Ethnic differences in glycaemic control in people with type 2 diabetes mellitus living in Scotland

Impact of migration on diabetes burden: audit in the metropolitan area of Bologna, Italy

PURPOSE

To investigate the impact of diabetes in immigrants on the Italian healthcare system, as well as their compliance with standard protocols of control and treatment.

METHODS

The prevalence of immigrants with diabetes living in the metropolitan area of Bologna (about 1 million inhabitants) in 2019 was investigated using a database containing all subjects in active follow-up for diabetes, based on antidiabetic drug use, disease-specific copayment exemption, ICD-9 codes, continuous care in diabetes units. Country of origin was derived from fiscal code.

RESULTS

The overall prevalence of diabetes (n = 53,941; 51.8% males, median age 64) was 6.1% in both Italy-born and immigrant cohorts. Immigrant prevalence was 12.4%, moderately higher than that observed in the total population (12.2%). Diabetes risk was increased in the whole immigrant cohort (odds ratio (OR) 1.74; 95% Confidence Interval (CI) 1.69-1.79). Among cases with incident diabetes, the proportion of immigrants (median age, 49 vs. 65 in Italy-born individuals) increased progressively from 11.7% to 26.5% from 2011 to 2019 (males, 8.9-21.0%; females, 14.9-32.8%) in all age groups, particularly in young adults, but also in older subjects. Metabolic control was lower in immigrants, as was adherence to shared diagnostic and therapeutic protocols, without systematic differences in antidiabetic drug use, but much lower use of drugs for comorbid conditions.

CONCLUSIONS

The population with diabetes in the metropolitan area of Bologna is rapidly changing. Quality improvement initiatives are needed to reduce the burden for the universalistic Italian health care system generated by the rapidly-growing high-risk immigrant population.

Glucose-lowering drug use in migrants and native Danes with type 2 diabetes: Disparities in combination therapy and drug types

AIM

To examine disparities in glucose-lowering drug (GLD) usage between migrants and native Danes with type 2 diabetes (T2D).

MATERIALS AND METHODS

In a nationwide, register-based cross-sectional study of 253 364 individuals with prevalent T2D on December 31, 2018, we examined user prevalence during 2019 of (i) GLD combination therapies and (ii) individual GLD types. Migrants were grouped by origin (Middle East, Europe, Turkey, Former Yugoslavia, Pakistan, Sri Lanka, Somalia, Vietnam), and relative risk (RR) versus native Danes was computed using robust Poisson regression to adjust for clinical and socioeconomic characteristics.

RESULTS

In 2019, 34.7% of native Danes received combination therapy, and prevalence was lower in most migrant groups (RR from 0.78, 95% confidence interval CI 0.71-0.85 [Somalia group] to 1.00, 95% CI 0.97-1.04 [former Yugoslavia group]). Among native Danes, the most widely used oral GLD was metformin (used by 62.1%), followed by dipeptidyl peptidase-4 inhibitors (13.3%), sodium-glucose cotransporter-2 inhibitors (11.9%) and sulphonylureas (5.2%), and user prevalence was higher in most migrant groups (RR for use of any oral GLD: 0.99, 95% CI 0.97-1.01 [Europe group] to 1.09, 95% CI 1.06-1.11 [Sri Lanka group]). Furthermore, 18.7% of native Danes used insulins and 13.3% used glucagon-like peptide-1 receptor agonists (GLP-1RAs), but use was less prevalent in migrants (RR for insulins: 0.66, 95% CI 0.62-0.71 [Sri Lanka group] to 0.94, 95% CI 0.89-0.99 [Europe group]; RR for GLP-1RAs: 0.29, 95% CI 0.22-0.39 [Somalia group] to 0.95, 95% CI 0.89-1.01 [Europe group]).

CONCLUSIONS

Disparities in GLD types and combination therapy were evident between migrants and native Danes. Migrants were more likely to use oral GLDs and less likely to use injection-based GLDs, particularly GLP-1RAs, which may contribute to complication risk and mortality among this group.

Use of herbal medicines for the management of type 2 diabetes: A systematic review of qualitative studies

BACKGROUND

Many people with Type 2 Diabetes Mellitus (T2DM) use herbal medicines, some of which can improve glycaemic control. Providing evidence-based advice on herbal medicines could be an effective intervention to improve control of diabetes, if it is designed to address key needs and concerns of T2DM patients.

AIM

To understand the views and experiences of patients and health professionals on herbal treatments for self-management of T2DM.

METHOD

MEDLINE, EMBASE, CINAHL, SOCIOFILE and Google Scholar were searched for qualitative studies in T2DM patients about their views on herbal medicines. Included papers were analysed using thematic synthesis.

RESULTS

Thirty-one papers (about 30 studies) were included: 20 from low-and-middle income countries, 10 from high income countries, and 1 internet-based study. Almost all studies from high income countries focussed on ethnic minorities. Many people with T2DM wanted a "cure", and often took advice from friends and family, but also traditional healers and mass media. However, they were reluctant to discuss herbal medicines with health professionals, whom they perceived as "closed-minded". They based their treatment decisions on personal experience (from "trial-and-error"), availability, cost and convenience of both herbal and conventional medicines. Most health professionals were reluctant to discuss herbal medicines, or recommended against their use, because of lack of knowledge and concerns about their quality, efficacy and potential interactions.

CONCLUSION

Evidence-based information could help to overcome the current lack of communication about herbal medicines between people with T2DM and health professionals.

Guideline-level monitoring, biomarker levels and pharmacological treatment in migrants and native Danes with type 2 diabetes: Population-wide analyses

The prevalence of type 2 diabetes (T2D) is higher in migrants compared to native populations in many countries, but the evidence on disparities in T2D care in migrants is inconsistent. Therefore, this study aimed to examine this in Denmark. In a cross-sectional, register-based study on 254,097 individuals with T2D, 11 indicators of guideline-level care were analysed: a) monitoring: hemoglobin-A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), screening for diabetic nephropathy, retinopathy, and foot disease, b) biomarker control: HbA1c and LDL-C levels, and c) pharmacological treatment: glucose-lowering drugs (GLD), lipid-lowering drugs, angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers, and antiplatelet therapy. Migrants were grouped by countries of origin: Middle East, Europe, Turkey, Former Yugoslavia, Pakistan, Sri Lanka, Somalia, Vietnam. In all migrant groups except the Europe-group, T2D was more prevalent than in native Danes (crude relative risk (RR) from 0.62 [0.61-0.64] (Europe) to 3.98 [3.82-4.14] (Sri Lanka)). In eight indicators, non-fulfillment was common (>25% among native Danes). Apart from monitoring in the Sri Lanka-group, migrants were at similar or higher risk of non-fulfillment than native Danes across all indicators of monitoring and biomarker control (RR from 0.64 [0.51-0.80] (HbA1c monitoring, Sri Lanka) to 1.78 [1.67-1.90] (LDL-C control, Somalia)), while no overall pattern was observed for pharmacological treatment (RR from 0.61 [0.46-0.80] (GLD, Sri Lanka) to 1.67 [1.34-2.09] (GLD, Somalia)). Care was poorest in migrants from Somalia, who had increased risk in all eleven indicators, and the highest risk in nine. Adjusted risks were elevated in some migrant groups, particularly in indicators of biomarker control (fully-adjusted RR from 0.84 [0.75-0.94] (LDL-C levels, Vietnam) to 1.44 [1.35-1.54] (LDL-C levels, Somalia)). In most migrant groups, T2D was more prevalent, and monitoring and biomarker control was inferior compared to native Danes. Migrants from Somalia received the poorest care overall, and had exceedingly high lipid levels.

Ethnic disparities attributed to the manifestation in and response to type 2 diabetes: insights from metabolomics

Type 2 diabetes (T2D) associated health disparities among different ethnicities have long been known. Ethnic variations also exist in T2D related comorbidities including insulin resistance, vascular complications and drug response. Genetic heterogeneity, dietary patterns, nutrient metabolism and gut microbiome composition attribute to ethnic disparities in both manifestation and progression of T2D. These factors differentially regulate the rate of metabolism and metabolic health. Metabolomics studies have indicated significant differences in carbohydrate, lipid and amino acid metabolism among ethnicities. Interestingly, genetic variations regulating lipid and amino acid metabolism might also contribute to inter-ethnic differences in T2D. Comprehensive and comparative metabolomics analysis between ethnicities might help to design personalized dietary regimen and newer therapeutic strategies. In the present review, we explore population based metabolomics data to identify inter-ethnic differences in metabolites and discuss how (a) genetic variations, (b) dietary patterns and (c) microbiome composition may attribute for such differences in T2D.

Type 2 diabetes burden among migrants in Europe: unravelling the causal pathways

European populations are ethnically and culturally diverse due to international migration. Evidence indicates large ethnic inequalities in the prevalence of type 2 diabetes. This review discusses the burden of type 2 diabetes and its related complications, and the potential explanatory mechanisms among migrants in Europe. The current available data suggest that the rate of type 2 diabetes is higher in all migrant groups and that they develop this disease at an earlier age than the host European populations. The level of diabetes awareness among migrant populations is high, but glycaemic control remains suboptimal compared with Europeans. The culturally adapted lifestyle modification intervention trials to prevent type 2 diabetes mainly focus on South Asian adults in Europe. Diabetes-related microvascular and macrovascular complications remain a major burden among migrant populations in Europe. Earlier studies found higher mortality rates among migrants, but recent studies seem to suggest a shifting trend in favour of first-generation migrants. However, the extent of the burden of type 2 diabetes varies across migrant groups and European countries. Despite the higher burden of type 2 diabetes among migrants, the key underlying factors are not well understood mainly due to limited investment in basic science research and development of prospective cohort studies. We hypothesise that the underlying risk factors for the high burden of type 2 diabetes and its related complications in migrants are multifaceted and include pre-migration factors, post-migration factors and genetic predispositions. Given the multi-ethnic nature of the current European population, there is a clear need for investment in research among migrant populations to gain insight into factors driving the high burden of type 2 diabetes and related complications to facilitate prevention and treatment efforts in Europe.

Recommending encounters according to the sociodemographic characteristics of patient strata can reduce risks from type 2 diabetes

Objectives

Physician encounters with patients with type 2 diabetes act as motivation for self-management and lifestyle adjustments that are indispensable for diabetes treatment. We elucidate the sociodemographic sources of variation in encounter usage and the impact of encounter usage on glucose control, which can be used to recommend encounter usage for different sociodemographic strata of patients to reduce risks from Type 2 diabetes.

Data and methods

We analyzed data from a multi-facility clinic in the Midwestern United States on 2124 patients with type 2 diabetes, from 95 ZIP codes. A zero-inflated Poisson model was used to estimate the effects of various ZIP-code level sociodemographic variables on the encounter usage. A multinomial logistic regression model was built to estimate the effects of physical and telephonic encounters on patients’ glucose level transitions. Results from the two models were combined in marginal effect analyses.

Results and conclusions

Conditional on patients’ clinical status, demographics, and insurance status, significant inequality in patient encounters exists across ZIP codes with varying sociodemographic characteristics. One additional physical encounter in a six-month period marginally increases the probability of transition from a diabetic state to a pre-diabetic state by 4.3% and from pre-diabetic to the non-diabetic state by 3.2%. Combined marginal effect analyses illustrate that a ZIP code in the lower quartile of high school graduate percentage among all ZIP codes has 1 fewer physical encounter per six months marginally compared to a ZIP code at the upper quartile, which gives 5.4% average increase in the probability of transitioning from pre-diabetic to diabetic. Our results suggest that policymakers can target particular patient groups who may have inadequate encounters to engage in diabetes care, based on their immediate environmental sociodemographic characteristics, and design programs to increase their encounters to achieve better care outcomes.

National diabetes registries: do they make a difference?

AIMS

The global epidemic of diabetes mellitus continues to expand, including its large impact on national health care. Measuring diabetes outcomes and their causes of variation highlights areas for improvement in care and efficiency gains; large registries carry this potential. By means of a systematic review, we aimed to give an overview of national registries worldwide by quantifying their data and assessing their influence on diabetes care.

METHODS

The literature on MEDLINE up to March 31, 2020, was searched, using keywords diabetes mellitus, national, registry, registration, and/or database. National disease-specific registries from corresponding articles were included. Database characteristics and clinical variables were obtained. All registries were compared to the ICHOM standard set of outcomes.

RESULTS

We identified 12 national clinical diabetes registries, comprising a total of 7,181,356 diabetic patients worldwide. Nearly all registries recorded weight, HbA1c, lipid profile, and insulin treatment; the recording of other variables varied to a great extent. Overall, registries corresponded fairly well with the ICHOM set. Most registries proved to monitor and improve the quality of diabetes care using guidelines as a benchmark. The effects on national healthcare policy were more variable and often less clear.

CONCLUSIONS

National diabetes registries confer clear insights into diagnostics, complications, and treatment. The extent to which registries influenced national healthcare policy was less clear. A globally implemented standard outcome set has the potential to improve concordance between national registries, enhance the comparison and exchange of diabetes outcomes, and allocate resources and interventions where most needed.

Long-term follow-up of a randomized controlled trial of a text-message diabetes self-management support programme, SMS4BG

AIMS

To determine the long-term effectiveness of an individually tailored text-message diabetes self-management support programme, SMS4BG, on glycaemic control at 2 years in adults with diabetes with an HbA_1c concentration > 64 mmol/mol (8%).

METHODS

We conducted a 2-year follow-up of a two-arm, parallel, randomized controlled trial across health services in New Zealand. Participants were English-speaking adults with type 1 or 2 diabetes and with an HbA_1c >64 mmol/mol (8%). In the main trial participants randomized to the intervention group (N=183) received up to 9 months of an automated tailored text-message programme in addition to usual care. Participants in the control group (N=183) received usual care for 9 months. In this follow-up study, 293 (80%) of 366 randomized participants in the main trial were included. The primary outcome measure was change in glycaemic control (HbA_1c ) from baseline to 2 years. Mixed-effect models were used to compare the group differences at 3, 6, 9 and 24 months, adjusted for baseline HbA_1c and stratification factors (health district category, diabetes type and ethnicity).

RESULTS

The decrease in HbA_1c at 2 years was significantly greater in the intervention group [mean (sd) -10 (18) mmol/mol or -0.9 (1.6)%] compared with the control group [mean (sd) -1 (20) mmol/mol or -0.1 (1.8)%], with an adjusted mean difference of -9 mmol/mol (95% CI -14, -5) or -0.8% (95% CI -1.2, -0.4; P<0.0001).

CONCLUSIONS

Improvements in glycaemic control resulting from a text-message diabetes self-management support programme were sustained at 2 years after randomization. These findings support the implementation of SMS4BG in current practice.

Ethnic Differences in the Prevalence of Type 2 Diabetes Diagnoses in the UK: Cross-Sectional Analysis of the Health Improvement Network Primary Care Database

AIMS/HYPOTHESIS

Type 2 diabetes mellitus is associated with high levels of disease burden, including increased mortality risk and significant long-term morbidity. The prevalence of diabetes differs substantially among ethnic groups. We examined the prevalence of type 2 diabetes diagnoses in the UK primary care setting.

METHODS

We analysed data from 404,318 individuals in The Health Improvement Network database, aged 0-99 years and permanently registered with general practices in London. The association between ethnicity and the prevalence of type 2 diabetes diagnoses in 2013 was estimated using a logistic regression model, adjusting for effect of age group, sex, and social deprivation. A multiple imputation approach utilising population-level information about ethnicity from the UK census was used for imputing missing data.

RESULTS

Compared with those of White ethnicity (5.04%, 95% CI 4.95 to 5.13), the crude percentage prevalence of type 2 diabetes was higher in the Asian (7.69%, 95% CI 7.46 to 7.92) and Black (5.58%, 95% CI 5.35 to 5.81) ethnic groups, while lower in the Mixed/Other group (3.42%, 95% CI 3.19 to 3.66). After adjusting for differences in age group, sex, and social deprivation, all minority ethnic groups were more likely to have a diagnosis of type 2 diabetes compared with the White group (OR Asian versus White 2.36, 95% CI 2.26 to 2.47; OR Black versus White 1.65, 95% CI 1.56 to 1.73; OR Mixed/Other versus White 1.17, 95% CI 1.08 to 1.27).

CONCLUSION

The prevalence of type 2 diabetes was higher in the Asian and Black ethnic groups, compared with the White group. Accurate estimates of ethnic prevalence of type 2 diabetes based on large datasets are important for facilitating appropriate allocation of public health resources, and for allowing population-level research to be undertaken examining disease trajectories among minority ethnic groups, that might help reduce inequalities.

Predictors of poor glycemic control in adult with type 2 diabetes in South-Eastern Nigeria

BACKGROUND

The study investigated predictors of poor glycemic control in type 2 diabetes (T2DM).

METHODS

Data on demographics, anthropometric and clinical parameters were collected in a cross-section survey from 140 adults with T2DM, using standard tools/instruments. Glycated hemoglobin (A1C) was assessed as a measure of glycemic control.

RESULTS

Majority (83.3%) had poor glycemic control status of which about 95% constitute the elderly. The elderly (OR= 5.90, 95% Cl: 1.66-20.96) were more likely associated with poor glycemic control than the non-elderly (p = 0.006). Adjustment for significant predictor variables: Age, waist-hip ratio (WHR), Fasting plasma glucose (FPG) and Systolic blood pressure (SBP), although attenuated the odds (OR= 5.00, 95% CI: 1.19-20.96) of poor glycemic control, it still remained significantly (p = 0.028) higher in the elderly. Patients outside tight FPG control significantly (p = 0.001) showed poor glycemic cotrol than those within tight FPG (OR= 17.39, 95%Cl: 5.83-51.90), even with attenuated OR (OR= 10.85, 95%Cl: 3.10-37.96) and (OR=12.08, 95%Cl: 3.64-40.09) when non-significant and significant predictor variables were accounted for, respectively.

CONCLUSION

Age, WHR, FPG, and SBP were significantly associated with differences in glycemic control. The elderly and FPG outside tight control showed significantly increased odds of poor glycemic control status.

Disparities in glycaemic control, monitoring, and treatment of type 2 diabetes in England: A retrospective cohort analysis

BACKGROUND

Disparities in type 2 diabetes (T2D) care provision and clinical outcomes have been reported in the last 2 decades in the UK. Since then, a number of initiatives have attempted to address this imbalance. The aim was to evaluate contemporary data as to whether disparities exist in glycaemic control, monitoring, and prescribing in people with T2D.

METHODS AND FINDINGS

A T2D cohort was identified from the Royal College of General Practitioners Research and Surveillance Centre dataset: a nationally representative sample of 164 primary care practices (general practices) across England. Diabetes healthcare provision and glucose-lowering medication use between 1 January 2012 and 31 December 2016 were studied. Healthcare provision included annual HbA1c, renal function (estimated glomerular filtration rate [eGFR]), blood pressure (BP), retinopathy, and neuropathy testing. Variables potentially associated with disparity outcomes were assessed using mixed effects logistic and linear regression, adjusted for age, sex, ethnicity, and socioeconomic status (SES) using the Index of Multiple Deprivation (IMD), and nested using random effects within general practices. Ethnicity was defined using the Office for National Statistics ethnicity categories: White, Mixed, Asian, Black, and Other (including Arab people and other groups not classified elsewhere). From the primary care adult population (n = 1,238,909), we identified a cohort of 84,452 (5.29%) adults with T2D. The mean age of people with T2D in the included cohort at 31 December 2016 was 68.7 ± 12.6 years; 21,656 (43.9%) were female. The mean body mass index was 30.7 ± SD 6.4 kg/m2. The most deprived groups (IMD quintiles 1 and 2) showed poorer HbA1c than the least deprived (IMD quintile 5). People of Black ethnicity had worse HbA1c than those of White ethnicity. Asian individuals were less likely than White individuals to be prescribed insulin (odds ratio [OR] 0.86, 95% CI 0.79-0.95; p < 0.01), sodium-glucose cotransporter-2 (SGLT2) inhibitors (OR 0.68, 95% CI 0.58-0.79; p < 0.001), and glucagon-like peptide-1 (GLP-1) agonists (OR 0.37, 95% CI 0.31-0.44; p < 0.001). Black individuals were less likely than White individuals to be prescribed SGLT2 inhibitors (OR 0.50, 95% CI 0.39-0.65; p < 0.001) and GLP-1 agonists (OR 0.45, 95% CI 0.35-0.57; p < 0.001). Individuals in IMD quintile 5 were more likely than those in the other IMD quintiles to have annual testing for HbA1c, BP, eGFR, retinopathy, and neuropathy. Black individuals were less likely than White individuals to have annual testing for HbA1c (OR 0.89, 95% CI 0.79-0.99; p = 0.04) and retinopathy (OR 0.82, 95% CI 0.70-0.96; p = 0.011). Asian individuals were more likely than White individuals to have monitoring for HbA1c (OR 1.10, 95% CI 1.01-1.20; p = 0.023) and eGFR (OR 1.09, 95% CI 1.00-1.19; p = 0.048), but less likely for retinopathy (OR 0.88, 95% CI 0.79-0.97; p = 0.01) and neuropathy (OR 0.88, 95% CI 0.80-0.97; p = 0.01). The study is limited by the nature of being observational and defined using retrospectively collected data. Disparities in diabetes care may show regional variation, which was not part of this evaluation.

CONCLUSIONS

Our findings suggest that disparity in glycaemic control, diabetes-related monitoring, and prescription of newer therapies remains a challenge in diabetes care. Both SES and ethnicity were important determinants of inequality. Disparities in glycaemic control and other areas of care may lead to higher rates of complications and adverse outcomes for some groups.

Ethnic differences in body composition, sociodemographic characteristics and lifestyle in people with type 2 diabetes mellitus living in Italy

This study aimed to compare immigrants and Italian natives with type 2 diabetes mellitus (DM2) in terms of anthropometric parameters and lifestyle-related characteristics and to investigate the relationship between ethnicity and glycemic control in men and women with DM2 living in Italy. The sample included 100 immigrants (55 Albanians and 45 Africans) and 100 Italians, followed by the Public Health Clinics of Rimini. The association of ethnicity with sex, socioeconomic status, anthropometric and hematological characteristics, and lifestyle were examined. In addition, differences among groups in glycemic control were evaluated. Among males, African participants presented significantly lower values than other groups in adiposity parameters and triglycerides. The highest percentage of obesity and of normal weight was found in Italians and in Africans, respectively. Among females, there were scanty differences, but Italians presented higher WHR values than the other groups. No statistical differences appeared in hematological parameters among groups. There were no significant differences in glycemic control among groups and sexes. Also considering the differences between subjects with optimal (L) or nonoptimal (H) glycemic control, the differences in lifestyle, anthropometric, and hematological variables remained scarce. Among all groups, significantly higher values of glucose were detected in H than in L. A similar condition appeared for triglycerides in males. Immigrant and native Italian diabetics did not present any difference in their clinical characteristics, but Italians generally presented worst lifestyle habits. The percentage of subjects with poor metabolic control of diabetes was not low, but similar in immigrants and natives.

Effectiveness of text message based, diabetes self management support programme (SMS4BG): two arm, parallel randomised controlled trial

OBJECTIVE

To determine the effectiveness of a theoretically based and individually tailored, text message based, diabetes self management support intervention (SMS4BG) in adults with poorly controlled diabetes.

DESIGN

Nine month, two arm, parallel randomised controlled trial.

SETTING

Primary and secondary healthcare services in New Zealand.

PARTICIPANTS

366 participants aged 16 years and over with poorly controlled type 1 or type 2 diabetes (HbA1c ≥65 mmol/mol or 8%) randomised between June 2015 and November 2016 (n=183 intervention, n=183 control).

INTERVENTIONS

The intervention group received a tailored package of text messages for up to nine months in addition to usual care. Text messages provided information, support, motivation, and reminders related to diabetes self management and lifestyle behaviours. The control group received usual care. Messages were delivered by a specifically designed automated content management system.

MAIN OUTCOME MEASURES

Primary outcome measure was change in glycaemic control (HbA1c) from baseline to nine months. Secondary outcomes included change in HbA1c at three and six months, and self efficacy, diabetes self care behaviours, diabetes distress, perceptions and beliefs about diabetes, health related quality of life, perceived support for diabetes management, and intervention engagement and satisfaction at nine months. Regression models adjusted for baseline outcome, health district category, diabetes type, and ethnicity.

RESULTS

The reduction in HbA1c at nine months was significantly greater in the intervention group (mean -8.85 mmol/mol (standard deviation 14.84)) than in the control group (-3.96 mmol/mol (17.02); adjusted mean difference -4.23 (95% confidence interval -7.30 to -1.15), P=0.007). Of 21 secondary outcomes, only four showed statistically significant improvements in favour of the intervention group at nine months. Significant improvements were seen for foot care behaviour (adjusted mean difference 0.85 (95% confidence interval 0.40 to 1.29), P<0.001), overall diabetes support (0.26 (0.03 to 0.50), P=0.03), health status on the EQ-5D visual analogue scale (4.38 (0.44 to 8.33), P=0.03), and perceptions of illness identity (-0.54 (-1.04 to -0.03), P=0.04). High levels of satisfaction with SMS4BG were found, with 161 (95%) of 169 participants reporting it to be useful, and 164 (97%) willing to recommend the programme to other people with diabetes.

CONCLUSION

A tailored, text message based, self management support programme resulted in modest improvements in glycaemic control in adults with poorly controlled diabetes. Although the clinical significance of these results is unclear, the findings support further investigation into the use of SMS4BG and other text message based support for this patient population.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614001232628.

Detection and Management of Diabetes in England: Results from the Health Survey for England

INTRODUCTION

As part of a control strategy current guidance in the UK recommends more intense surveillance of HbA1C levels among those of South-east Asian or Chinese ethnicity above specified BMI thresholds. The objective of this study was to determine whether disparities in the identification and control of diabetes in England persisted despite these guidelines and assess current strategies in light of these findings.

METHODS

Data were extracted from the 2013 Health Survey for England that included ethnicity, BMI status and HbA1C levels. Descriptive statistics and logistic regression analyses were used to examine relationships among undetected diabetes, poorly controlled diabetes and a range of covariates including ethnicity and BMI. Concentration indices were used to examine the socio-economic gradient in disease detection and control among and between ethnic groups.

RESULTS

In regression models that controlled for a range of covariates Asians were found to have a 5% point higher risk of undetected diabetes than Whites. With respect to disease management, Bangladeshis and Pakistanis were found to be at a 28% point and 21% point higher risk of poor disease control respectively than Whites. Concentration indices revealed better disease control among more affluent Whites than poor Whites, no significant pattern between income and disease management was found among Pakistanis and poorer disease control was more evident among more affluent than poorer Bangladeshis.

CONCLUSION

In the UK current guidance recommends practitioners consider testing for diabetes among South-east Asians and Chinese where BMI exceeds 23. Our findings suggest that the risk experienced by Asians in disease detection is independent of BMI and may warrant a more active screening policy than currently recommended. With respect to disease management, our findings suggest that Indians and Pakistanis experience particularly high levels of poor disease control that may also be usefully reflected in guidance.

Cardiovascular and Mortality Risks in Migrant South Asians with Type 2 Diabetes: Are We Winning the Battle?

PURPOSE OF REVIEW

We seek to describe the relationship between diabetes mellitus and cardiovascular risk in migrant South Asians compared to native white Europeans, and to determine the temporal change in this relationship over recent years.

RECENT FINDINGS

Recent evidence suggests that the excess mortality risk associated with diabetes is lower in the migrant South Asian population compared with white Europeans. By contrast, South Asians continue to demonstrate elevated cardiovascular morbidity compared to white Europeans, although to a lesser extent than was observed in previous decades. The excess mortality previously observed in South Asian migrants has attenuated with a lower mortality risk compared to white Europeans observed in several recent studies. We speculate that these findings may relate in part to earlier diabetes diagnosis and more prolonged exposure to cardiovascular risk factor management in the South Asian population. Further study is required to confirm these hypotheses.

Case Finding and Medical Treatment of Type 2 Diabetes among Different Ethnic Minority Groups: The HELIUS Study

Aims. Prevention of diabetes complications depends on the level of case finding and successful treatment of diabetes, which may differ between ethnicities. Therefore, we studied the prevalence by age, awareness, treatment, and control of type 2 diabetes, among a multiethnic population. Methods. We included 4,541 Dutch, 3,032 South-Asian Surinamese, 4,109 African Surinamese, 2,323 Ghanaian, 3,591 Turkish, and 3,887 Moroccan participants (aged 18-70 y) from the HELIUS study. The prevalence of diabetes was analysed by sex, ethnicity, and 10-year age groups. Ethnic differences in the prevalence, awareness, treatment, and control of diabetes were studied by logistic regression. Results. From the age of 31-40 years and older, the prevalence of diabetes was 3 to 12 times higher among ethnic minority groups than that among the Dutch host population. Awareness and medical treatment of diabetes were 2 to 5 times higher among ethnic minorities than that among Dutch. Among those medically treated, only 37-53% had HbA1c levels on target (≤7.0%); only Dutch men had HbA1c levels on target more often (67%). Conclusions. Our results suggest that the age limit for case finding among ethnic minority groups should be lower than that for the general population. Importantly, despite higher awareness and treatment among ethnic minorities, glycemic control was low, suggesting a need for increased efforts to improve the effectiveness of treatment in these groups.

Socioeconomic disparities in type 2 diabetes mellitus prevalence and self-management behaviors in rural southwest China

BACKGROUND

This study examines how socioeconomic factors are associated with prevalence and self-management of diabetes among ethnic minority groups in the rural Yunnan province, which has the most ethnic minority groups per province in southwest China.

METHODS

A cross-sectional survey was carried out in 2014 in a rural southwest population consisting of 5532 consenting individuals aged ⩾35years. Information about participants' demographic characteristics, as well as diabetes diagnosis, treatment, and self-management behaviors, were obtained using a standard questionnaire. Fasting blood sugar levels were recorded for each individual. A socioeconomic position (SEP) index was constructed using principal component analysis.

RESULTS

The age-standardized prevalence of diabetes in the study population was 4.8%. In persons with diabetes, 23.1% regularly self-monitored blood glucose, 43.2% adhered to taking prescribed anti-diabetic drugs or insulin injections, and 63.1% took at least one measure to control blood glucose. Individual educational level was found to be negatively associated with the prevalence of diabetes, whereas individuals with greater household assets and higher SEP were more likely to be suffered from diabetes. Persons with diabetes with greater household assets, higher level of education, and higher SEP had a greater probability of regularly self-monitoring blood glucose, compliance to prescribed medicines, and taking measures to control diabetes. Access to medical services was positively associated with regularly self-monitoring blood glucose and compliance to prescribed medicines.

CONCLUSIONS

Socioeconomic disparities in diabetes prevalence and self-management do exist. Future interventions to further control diabetes and improve diabetes management must be tailored to address socioeconomic factors.

The Inclusion of Ethnic Minority Patients and the Role of Language in Telehealth Trials for Type 2 Diabetes: A Systematic Review

BACKGROUND

Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and prevent secondary complications. However, trials designed to test the effectiveness of telehealth interventions may underrecruit or exclude ethnic minority patients, with language a potential barrier to recruitment. The underrepresentation of minorities in trials limits the external validity of the findings for this key patient demographic.

OBJECTIVE

This systematic review examines (1) the research reporting practices and prevalence of ethnic minority patients included in telehealth randomized controlled trials (RCTs) targeting type 2 diabetes and the trial characteristics associated with recruiting a high proportion of minority patients, and (2) the proportion of included RCTs that report using English language proficiency as a patient screening criterion and how and why they do so.

METHODS

Telehealth RCTs published in refereed journals targeting type 2 diabetes as a primary condition for adults in Western majority English-speaking countries were included. Ethnically targeted RCTs were excluded from the main review, but were included in a post hoc subgroup analysis. Abstract and full-text screening, risk of bias assessment, and data extraction were independently conducted by two reviewers.

RESULTS

Of 3358 records identified in the search, 79 articles comprising 58 RCTs were included. Nearly two-thirds of the RCTs (38/58) reported on the ethnic composition of participants, with a median proportion of 23.5% patients (range 0%-97.7%). Fourteen studies (24%) that included at least 30% minority patients were all US-based, predominantly recruited from urban areas, and described the target population as underserved, financially deprived, or uninsured. Eight of these 14 studies (57%) offered intervention materials in a language other than English or employed bilingual staff. Half of all identified RCTs (29/58) included language proficiency as a participant-screening criterion. Language proficiency was operationalized using nonstandardized measures (eg, having sufficient "verbal fluency"), with only three studies providing reasons for excluding patients on language grounds.

CONCLUSIONS

There was considerable variability across studies in the inclusion of ethnic minority patients in RCTs, with higher participation rates in countries with legislation to mandate their inclusion (eg, United States) than in those without such legislation (eg, United Kingdom). Less than 25% of the RCTs recruited a sizeable proportion of ethnic minorities, which raises concerns about external validity. The lack of objective measures or common procedures for assessing language proficiency across trials implies that language-related eligibility decisions are often based on trial recruiters' impressionistic judgments, which could be subject to bias. The variability and inconsistent reporting on ethnicity and other socioeconomic factors in descriptions of research participants could be more specifically emphasized in trial reporting guidelines to promote best practice.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews: CRD42015024899; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015024899 (Archived by WebCite at http://www.webcitation.org/6kQmI2bdF).

Patterns of weight change after the diagnosis of type 2 diabetes in Scotland and their relationship with glycaemic control, mortality and cardiovascular outcomes: a retrospective cohort study

OBJECTIVES

To determine weight change patterns in Scottish patients 2 years after diagnosis of type 2 diabetes and to examine these in association with medium-term glycaemic, mortality and cardiovascular outcomes.

SETTING

Using a retrospective cohort design, ethical approval was obtained to link the Scottish diabetes care database to hospital admission and mortality records.

PARTICIPANTS

29 316 overweight/obese patients with incident diabetes diagnosed between 2002 and 2006 were identified with relevant information for ≥2 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Weight records over time provided intrapatient weight change and variation and glycated haemoglobin (HbA1c) gave measures of glycaemic control. These characteristics and demographic variables at diagnosis were linked with notifications of death (2-5 years after diagnosis) and cardiovascular events (0-5 year after diagnosis).

RESULTS

By 2 years, 36% of patients had lost ≥2.5% of their weight. Increasing age, being female and a higher body mass index at diagnosis were associated with larger proportions of weight lost (p<0.001). Multivariable modelling showed that inadequate glycaemic control at 2 years was associated with being younger at baseline, being male, having lower levels of obesity at diagnosis, gaining weight or being weight stable with weight change variability, and starting antidiabetic medication. While weight change itself was not related to mortality or cardiovascular outcomes, major weight variability was independently associated with poorer survival and increased cardiovascular outcome risks, as was deprivation.

CONCLUSIONS

Our results suggest that weight loss or being weight stable with little weight variability early after diabetes diagnosis, are associated with better glycaemic control and we identified groups less able to lose weight. With respect to mortality and cardiovascular outcomes, although weight change at 2 years was a weak predictor, major weight variability appeared to be the more relevant factor.

Using an interactive DVD about type 2 diabetes and insulin therapy in a UK South Asian community and in patient education and healthcare provider training

OBJECTIVES

To develop and pilot-test the feasibility and effectiveness of an interactive DVD about misconceptions within South Asian communities regarding insulin treatment in type 2 diabetes, for educating patients and community members and training healthcare providers.

METHODS

The project setting was a South Asian (mainly Indian) community in Leicester, UK. Qualitative evidence from our previous studies was used to inform the content of the DVD script and accompanying resources. The intervention involved three components: facilitating DVD viewings for people with/without diabetes in community settings; training healthcare providers involved in managing South Asian patients with diabetes in primary care; and using the DVD and resources in primary care patient consultations. Evaluation involved a range of approaches including face-to-face interviews, telephone feedback and questionnaires.

RESULTS

Analysis of questionnaires and qualitative feedback from community participants showed some significant changes in attitudes and understanding about insulin and high acceptability of the DVD. Healthcare providers who attended the training found it informative and perceived the DVD and visual resources as potentially useful for facilitating acceptance of insulin. Primary care patient recruitment was challenging, but participants described the DVD as an acceptable and informative way of learning about insulin therapy.

CONCLUSION

The DVD intervention was effective and feasible at community and healthcare provider levels.

PRACTICE IMPLICATIONS

Although based on a small sample, at patient level our findings suggested that the DVD worked at different levels helping some to accept the need for insulin and others to consolidate a decision to commence this treatment. Consideration needs to be given to patient engagement strategies for implementation in primary care consultations.

Impact of ethnicity on progress of glycaemic control in 131,935 newly diagnosed patients with type 2 diabetes: a nationwide observational study from the Swedish National Diabetes Register

OBJECTIVES

Studies on ethnic disparities in glycaemic control have been contradictory, and compromised by excessively broad categories of ethnicity and inadequate adjustment for socioeconomic differences. We aimed to study the effect of ethnicity on glycaemic control in a large cohort of patients with type 2 diabetes.

SETTING

We used nationwide data (mainly from primary care) from the Swedish National Diabetes Register (2002-2011) to identify patients with newly diagnosed (within 12 months) type 2 diabetes.

PARTICIPANTS

We included 131,935 patients (with 713,495 appointments), representing 10 ethnic groups, who were followed up to 10 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Progress of glycated haemoglobin (HbA1c) for up to 10 years was examined. Mixed models were used to correlate ethnicity with HbA1c (mmol/mol). The effect of glycaemic disparities was examined by assessing the risk of developing albuminuria. The impact of ethnicity was compared to that of income, education and physical activity.

RESULTS

Immigrants, particularly those of non-Western origin, received glucose-lowering therapy earlier, had 30% more appointments but displayed poorer glycaemic control (2-5 mmol/mol higher HbA1c than native Swedes). Probability of therapy failure was 28-111% higher for non-Western groups than for native Swedes. High-income Western groups remained below the target-level of HbA1c for 4-5 years, whereas non-Western populations never reached the target level. These disparities translated into 51-92% higher risk of developing albuminuria. The impact of ethnicity was greater than the effect of income and education, and equal to the effect of physical activity.

CONCLUSIONS

Despite earlier pharmacological treatment and more frequent appointments, immigrants of non-Western origin display poorer glycaemic control and this is mirrored in a higher risk of developing albuminuria.

Ethnicity and risk of cardiovascular disease (CVD): 4.8 year follow-up of patients with type 2 diabetes living in Scotland

AIMS/HYPOTHESIS

Potential differences in cardiovascular risk by ethnicity remain uncertain. We evaluated the association of ethnicity with cardiovascular disease (CVD) incidence in a large cohort of people with type 2 diabetes living in Scotland.

METHODS

Data from Scottish Care Information-Diabetes (SCI-Diabetes) were linked to Scottish Morbidity Records (SMR01) and National Records of Scotland data for mortality for dates between 2005 and 2011. Of 156,991 people with type 2 diabetes with coded ethnicity, 121,535 (77.4%) had no CVD at baseline (White: 114,461; Multiple Ethnic: 2,554; Indian: 797; Other Asian: 319; Pakistani: 2,250; Chinese: 387; African-Caribbean: 301 and Other: 466) and were followed up (mean ± SD: 4.8 ± 2.3 years) for the development of fatal and non-fatal CVD.

RESULTS

During follow-up, 16,265 (13.4%) patients developed CVD (ischaemic heart or cerebrovascular diseases). At baseline, Pakistanis were younger and had developed diabetes earlier, had higher HbA1c and longer duration of diabetes, but had lower BP, BMI, creatinine, proportion of smokers and proportion on antihypertensive therapy than whites. The age and sex adjusted HRs for CVD were HR 1.31 (CI 1.17, 1.47), p < 0.001 in Pakistanis and HR 0.66 (CI 0.47, 0.92), p = 0.014 in Chinese compared with whites. Adjusting additionally for an area measure of deprivation, duration of diabetes, conventional CVD and other risk factors, the HR for Pakistanis (HR 1.45 [CI 1.14, 1.85], p = 0.002) was significantly higher, and that for Chinese (HR = 0.58 [CI 0.24, 1.40], p = 0.228) lower, compared with whites.

CONCLUSIONS/INTERPRETATION

Compared with whites with type 2 diabetes, those of Pakistani ethnicity in Scotland were at increased risk of CVD, whereas Chinese were at lower risk, with these differences unexplained by known risk factors.

Prescribing patterns and adherence to medication among South-Asian, Chinese and white people with type 2 diabetes mellitus: a population-based cohort study

AIM

To determine the prescribing of and adherence to oral hypoglycaemic agents, insulin, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statin therapy among South-Asian, Chinese and white people with newly diagnosed diabetes.

METHODS

The present study was a population-based cohort study using administrative and pharmacy databases to include all South-Asian, Chinese and white people aged ≥ 35 years with diabetes living in British Columbia, Canada (1997-2006). Adherence to each class of medication was measured using proportion of days covered over 1 year with optimum adherence defined as ≥ 80%.

RESULTS

The study population included 9529 South-Asian, 14 084 Chinese and 143 630 white people with diabetes. The proportion of people who were prescribed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statin or oral hypoglycaemic agents was ≤ 50% for all groups. South-Asian and Chinese people had significantly lower adherence for all medications than white people, with the lowest adherence to angiotensin-converting enzyme inhibitor treatment (South-Asian people: adjusted odds ratio 0.37, 95% CI 0.34-0.39; P<0.0001; Chinese people: adjusted odds ratio 0.50, 95% CI 0.47-0.54; P<0.0001) and statin therapy (South-Asian people: adjusted odds ratio 0.47, 95% CI 0.41 - 0.53, P < 0.0001; Chinese people: adjusted odds ratio 0.72, 95% CI 0.67 - 0.77; P<0.0001) compared with white people.

CONCLUSION

Adherence to evidence-based pharmacotherapy was substantially worse among the South-Asian and Chinese populations. Care providers need to be alerted to the high levels of non-adherence in these groups and the underlying causes need to be investigated.