of any single study on the pooled estimates. Two authors screened articles, extracted data and evaluated the quality of selected studies.

RESULTS

A total of 479 articles were reviewed, and 15 studies (n=30 137 participants) were selected in the final analysis. The overall pooled prevalence of diabetes was 12.07% (95% CI, 8.71% to 15.89%; prediction interval: 1.28-31.35). The pooled pre-diabetes prevalence was 15.57% (95% CI, 9.45% to 22.88%; prediction interval: 0.02-49.87). The pooled type 2 diabetes prevalence was the highest in the latest period of 2011-2021 (17.25%) than in the period of 2000s (11.84%) and 1990s (5.62%).

CONCLUSIONS

The growing trend of diabetes and pre-diabetes over the last 30 years is alarming in Sri Lanka. The government of Sri Lanka needs to take steps to improve diabetes education, screening, diagnosis and treatment.

PROSPERO REGISTRATION NUMBER

CRD42021288591.

Prevalence and gender disparities of type 2 diabetes mellitus and obesity in Esmeraldas, Ecuador: a population-based survey in a hard-to-reach setting

BACKGROUND

Type 2 Diabetes (T2DM) prevalence is increasing in low- and middle-income countries along with high levels of obesity which vary according to socioeconomic and contextual characteristics. We aim to estimate the prevalence of T2DM and obesity in men and women in a hard-to-reach rural area in northern Ecuador considering socio-demographic characteristics.

METHODS

Cross-sectional descriptive study based on a population-based survey in the Eloy Alfaro health district of Esmeraldas between October 2020 and January 2022. We collected sociodemographic information and risk factors for non-communicable diseases with an adapted version of the STEPS survey, performed oral glucose tolerance tests, biochemistry and took physical measurements. We estimated the prevalence of T2DM, obesity, and calculated Odds Ratios (OR) with confidence intervals by logistic regression in Stata v.15.

RESULTS

The overall prevalence of T2DM was 6.8% (CI95%: 4.9-8.7), markedly higher among women compared to men (10.4%, CI95% 7.3-13.4%, compared 2.0%, CI95% 0.4-3.7% respectively). The risk of having T2DM in women was 5 times higher than in men adjusting for age, ethnicity, employment, household earnings and obesity (OR: 5.03; 95%CI: 1.68-15.01). Regarding age, the risk of T2DM increased by 6% per year (adjusted OR: 1.06; 95%CI: 1.03-1.08). Obesity prevalence was 30.8% (CI95%: 27.3-34.3), in women was nearly three times higher than in men (43.2% CI95%: 38.2-48.2, compared to 14.7% prevalence, CI95%: 10.6-18.8). Indigenous women had a lower prevalence of obesity compared with the Afro-Ecuadorian women (OR: 0.05; 95%CI: 0.02-0.18) after adjusting for age, employment status, household earnings and setting.

CONCLUSION

We found alarming differences between the prevalence of T2DM and obesity in women and men that may be explained by gender roles, exacerbated in the rural context. Health promotion measures with a gender perspective should be adapted according to the characteristics of isolated rural contexts.

Prevalence of diabetes and pre-diabetes in Sri Lanka: a new global hotspot-estimates from the Sri Lanka Health and Ageing Survey 2018/2019

INTRODUCTION

This study's objective was to produce robust, comparable estimates of the prevalence of diabetes and pre-diabetes in the Sri Lankan adult population, where previous studies suggest the highest prevalence in South Asia.

RESEARCH DESIGN AND METHODS

We used data on 6661 adults from the nationally representative 2018/2019 first wave of the Sri Lanka Health and Ageing Study (SLHAS). We classified glycemic status based on previous diabetes diagnosis, and either fasting plasma glucose (FPG), or FPG and 2-hour plasma glucose (2-h PG). We estimated crude and age-standardized prevalence of pre-diabetes and diabetes and by major individual characteristics weighting the data to account for study design and subject participation.

RESULTS

Crude prevalence of diabetes in adults was 23.0% (95% CI 21.2% to 24.7%) using both 2-h PG and FPG, and age-standardized prevalence was 21.8% (95% CI 20.1% to 23.5%). Using only FPG, prevalence was 18.5% (95% CI 7.1% to 19.8%). Previously diagnosed prevalence was 14.3% (95% CI 13.1% to 15.5%) of all adults. The prevalence of pre-diabetes was 30.5% (95% CI 28.2% to 32.7%). Diabetes prevalence increased with age until ages ≥70 years and was more prevalent in female, urban, more affluent, and Muslim adults. Diabetes and pre-diabetes prevalence increased with body mass index (BMI) but was as high as 21% and 29%, respectively, in those of normal weight.

CONCLUSIONS

Study limitations included using only a single visit to assess diabetes, relying on self-reported fasting times, and unavailability of glycated hemoglobin for most participants. Our results indicate that Sri Lanka has a very high diabetes prevalence, significantly higher than previous estimates of 8%-15% and higher than current global estimates for any other Asian country. Our results have implications for other populations of South Asian origin, and the high prevalence of diabetes and dysglycemia at normal body weight indicates the need for further research to understand the underlying drivers.

Inequalities in the prevalence, diagnosis awareness, treatment coverage and effective control of diabetes: a small area estimation analysis in Iran

OBJECTIVE

This study aims to assess geographic inequalities in the prevalence, awareness of diagnosis, treatment coverage and effective control of diabetes in 429 districts of Iran.

METHODS

A modelling study by the small area estimation method, based on a nationwide cross-sectional survey, Iran STEPwise approach to surveillance (STEPS) 2016, was performed. The modelling estimated the prevalence, awareness of diagnosis, treatment coverage, and effective control of diabetes in all 429 districts of Iran based on data from available districts. The modelling results were provided in different geographical and socio-economic scales to make the comparison possible across the country.

RESULTS

In 2016, the prevalence of diabetes ranged from 3.2 to 19.8% for women and 2.4 to 19.1% for men. The awareness of diagnosis ranged from 51.9 to 95.7% for women and 35.7 to 100% for men. The rate of treatment coverage ranged from 37.2 to 85.6% for women and 24.4 to 80.5% for men. The rate of effective control ranged from 12.1 to 63.6% for women and 12 to 73% for men. The highest treatment coverage rates belonged to Ardebil for women and Shahr-e-kord for men. The highest effective control rates belonged to Sanandaj for women and Nehbandan for men. Across Iran districts, there were considerable differences between the highest and lowest rates of prevalence, diagnosis awareness, treatment coverage, and effective control of diabetes. The concentration indices of diabetes prevalence, awareness of diagnosis, and treatment coverage were positive and significant for both sexes.

CONCLUSION

Findings of this study highlight the existence of inequalities in diagnosis awareness, treatment coverage, and effective control of diabetes in all Iran regions. More suitable population-wide strategies and policies are warranted to handle these inequalities in Iran.

Coverage and equity of essential care services among stroke survivors in the Western Province of Sri Lanka: a community-based cross-sectional study

BACKGROUND

Stroke survivors require continuing services to limit disability. This study assessed the coverage and equity of essential care services received during the first six months of post-stroke follow-up of stroke survivors in the Western Province of Sri Lanka.

METHODS

A multidisciplinary team defined the essential post-stoke follow-up care services and agreed on a system to categorize the coverage of services as adequate or inadequate among those who were identified as needing the said service. We recruited 502 survivors of first ever stroke of any type, from 11 specialist hospitals upon discharge. Six months following discharge, trained interviewers visited their homes and assessed the coverage of essential services using a structured questionnaire.

RESULTS

Forty-nine essential post-stroke follow-up care services were identified and categorized into six domains: monitoring of risk conditions, treatment, services to limit disabilities, services to prevent complications, lifestyle modification and supportive services. Of the recruited 502 stroke survivors, 363 (72.3%) were traced at the end of 6 months. Coverage of antiplatelet therapy was the highest (97.2% (n = 289, 95% CI 95.3- 99.1)) while referral to mental health services (3.3%, n = 12, 95% CI 1.4-5.1) and training on employment for the previously employed (2.2%, n = 4, 95% CI- 0.08-4.32), were the lowest among the six domains of care. In the sample, 59.8% (95% CI 54.76-64.48) had received an 'adequate' level of essential care services related to treatment while none received an 'adequate' level of services in the category of support services. Disaggregated service coverage by presence and type of limb paralysis within the domain of services to prevent complications, and by sex and education level within the domain of education level, show statistically significant differences (p < 0.05).

CONCLUSIONS

Apart from treatment services to limit disabilities, coverage of essential care services during the post-stroke period was inadequate. There were no apparent inequities in the coverage of vast majority of services. However focused policy decisions are required to address these gaps in services.

Socioeconomic Inequalities in the Prevalence of Diabetes in Argentina: A Repeated Cross-Sectional Study in Urban Women and Men

This study measured the socioeconomic inequalities in the prevalence of diabetes between 2005 and 2018 in an urban Argentinian population. Data were obtained from the repeated cross-sectional surveys “National Survey of Risk Factors” (ENFR is its acronym in Spanish). From 2005 to 2018, four rounds of ENFR were administered to men and women over 18 years of age. Concentration curves (CC) and the Erreygers concentration index (ECI) were used to describe the socioeconomic inequalities in diabetes’ prevalence. A decomposition analysis was performed to determine the contribution of each variable to inequality in diabetes’ prevalence. Data from 41,219 (2005), 34,583 (2009), 32,232 (2013), and 29,094 (2018) individuals were analyzed. Women reported a greater prevalence of diabetes compared with men for all the years included. According to the CC and ECI, we found no evidence of inequality in men throughout all study years. For women, throughout all years, the CCs were above the line of equity, and the ECIs during all the years were negative and different from zero (p < 0.01). For women, we found no evidence of a reduction in inequalities between 2005 and 2018 (p = 0.475). The socioeconomic inequality for women was largely driven by public insurance, primary and secondary education, and employment. Diabetes’ prevalence was not associated with socioeconomic status in men, while the prevalence of diabetes in women was more concentrated among poorer women. During the 13 years, there was no evidence of a reduction of inequality in women, noting that interventions must prioritize and should focus on the main contribution of inequalities, such as education and employment.

Socio-economic inequalities in diabetes and prediabetes among Bangladeshi adults

Diabetes and prediabetes are overwhelming public health concerns in Bangladesh. However, there is a paucity of the literature examining and measuring socioeconomic inequalities in the prevalence of diabetes in Bangladesh. To provide reliable data and contribute to a nationwide scenario analysis, this study aims to estimate the inequality in prevalence of diabetes and prediabetes and to identify factors potentially contributing to socioeconomic inequalities in Bangladesh. This study used data from the latest Bangladesh Demographic and Health Survey (BDHS) 2017-18, a nationally representative survey. A regression-based decomposition method was applied to assess the socioeconomic contributors to inequality. The prevalence of diabetes and prediabetes were about 10 and 15% among Bangladeshi adults, respectively. Both diabetes and prediabetes were significantly associated with age, wealth status, suffering from overweight or obesity and administrative divisions of the respondents (p < 0.001). Respondents' household wealth status accounted for about 74 and 81% of the total inequality in diabetes and prediabetes in Bangladesh, respectively. Administrative region contributed 24.85% of the inequality in prediabetes and 12.26% of the inequality in diabetes. In addition, overweight or obesity status contributed 11.37% and exposure to television contributed 5.17% of the inequality in diabetes. Diabetes and prediabetes affect a substantial proportion of the Bangladeshi adult population. Therefore, these findings should be considered in the context of current and proposed policy decision making and for tracking its progression with economic development in Bangladesh.

Economic inequality in malnutrition: a global systematic review and meta-analysis

OBJECTIVE

To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

METHODS

We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

RESULTS

From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

CONCLUSIONS

There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO REGISTRATION NUMBER

CRD42020201572.

Active screening of patients with diabetes mellitus for pulmonary tuberculosis in a tertiary care hospital in Sri Lanka

End TB strategy by the WHO suggest active screening of high-risk populations for tuberculosis (TB) to improve case detection. Present study generates evidence for the effectiveness of screening patients with diabetes mellitus (DM) for Pulmonary TB (PTB). A study was conducted among 4548 systematically recruited patients over 45 years attending DM clinic at the National Hospital of Sri Lanka. The study units followed an algorithm specifying TB symptom and risk factor screening for all, followed by investigations and clinical assessments for those indicated. Bacteriologically confirmed or clinically diagnosed PTB were presented as proportions with 95% CI. Mean (SD) age was 62·5 (29·1) years. Among patients who completed all indicated steps of algorithm, 3500 (76·9%) were investigated and 127 (2·8%) underwent clinical assessment. Proportion of bacteriologically confirmed PTB patients was 0·1% (n = 6,95%CI = 0·0-0·3%). None were detected clinically. Analysis revealed PTB detection rates among males aged ≥60 years with HbA1c ≥ 8 to be 0·4% (n = 2, 95%CI = 0·0-1·4%). The study concludes that active screening for PTB among all DM patients at clinic settings in Sri Lanka, to be non-effective measure to enhance TB case finding. However, the sub-category of diabetic males with uncontrolled diabetics who are over 60 years of age is recommended as an option to consider for active screening for PTB.

Decomposition of Gender Differences in Body Mass Index in Saudi Arabia using Unconditional Quantile Regression: Analysis of National-Level Survey Data

Understanding gender differences in body mass index (BMI) between males and females has been much debated and received considerable attention. This study aims to decompose gender differentials in the BMI of people of the Kingdom of Saudi Arabia. The study decomposed the BMI gender gap into its associated factors across the entire BMI distribution by using counterfactual regression methods. The main method of analysis was newly developed unconditional quantile regression-based decomposition, which applied Blinder-Oaxaca decomposition using data from the Saudi Health Interview Survey. Gender differentials were found in the BMI, with females showing a higher BMI than males. The aggregate decomposition showed that both the covariate effect and the structural effect were significant at the 25th and 50th quantiles. Detailed decomposition indicated that income level and employment status as well as soda consumption and the consumption of red meat were significantly correlated in explaining gender differentials in BMI across various quantiles, but the magnitude varied by quantile. Our study suggests the government should consider introducing programs that specifically target women to help them reduce BMI. These programs could include organizing sporting events at the workplace and at the national level. Furthermore, the effect of soda consumption could be reduced by levying a tax on beverages, which might reduce the demand for soda due to the increased price.

Socio-economic inequalities in diabetes prevalence in the Kingdom of Saudi Arabia

BACKGROUND

Rising prevalence of non-communicable diseases, including diabetes in the Middle East, is a major public health concern of the 21st century. However, there is a paucity of literature to understand and measure socio-economic inequalities in diabetes prevalence in this region, including the Kingdom of Saudi Arabia (KSA).

METHODS

This study investigated socio-economic inequalities in diabetes prevalence in the KSA using data from the Saudi Arabia Health Interview Survey. Concentration curve, concentration index, and multivariate logistic regression were used to measure and examine income- and education-related inequalities in diabetes prevalence.

RESULTS

The results showed significant socio-economic inequalities in the prevalence of diabetes through analysing a nationally representative sample of the KSA population. Diabetes prevalence was concentrated among the poor and among people with less education. In addition, education-related inequality was higher than income-related inequality.

CONCLUSIONS

The findings of this study are important for policymakers to combat both the increasing prevalence of and socio-economic inequalities in diabetes. The government should promote health education programmes and increase the level of public awareness of diabetes management, especially among the lower educated population in the KSA.

Lifestyle and socio-economic inequalities in diabetes prevalence in South Africa: A decomposition analysis

BACKGROUND

Inequalities in diabetes are widespread and are exacerbated by differences in lifestyle. Many studies that have estimated inequalities in diabetes make use of self-reported diabetes which is often biased by differences in access to health care and diabetes awareness. This study adds to this literature by making use of a more objective standardised measure of diabetes in South Africa. The study estimates socio-economic inequalities in undiagnosed diabetes, diagnosed diabetes (self-reported), as well as total diabetes (undiagnosed diabetics + diagnosed diabetics). The study also examines the contribution of lifestyle factors to diabetes inequalities in South Africa.

METHODS

This cross sectional study uses data from the 2012 South African National Health and Nutrition Examination Survey (SANHANES-1) and applies the Erreygers Concentration Indices to assess socio-economic inequalities in diabetes. Contributions of lifestyle factors to inequalities in diabetes are assessed using a decomposition method.

RESULTS

Self-reported diabetes and total diabetes (undiagnosed diabetics + diagnosed diabetics) were significantly concentrated amongst the rich (CI = 0.0746; p < 0.05 and CI = 0.0859; p < 0.05). The concentration index for undiagnosed diabetes was insignificant but pro-poor. The decomposition showed that lifestyle factors contributed 22% and 35% to socioeconomic inequalities in self-reported and total diabetes, respectively.

CONCLUSION

Diabetes in South Africa is more concentrated amongst higher socio-economic groups when measured using self-reported diabetes or clinical data. Our findings also show that the extent of inequality is worse in the total diabetes outcome (undiagnosed diabetics + diagnosed diabetics) when compared to the self-reported diabetes outcome. Although in comparison to other determinants, the contribution of lifestyle factors was modest, these contributions are important in the development of policies that address socio-economic inequalities in the prevalence of diabetes.