Socioeconomic status and type 2 diabetes complications among young adult patients in Japan

Associations between income/employment status and diabetes care processes, health behaviors, and health outcomes in Japan: A cross-sectional study using claims data linked to a questionnaire survey

AIMS/INTRODUCTION

We aimed to explore the associations between income/employment status and diabetes care processes, health behaviors and health outcomes.

MATERIALS AND METHODS

This cross-sectional study used health insurance claims data between April 2021 and March 2022, and a questionnaire survey between December 2022 and January 2023 in Tsukuba City. The study analyzed the participants with diabetes (other than type 1) from those selected by stratified random sampling. We evaluated diabetes care processes, health behaviors and health outcomes by calculating weighted proportions among the groups. We also assessed the associations between income/employment status and these variables using multivariable modified Poisson regression models.

RESULTS

Of the 264 identified participants, 161 (64.2%) were men and 168 (72.8%) were aged ≥65 years old. Compared with the low-income groups, the high-income group had a higher proportion of sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists use (adjusted risk ratio [aRR] 1.70, 95% confidence interval (CI) 1.07-2.72), a higher proportion of attendance to annual health checkups for ≥2 years (aRR 1.68, 95% CI 1.07-2.64) and a lower proportion of all-cause hospitalization (aRR 0.15, 95% CI 0.04-0.48); additionally, the middle-income group had a lower proportion of high total outpatient medical expenses (aRR 0.57, 95% CI 0.35-0.92). Compared to the no work time group, the full-time work group had a lower proportion of exercise habits (aRR 0.59, 95% CI 0.35-0.99) and a higher proportion of good self-reported health (aRR 2.08, 95% CI 1.22-3.55).

CONCLUSIONS

Several variables were associated with income/employment status. Policy intervention should focus on high-risk groups identified by considering these associations.

Young-onset type 2 diabetes mellitus enhances proteinuria, but not glomerular filtration rate decline: A Japanese cohort study

AIMS/INTRODUCTION

The time course of chronic kidney disease in young-onset type 2 diabetes mellitus remains unclear. We compared the trajectories of proteinuria and estimated glomerular filtration rate (eGFR) decline between young-onset (aged ≤40 years) and late-onset (aged >40 years) type 2 diabetes mellitus in a Japanese multicenter cohort.

MATERIALS AND METHODS

Participants without diabetic kidney disease were divided into two groups according to age at diagnosis: young- and late-onset. The primary endpoint was eGFR <60 mL/min/1.73 m2, proteinuria or both. Multivariable Cox proportional hazards were calculated to estimate incidence.

RESULTS

Among 626 participants with type 2 diabetes mellitus, 78 (12.4%) had young-onset and 548 (87.6%) had late-onset diabetes. The incidence of eGFR <60 mL/min/1.73 m2 was lower (16.7% vs 33.5%, P = 0.003), but that of proteinuria was higher (46.2% vs 28.9%, P = 0.002) in the young-onset type 2 diabetes mellitus group. The Kaplan-Meyer curve showed that young-onset type 2 diabetes mellitus was associated with a decreased hazard ratio (HR) for eGFR <60 mL/min/1.73 m2 and an increased HR for proteinuria compared with late-onset type 2 diabetes mellitus. In the multivariate Cox analysis, young-onset type 2 diabetes mellitus increased the HR (95% confidence interval) of proteinuria (1.53, 95% confidence interval 1.03-2.26), but did not change the eGFR <60 mL/min/1.73 m2 HR.

CONCLUSIONS

Young-onset type 2 diabetes mellitus has a lower HR of eGFR <60 mL/min/1.73 m2 and an increased HR of proteinuria compared with late-onset type 2 diabetes mellitus, indicating that young-onset type 2 diabetes mellitus has a different time course for the development of proteinuria and subsequent eGFR decline.

A cross-sectional time series of cardiometabolic health education format preferences across sociodemographic groups

AIMS

Health education is integral to cardiometabolic disease (CMD) management. This study aimed to assess whether and how education preferences have changed over time, and whether trends differ by sociodemographic characteristics (education status, age, ethnicity, and sex).

METHODS

A cross-sectional questionnaire was deployed across five counties in the East Midlands, UK between 2017 and 2022 to adults with CMD (type 2 diabetes, cardiovascular disease or cerebrovascular disease). Respondent demographic data were collected alongside health education preferences. Statistical analyses ascertained whether demographic characteristics influenced preferences. The distribution of preferences over time was charted to identify trends.

RESULTS

A total of 4301 eligible responses were collected. Face-to-face one-to-one education was preferred (first choice for 75.1% of participants) but popularity waned over the five-year period. Trends were similar amongst demographic groups. Online education showed a U-shaped trend: In 2017, 44% of respondents ranked it as acceptable, peaking at 53% in 2019, but declining again, to below base line, 43%, by 2022. This modality was more popular with participants aged younger than 65 years, but popularity in people older than 65 years increased over the study period. The popularity of printed information also declined over time across all demographic groups except those of South Asian ethnicity, for whom it remained static.

CONCLUSIONS

The overwhelming preference for face-to-face one-to-one health education from a doctor or nurse highlights the importance of preserving access to this modality, even in the face of current NHS pressures and trends towards digitalisation. Trends are changing, and should continue to be monitored, including between different sociodemographic groups.

Building a multistate model from electronic health records data for modeling long-term diabetes complications

Objective

The progression of long-term diabetes complications has led to a decreased quality of life. Our objective was to evaluate the adverse outcomes associated with diabetes based on a patient's clinical profile by utilizing a multistate modeling approach.

Methods

This was a retrospective study of diabetes patients seen in primary care practices from 2013 to 2017. We implemented a five-state model to examine the progression of patients transitioning from one complication to having multiple complications. Our model incorporated high dimensional covariates from multisource data to investigate the possible effects of different types of factors that are associated with the progression of diabetes.

Results

The cohort consisted of 10,596 patients diagnosed with diabetes and no previous complications associated with the disease. Most of the patients in our study were female, White, and had type 2 diabetes. During our study period, 5928 did not develop complications, 3323 developed microvascular complications, 1313 developed macrovascular complications, and 1129 developed both micro- and macrovascular complications. From our model, we determined that patients had a 0.1334 [0.1284, .1386] rate of developing a microvascular complication compared to 0.0508 [0.0479, .0540] rate of developing a macrovascular complication. The area deprivation index score we incorporated as a proxy for socioeconomic information indicated that patients who reside in more disadvantaged areas have a higher rate of developing a complication compared to those who reside in least disadvantaged areas.

Conclusions

Our work demonstrates how a multistate modeling framework is a comprehensive approach to analyzing the progression of long-term complications associated with diabetes.

Recipients of public assistance with advanced chronic kidney disease: insights into receiving a presentation of kidney replacement therapy options and polypharmacy from Japanese investigators with innovative network about kidney disease study

BACKGROUND

The characteristics of patients with advanced chronic kidney disease (CKD) who are recipients of public assistance in Japan, and the adequacy of their medical care have not been reported previously.

METHODS

The records of patients with CKD stage G5 who visited nine facilities in Japan from April to June 2013 were retrospectively reviewed to compare the characteristics and care of recipients of public assistance with those of non-recipients. Receiving a presentation of kidney replacement therapy (KRT) options and polypharmacy were used as indicators of suboptimal medical care.

RESULTS

Of the 592 patients included in this analysis (mean age, 69.6 years; male, 59.3%), 56 (9.5%) were recipients of public assistance and 536 (90.5%) were non-recipients of public assistance. The prevalence of diabetes mellitus, unmarried status, and living alone were higher in recipients of public assistance. In multivariable logistic regression analysis, compared with non-recipients of public assistance, recipients of public assistance were less likely to receive a presentation of KRT options (adjusted odds ratio [aOR], 0.31; 95% confidence interval [CI], 0.17-0.56), and were more likely to receive ≥ 10 (aOR, 1.92; 95% CI, 1.05-3.51), and ≥ 15 (aOR, 2.78; 95% CI, 1.23-6.26) types of medication.

CONCLUSIONS

Patients with advanced CKD receiving public assistance were less likely to receive a presentation of KRT options and more likely to receive ≥ 10 and ≥ 15 types of medication, suggesting that recipients of public assistance are more likely to receive suboptimal medical care.

The impact of social deprivation on development and progression of diabetic kidney disease

Introduction

Diabetes is one of the leading causes of chronic kidney disease. Social deprivation is recognised as a risk factor for complications of diabetes, including diabetic kidney disease. The effect of deprivation on rate of decline in renal function has not been explored in the Irish Health System to date. The objective of this study is to explore the association between social deprivation and the development/progression of diabetic kidney disease in a cohort of adults living with diabetes in Ireland.

Methods

This is a retrospective cohort study using an existing dataset of people living with diabetes who attended the diabetes centre at University Hospital Galway from 2012 to 2016. The variables included in this dataset include demographic variables, type and duration of diabetes, clinical variables such as medication use, blood pressure and BMI and laboratory data including creatinine, urine albumin to creatinine to ratio, haemoglobin A1c and lipids. This dataset will be updated with laboratory data until January 2023. Individual's addresses will be used to calculate deprivation indices using the Pobal Haase Pratschke (HP) deprivation index. Rate of renal function decline will be calculated using linear mixed-effect models. The relationship between deprivation and renal function will be assessed using linear regression (absolute and relative rate of renal function decline based on eGFR) and logistic regression models (rapid vs. non-rapid decline).

The relationship between loneliness and blood glucose: a cross-sectional survey among Japanese

Recently, researchers have uncovered a correlation between loneliness and both the development and management of diabetes. Nevertheless, previous studies employing an unvalidated loneliness questionnaire impair result accuracy. Furthermore, this aspect has not been researched in the Japanese population. Therefore, this cross-sectional study analyzed data from the Kanagawa prospective "ME-BYO" Cohort Study (ME-BYO cohort) to investigate the correlation between loneliness, as measured by 20 items on the UCLA Loneliness Scale, and blood glucose levels. A total of 666 participants were included in the analysis, with a mean age of 54.1 years and a mean BMI of 23 kg/m2. Half of the participants had obtained an education level beyond high school. The mean household income and physical activity level were reported as 6.83 million Japanese yen and 12.3 METs-h/day, respectively. Model 1 of the linear regression analysis determined that there was no significant association between the loneliness scale and HbA1c (p = 0.512). After adjusting for age, gender, BMI (model 2), sitting time, physical activity level (model 3), housemates, household income, and final education (model 4), and controlling for social support, quality of life, and depression (model 5), the results showed no significant association, with a p-value of 0.823, 0.791, 0.792, and 0.816, respectively. Thus, the study found no link between loneliness and HbA1c in the high SES population. This finding contradicts previous results and may be attributed to the impact of population characteristics, SES status, or genetic backgrounds.

Health Statuses of People in Poverty Receiving Public Assistance in Japan: A Scoping Review

Background

Promoting health and well-being is essential to ensure dignified lives of the entire population, including those living in poverty. Guaranteeing the human right to health is a critical responsibility of social security policies. To address emerging issues associated with poverty, the Japanese government has implemented a welfare program known as public assistance-seikatsu-hogo. However, financial welfare programs may not fully mitigate health risks due to the complex impact of poverty on health. Although a global systematic review of the health status of public and social assistance recipients has been conducted, it did not include any studies from Japan. Furthermore, evidence for the development of health support strategies for Japanese recipients remains scarce. This scoping review aims to identify the current situation and potential issues concerning the health of recipients.

Methods

PubMed was searched for articles published before November 2023. Of the 357 articles identified, 56 were included. Among those included, 35 used the individual status of receiving public assistance as an exposure variable, 13 considered public assistance recipients as the study population, and 8 used the prefectural proportion of the population receiving public assistance as an environmental predictor.

Results

We found that public assistance recipients tend to have more disadvantageous health and well-being statuses than the general population, as reported in the global systematic review. Health inequalities were also observed among recipients based on their sociodemographic characteristics. In Japan, public assistance recipients face several health risks and are at a disadvantage compared with the general population.

Conclusions

The distribution of risks is heterogeneous among recipients, despite the minimum income protection and financial benefits in health and long-term care use. Further studies to identify the effects of public assistance policy on the health of the impoverished population, evidence-based discussions, and reform of social security policies are warranted.

Healthcare utilisation by diabetic patients in Denmark: the role of primary care in reducing emergency visits

Improving the management of diabetic patients is receiving increasing attention in the health policy agenda due to increasing prevalence in the population and raising pressure on healthcare resources. This paper examines the determinants of healthcare services utilisation in patients with type-2 diabetes, investigating the potential substitution effect of general practice visits on the utilisation of emergency department visits. By using rich longitudinal data from Denmark and a bivariate econometric model, our analysis highlights primary care services that are more effective in preventing emergency department visits and socioeconomic groups of patients with a weak substitution response. Our results suggest that empowering primary care services, such as preventive assessment visits, may contribute to reducing emergency department visits significantly. Moreover, special attention should be devoted to vulnerable groups, such as patients from low socioeconomic background and older patients, who may find more difficult achieving a large substitution response.

Role of Systemic Factors in Improving the Prognosis of Diabetic Retinal Disease and Predicting Response to Diabetic Retinopathy Treatment

Topic

To review clinical evidence on systemic factors that might be relevant to update diabetic retinal disease (DRD) staging systems, including prediction of DRD onset, progression, and response to treatment.

Clinical relevance

Systemic factors may improve new staging systems for DRD to better assess risk of disease worsening and predict response to therapy.

Methods

The Systemic Health Working Group of the Mary Tyler Moore Vision Initiative reviewed systemic factors individually and in multivariate models for prediction of DRD onset or progression (i.e., prognosis) or response to treatments (prediction).

Results

There was consistent evidence for associations of longer diabetes duration, higher glycosylated hemoglobin (HbA1c), and male sex with DRD onset and progression. There is strong trial evidence for the effect of reducing HbA1c and reducing DRD progression. There is strong evidence that higher blood pressure (BP) is a risk factor for DRD incidence and for progression. Pregnancy has been consistently reported to be associated with worsening of DRD but recent studies reflecting modern care standards are lacking. In studies examining multivariate prognostic models of DRD onset, HbA1c and diabetes duration were consistently retained as significant predictors of DRD onset. There was evidence of associations of BP and sex with DRD onset. In multivariate prognostic models examining DRD progression, retinal measures were consistently found to be a significant predictor of DRD with little evidence of any useful marginal increment in prognostic information with the inclusion of systemic risk factor data apart from retinal image data in multivariate models. For predicting the impact of treatment, although there are small studies that quantify prognostic information based on imaging data alone or systemic factors alone, there are currently no large studies that quantify marginal prognostic information within a multivariate model, including both imaging and systemic factors.

Conclusion

With standard imaging techniques and ways of processing images rapidly evolving, an international network of centers is needed to routinely capture systemic health factors simultaneously to retinal images so that gains in prediction increment may be precisely quantified to determine the usefulness of various health factors in the prognosis of DRD and prediction of response to treatment.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Association between the Decrease in Medical Visit Frequency and Chronic Disease Worsening in the Early Stages of COVID-19 - A Longitudinal Study

Objective This longitudinal study aimed to clarify the changes in the medical treatment behavior of Japanese patients with chronic diseases during the early phase of the coronavirus disease 2019 (COVID-19) pandemic and examine the factors associated with disease worsening. Methods Subjects with chronic diseases were selected from a panel survey that started at the beginning of the COVID-19 pandemic consists of 2,400 participants recruited via the Internet. Medical treatment behaviors (decrease in medical visit frequency, inability to take regular medications, and utilization of telephone/online medical care), psychological distress, and sociodemographic factors were evaluated at baseline (May 2020) and at the follow-up survey (February 2021). A worsening of chronic diseases was defined as those who answered "yes" to the question, "Has-the-condition-of-the-chronic-disease-worsened?". The factors related to the worsening of chronic diseases at follow-up were examined. Results A total of 514 participants (mean age 61.6±12.9 years) were analyzed. The percentage of participants who reported decreasing medical visit frequency was 34% at the baseline and 16.5% at follow-up, and those who reported a worsening of chronic diseases was 5.1% and 5.1%, respectively. A worsening of chronic diseases at follow-up was significantly associated with a younger age, a decreased frequency of medical visits, unemployment, a history of smoking, and psychological distress. Conclusions A decreased frequency of medical visits was observed among one-third of the participants with chronic disease in the early stage of the pandemic, and it reduced by half at follow-up. In the early stages of an emerging infectious disease pandemic, decreased regular hospital/clinic visits can lead to a worsening of chronic diseases. Those who had psychological distress, unemployment, and a history of smoking were vulnerable to a worsening chronic disease.

Social deprivation and diabetic kidney disease: A European view

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

Association between Glucose-lowering Treatments and Risk of Diabetic Retinopathy in People with Type 2 Diabetes: A Nationwide Cohort Study

INTRODUCTION

Glycaemic variability is possibly linked to the development of diabetic retinopathy, and newer second-line glucose-lowering treatments in type 2 diabetes might reduce glycaemic variability.

AIM

This study aimed to investigate whether newer second-line glucose-lowering treatments are associated with an alternative risk of developing diabetic retinopathy in people with type 2 diabetes.

METHODS

A nationwide cohort of people with type 2 diabetes on second-line glucose-lowering treatment regimens in 2008-2018 was extracted from the Danish National Patient Registry. Adjusted time to diabetic retinopathy was estimated with a Cox Proportional Hazards model. The model was adjusted for age, sex, diabetes duration, alcohol abuse, treatment start year, education, income, history of late-diabetic complications, history of non-fatal major adverse cardiovascular events, history of chronic kidney disease, and history of hypoglycaemic episodes.

RESULTS

Treatment regimens of metformin + basal insulin (HR: 3.15, 95% CI: 2.42-4.10) and metformin + glucagon-like peptide-1 receptor agonist (GLP-1-RA, HR: 1.46, 95% CI: 1.09-1.96) were associated with an increased risk of diabetic retinopathy compared with metformin + dipeptidyl peptidase-4 inhibitors (DPP-4i). Treatment with metformin + sodium-glucose cotransporter-2 inhibitor (SGLT2i, HR: 0.77, 95% CI: 0.28-2.11) was associated with the numerically lowest risk of diabetic retinopathy compared with all regimens investigated.

CONCLUSION

Findings from this study indicate that basal insulin and GLP-1-RA are suboptimal second- line choices for people with type 2 diabetes at risk of developing diabetic retinopathy. However, many other considerations concerning the choice of second-line glucose-lowering treatment for type 2 diabetes patients should be taken into account.

The burden of type 2 diabetes in adolescents and young adults in Mexico: analysis from the Global Burden of Disease Study, 1990 to 2019

Purpose

The aim was to analyze the findings from the 2019 Global Burden of Disease (GBD-2019) study on type-2 diabetes in Mexico's adolescents and young adults, at a national and subnational scale from 1990 to 2019, and to assess its association with the socio-demographic, and the healthcare access and quality indices.

Methods

Following the GBD-2019 study, young-onset type 2 diabetes mortality, premature mortality, years lived with disability and disability-adjusted life-years (DALYs) are reported.

Results

A significant increase in the overall number of deaths attributed to young-onset T2D was found. There was a non-significant decrease in mortality rates for both sexes across most age groups. DALYs in men were greater than that in women, with almost half attributed to premature death in males, while disability accounted for two thirds of DALYs in females. The DALY rate increased significantly in most states. Premature mortality decreased, while disability increased across all age-groups, and in all states for both sexes.

Conclusion

The surge in disability corresponded to the upsurge in obesity and overweight rates in Mexico among the younger population. This happened despite improvements in socio-economic status and healthcare access in Mexico which underscores the need for diabetes education in the public health sector.

Association Between Educational Status and Mortality According to Diabetes Status Among US Adults

Objective

To examine differences in the association between educational attainment and mortality by the presence of diabetes and diabetic retinopathy (DR)-a major complication of diabetes.

Patients and Methods

We used a nationally representative sample of 54,924 US adults aged 20 years or older with diabetes from the National Health and Nutrition Examination Survey 1999-2018 and its mortality data through 2019. We applied the multivariable Cox proportional hazard models to investigate the associations between educational attainment (low, less than high school; middle, high school; and high, more than high school) and all-cause mortality according to diabetes status: nondiabetes, diabetes without DR, and diabetes with DR. Differences in the survival rate by educational attainment were evaluated using the slope inequality index (SII).

Results

Among the 54,924 participants (mean age, 49.9 years), adults in the low educational group reported an increased risk of all-cause mortality compared with those of the high educational group in any diabetes status (nondiabetes-hazard ratio [HR], 1.69; 95% CI, 1.56-1.82; diabetes without DR-HR, 1.61; 95% CI, 1.37-1.90; diabetes with DR-HR, 1.43; 95% CI, 1.10-1.86). SIIs among the diabetes without DR group and diabetes with DR group were 22.17 and 20.87 per 1000 person-years, respectively, which were 2 times greater than those among the nondiabetes group (SII=9.94).

Conclusion

The differences in the mortality risks owing to the educational attainment increased by the presence of diabetes regardless of the complication of DR. Our findings indicate that prevention of diabetes itself is critical to mitigate health disparities by socioeconomic status such as education status.

Diabetic retinopathy in African-Americans with end-stage kidney disease: a cross-sectional study on prevalence and impact on quality of life

INTRODUCTION

The prevalence, severity, and quality of life (QoL) impact of diabetic retinopathy (DR) among African-Americans (AAs) with end-stage kidney disease (ESKD) undergoing dialysis are unknown.

RESEARCH DESIGN AND METHODS

A cross-sectional study was conducted on 93 AA adults with diabetes and ESKD. The diagnosis of DR was based on a review of medical records and/or a positive photograph with a portable hand-held device reviewed by both artificial intelligence software and a retinal specialist. QoL, physical disability social determinants of health (SDoHs) were assessed by standardized questionnaires.

RESULTS

The prevalence of DR was 75%, with 33% of participants having mild, 9.6% moderate and 57.4% severe DR. A total of 43% had normal visual acuity; 45% had moderate visual impairment; and 12% had severe visual impairment. We found a high burden of disease, multiple SDoH challenges, and low QoL and general health among patients with ESKD. The presence of DR had no significant impact on physical health and QoL compared with participants without DR.

CONCLUSIONS

DR is present in 75% of AA patients with diabetes and ESKD on haemodialysis. ESKD has a significant burden on general health and QoL; however, DR has a minor additional impact on the overall physical health and QoL in people with ESKD.

Are social determinants of health associated with the development of early complications among young adults with type 2 diabetes? A population based study using linked databases

AIMS

To quantify the impact of social determinants of health (SDOH) on top of medical determinants on the development of diabetes-related complications in young adults with type 2 diabetes.

METHODS

In this observational population-based study, SDOH (income and origin) were linked to routine primary care data. Young adults (18-45 years) with incident type 2 diabetes between 2007 and 2013 were included. The main outcome, the development of the first micro- or macrovascular complication, was analyzed by multivariate Cox regression. Medical determinants included antidiabetic treatment, HbA1c in the year after diagnosis, body mass index, comorbidity and smoking.

RESULTS

Of 761 young adults (median age: 39 years (IQR 33-42), men: 49%, Western origin: 36%, low income: 48%), 154 developed at least one complication (median follow-up 99 months (IQR 73-123)). Young men of non-Western origin were more likely to develop a complication (HR 1.98 (1.19-3.30)), as were young adults with HbA1c > 7% (>53 mmol/mol) (HR: 1.72 95% CI: 1.15-2.57). No associations were found with income. Being women was protective.

CONCLUSION

In this multi-ethnic population, non-Western origin was associated with the development of complications, but only in men. Low income was not associated with developing complications. The importance of adequate HbA1c regulation was re-emphasized by this study.

Defining the observable processes of patient care related to social determinants of health

INTRODUCTION

An understanding of social determinants of health (SDH) and patients' social circumstances is recommended to deliver contextualised care. However, the processes of patient care related to SDH in clinical settings have not been described in detail. Observable practice activities (OPAs) are a collection of learning objectives and activities that must be observed in daily practice and can be used to describe the precise processes for professionals to follow in specific situations (process OPA.) METHODS: We used a modified Delphi technique to generate expert consensus about the process OPA for patient care related to SDH in primary care settings. To reflect the opinions of various stakeholders, the expert panel comprised clinical professionals (physicians, nurses, public health nurses, social workers, pharmacists and medical clerks), residents, medical students, researchers (medical education, health care, sociology of marginalised people), support members for marginalised people and patients. The Delphi rounds were conducted online. In Round 1, a list of potentially important steps in the processes of care was distributed to panellists. The list was modified, and one new step was added. In Round 2, all steps were acknowledged with few modifications.

RESULTS

Of 63 experts recruited, 61 participated, and all participants completed the Delphi rounds. A total of 14 observable steps were identified, which were divided into four components: communication, practice, maintenance and advocacy. The importance of ongoing patient-physician relationships and collaboration with professionals and stakeholders was emphasised for the whole process of care.

DISCUSSION

This study presents the consensus of a variety of experts on the process OPA for patient care related to SDHs. Further research is warranted to investigate how this Communication-Practice-Maintenance-Advocacy framework could affect medical education, quality of patient care, and patient outcomes.

Level of education is associated with coronary heart disease and chronic kidney disease in individuals with type 2 diabetes: a population-based study

INTRODUCTION

To study the relationship between education level and vascular complications in individuals with type 2 diabetes in Norway.

RESEARCH DESIGN AND METHODS

Multiregional population-based cross-sectional study of individuals with type 2 diabetes in primary care. Data were extracted from electronic medical records in the period 2012-2014. Information on education level was obtained from Statistics Norway. Using multivariable multilevel regression analyses on imputed data we analyzed the association between education level and vascular complications. We adjusted for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration. Results are presented as ORs and 95% CIs.

RESULTS

Of 8192 individuals with type 2 diabetes included, 34.0% had completed compulsory education, 49.0% upper secondary education and 16.9% higher education. The prevalence of vascular complications in the three education groups was: coronary heart disease 25.9%, 23.0% and 16.9%; stroke 9.6%, 7.4% and 6.6%; chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m²) 23.9%, 16.8% and 12.6%; and retinopathy 13.9%, 11.5% and 11.7%, respectively. Higher education was associated with lower odds for coronary heart disease (OR 0.59; 95% CI 0.49 to 0.71) and chronic kidney disease (OR 0.75; 95% CI 0.60 to 0.93) compared with compulsory education when adjusting for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration.

CONCLUSIONS

In a country with equal access to healthcare, high education level was associated with lower odds for coronary heart disease and chronic kidney disease in individuals with type 2 diabetes.

Poor Self-Care Practices and Being Urban Resident Strongly Predict Chronic Complications Among Patients with Type 2 Diabetes in Eastern Ethiopia: A Hospital-Based Cross-Sectional Study

Background

Diabetes, together with its complications, has a considerable negative influence on people's quality of life and healthcare delivery and raises diabetic mortality. However, there is limited information about the diabetes-associated chronic complications in the study setting. Therefore, this study aimed to determine the burden and factors related to the chronic complications among patients with type 2 diabetes (T2D) in Eastern Ethiopia.

Methods

A hospital-based cross-sectional study was conducted among 879 patients with T2D at two public hospitals in Harar. The data were collected through interviews using a structured questionnaire. Data related to the diagnosis of chronic complications and biochemical tests were extracted from medical records. The outcome variable was the number of chronic complications that happened to the patients. A generalized Poisson regression model with robust variance estimation was used to investigate the association of independent variables with chronic complications. An adjusted prevalence ratio with a 95% CI was reported to show an association using a p-value ≤0.05.

Results

One or more chronic complications were presented in 43% of T2D (95% CI: 39.65, 46.19). Macrovascular and microvascular complications were found in 27.6% and 23.5% of patients, respectively. Urban residence (APR = 2.64; 95% CI: 1.54, 4.54), low wealth status (APR = 1.80; 95% CI: 1.17, 2.76), diabetes duration ≥5 years (APR = 1.46; 95% CI: 1.05, 2.01), hypertriglyceridemia (APR = 1.48; 95% CI: 1.07, 2.09) and poor self-care practices (APR = 1.62; 95% CI: 1.18, 2.23) were factors significantly associated with the chronic complications.

Conclusion

The burden of chronic complications was high, with nearly half of T2D patients experiencing one or more chronic complications. Almost one in ten patients suffered from multiple chronic complications. The complications were mainly influenced by being urban resident, low wealth status, and poor self-care practices. Therefore, health care providers need to educate patients and promote self-care practices and healthy lifestyles to achieve treatment goals and lower the risk of chronic complications.

Effect of Chronic Heart Failure Complicated with Type 2 Diabetes Mellitus on Cognitive Function in the Elderly

Objective

To explore the effect of chronic heart failure complicated with type 2 diabetes mellitus on cognitive function in the elderly.

Methods

600 patients with chronic heart failure were selected from January 2018 to January 2021. All patients were divided into observation group (A) and control group (B). A was chronic heart failure complicated with type 2 diabetes mellitus group. B was chronic heart failure group. The clinical effects of the two groups were observed.

Results

Compared with the clinical indexes during and after operation, there were differences in operation time, postoperative recovery time, and treatment cost between A and B, but the difference is not significant (all P > 0.05). LVEF cardiac function index score, LVEF score of A compared with B, the difference was statistically significant (P < 0.05). The MMSE score and MoCA score of the two groups were compared. Before operation, the MMSE score and MoCA score of A were lower than those of B, and the difference was statistically significant (P < 0.05). After operation, the MMSE score and MoCA score in B were significantly higher than those in B, but the increasing trend of MMSE score and MoCA score in B was significantly higher than that in A (P < 0.05). Comparison of HAMA score and HAMD score: before operation, the HAMA score and HAMD score were higher in A, but the difference is not significant (P > 0.05). After operation, the scores of HAMA and HAMD in A and B decreased significantly, but the difference is not significant (P > 0.05). Multivariate analysis showed that the fasting blood glucose and glycosylated hemoglobin were the risk factors of cognitive impairment.

Conclusion

Type 2 diabetes mellitus in elderly patients with chronic heart failure will further aggravate cognitive impairment, and type 2 diabetes is an important independent risk factor affecting cognitive function, which accelerates cognitive impairment and significantly reduces the executive ability of elderly patients with chronic heart failure, resulting in a significant decline in patients' ability to understand and apply information.

The public economic burden of suboptimal type 2 diabetes control upon taxpayers in Sweden: Looking beyond health costs

AIM

To estimate the fiscal burden for taxpayers in Sweden associated with type 2 diabetes (T2D) attributed to diabetes-related complications in patients failing to meet HbA1c targets.

MATERIAL AND METHODS

We developed a public economic framework to assess how changes in diabetes-related complications influenced projected tax contributions and government disability payments for people with T2D. The analysis applied accepted disease-modelling practices to estimate different rates of diabetes-related complications based on an HbA1c of 6.9% (52 mmol/mol) and of 6.0% (42 mmol/mol). We adjusted the employment activity rates for those experiencing T2D-related events, applying age-specific earnings to estimate lifetime tax losses. Furthermore, the likelihood of receiving payments for health-related employment inactivity was estimated. Direct healthcare costs are excluded from this analysis.

RESULTS

The estimated per person earnings loss for immediate and delayed HbA1c control was Swedish krona (SEK) 42 299 and SEK 44 157, respectively, over 10 years. The lost employment activity of people with T2D translates to lost tax revenues of SEK 23 265 and SEK 24 287 for immediate and delayed control, respectively. The estimated difference in disability payments was SEK 538. Combining the tax revenue loss and excess disability payments defines the broader fiscal costs, where we observe combined fiscal losses that favour immediate and sustained control by SEK 1560 over 10 years.

CONCLUSIONS

We show that conducting fiscal analysis of diabetes interventions offers an enriched perspective capturing a range of costs that fall on government in relation to lost tax revenue and disability payments. Tax-financed health systems may benefit from broadening the consideration of costs and benefits when evaluating new interventions and treatment practices.

Occupations associated with diabetes complications: A nationwide-multicenter hospital-based case-control study

AIM

Investigating the risks of diabetes complications among inpatients with diabetes associated with longest-held and current occupations.

METHOD

Using a Japanese nationwide, multicenter, hospital inpatient dataset (2005-2015), a matched case-control study with 39,550 inpatients with diabetes was conducted. We considered both the longest-held and current occupations of the study subjects.

RESULT

Diabetes complications such as retinopathy, nephropathy, neuropathy, and peripheral vascular complications occur more often in managers, sales workers, service workers, transportation workers, construction and mining workers and carrying, cleaning and packing workers. Among these occupations, particularly the service workers indicated consistently significant increased risks (OR = 1.36 (1.23-1.51)) in developing all the considered subtypes of diabetes complications, and the performed sensitivity analysis confirmed this conclusion. Moreover, among service workers, cooks, waiters, building service staff and other service workers were identified as having the highest risks in developing diabetes complications (ORs = 1.30 (1.12-1.51), 1.63 (1.36-1.95), 1.79 (1.21-2.67), and 2.05 (1.30-3.22), respectively).

CONCLUSIONS

Our study's potential translational impact should lead to subsequent investigations on the causes connected to certain occupations of various diabetes complications and particularly to more carefully dealing with patients with diabetes who work in the identified occupational areas and their health risks.

Incidence and relative risk of metachronous second primary cancers for 16 cancer sites, Osaka, Japan, 2000-2015: Population-based analysis

Background

An increasing number of cancer survivors have developed multiple primaries. This study aims to describe the incidence and risk patterns of metachronous second primary cancers (SPCs) in Osaka, Japan.

Methods

Data were obtained from the Osaka Cancer Registry, a population‐based database of all cancers diagnosed in Osaka. The study subjects were individuals who were first diagnosed with invasive cancers in 16 major cancer sites during 2000–2014, aged 15–79 years, survived at least 3 months, and were followed up for 10 years. We measured incidence rates, cumulative risks, and standardized incidence ratios (SIRs: with the Osaka general population as the referent) of developing SPCs during 3 months to 10 years after the first diagnosis.

Results

During 2000–2015, among 418,791 cancer survivors, 24,368 (5.8%) developed SPCs within 10 years of first diagnosis. Males had higher incidence rates than females except among young‐onset survivors (aged 15–39 years). 10‐year cumulative risks among survivors aged 70–79 years (the most dominant age group) were 24.0% (male) and 11.8% (female). 10‐year SIRs were 1.38 (95% CI, 1.36–1.40; male) and 1.44 (95% CI, 1.41–1.48; female) with higher estimates among younger survivors in both sexes. Strong bidirectional associations were observed between oral/pharyngeal, esophageal, and laryngeal cancers. Survivors of any smoking‐related cancers had elevated SIRs of developing smoking‐related SPCs. Similar results were observed for alcohol‐related cancers.

Conclusions

Cancer survivors are at excess risk of developing SPCs compared to the general population. Continued surveillance is warranted to inform survivorship care through risk‐based long‐term care planning and lifestyle‐changing efforts to prevent new cancers.

Clinical profile and magnitude of diabetic retinopathy: An electronic medical record-driven big data analytics from an eye care network in India

Purpose:

This study aimed to describe the clinical profile and magnitude of diabetic retinopathy (DR) in patients presenting to a multitier eye hospital network in India.

Methods:

This cross-sectional hospital-based study included 263,419 individuals with diabetes mellitus (DM) presenting between February 2012 and February 2021 (9-year period). The data were collected using an electronic medical record (EMR). Patients with a clinical diagnosis of DR in at least one eye were included in the analysis. Severe nonproliferative DR/proliferative DR/diabetic macular edema (DME) were considered sight-threatening DR (STDR).

Results:

In the study period, 25% (n = 66,913) were new patients diagnosed with DR. The majority of patients were males (70%). The mean age of the patients was 57 ± 10 years. The risk factors for DR were increased age: 30 to 50 years (odds ratio [OR] = 2.42), and 51 to 70 years (OR = 3.02), increased duration of DM: 6 to 10 years (OR = 2.88) and >10 years (OR = 6.52), blindness (OR = 2.42), male gender (OR = 1.36), lower socioeconomic status (OR = 1.43), and rural habitation (OR = 1.09). STDR was seen in 58% (n = 38,538) of examined patients. Risk factors for STDR were increased age 31 to 50 years (OR = 3.51), increased duration of DM: 6 to 10 years (OR = 1.23) and >10 years (OR = 1.68), blindness (OR = 3.68), male gender (OR = 1.12), and higher socioeconomic status (OR = 1.09).

Conclusion:

Every fourth person with DM was found to have DR, and every second person with DR had STDR in this study cohort. These real-world big data might provide greater insight into the current status of DR. Additional big data from similar EMR-based sources will help in planning and resource allocation.

Prevalence of type 2 diabetes by age, sex and geographical area among two million public assistance recipients in Japan: a cross-sectional study using a nationally representative claims database

BACKGROUND

Recognising the importance of the social determinants of health, the Japanese government introduced a health management support programme targeted at type 2 diabetes (T2D) for public assistance recipients (PAR) in 2018. However, evidence of the T2D prevalence among PAR is lacking. We aimed to estimate T2D prevalence by age and sex among PAR, compared with the prevalence among health insurance enrollees (HIE). Additionally, regional differences in T2D prevalence among PAR were examined.

METHODS

This was a cross-sectional study using 1-month health insurance claims of both PAR and HIE. The Fact-finding Survey data on Medical Assistance and the National Database of Health Insurance Claims data were used. T2D prevalence among PAR and HIE were assessed by age and sex, respectively. Moreover, to examine regional differences in T2D prevalence of inpatients and outpatients among PAR, T2D crude prevalence and age-standardised prevalence were calculated by prefecture. Multilevel logistic regression analysis was also conducted at the city level.

RESULTS

T2D crude prevalence was 7.7% in PAR (inpatients and outpatients). Among outpatients, the prevalence was 7.5% in PAR and 4.1% in HIE, respectively. The mean crude prevalence and age-standardised prevalence of T2D (inpatients and outpatients) among 47 prefectures were 7.8% and 3.9%, respectively. In the city-level analysis, the OR for the prevalence of T2D by region ranged from 0.31 to 1.51.

CONCLUSION

The prevalence of T2D among PAR was higher than HIE and there were regional differences in the prevalence of PAR. Measures to prevent the progression of diabetes among PAR by region are needed.

Analysis of the regional difference in the number of multi-drug prescriptions and its predictors in Japan, 2015-2018

Objective

Polypharmacy and multi-drug prescription are major public health problems in Japan, but only a few studies have investigated the regional differences. By revealing regional differences in the multi-drug prescriptions, we can infer regions with high rates of multimorbidity or inappropriate prescribing. This study revealed regional differences in multi-drug prescriptions (the number of simultaneous prescriptions of seven or more internal medicines) and investigated the factors affecting the difference using the National Database of Health Insurance Claims and Specific Health Checkups of Japan data.

Results

The standardized claim ratio (SCR) of the number of multi-drug prescriptions, which corrected the difference in sex and age distribution of prefectures, varied depending on prefectures. A panel data analysis investigating the association between the SCR and explanatory variables (Medical institutions, socioeconomic factors, and physical characteristics of people in prefectures) revealed that the number of public assistance recipients per 1,000 persons was positively and significantly associated with the SCR (Standardized partial regression coefficient = 0.244, p-value = 0.038). In conclusion, regional differences in the number of the multi-drug prescriptions were revealed in Japan, suggesting that public assistance recipients tend to experience multi-drug prescriptions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05787-2.

Socioeconomic Predictors of Diabetes Mortality in Japan: An Ecological Study Using Municipality-specific Data

OBJECTIVES

The aim of this study was to examine the geographic distribution of diabetes mortality in Japan and identify socioeconomic factors affecting differences in municipality-specific diabetes mortality.

METHODS

Diabetes mortality data by year and municipality from 2013 to 2017 were extracted from Japanese Vital Statistics, and the socioeconomic characteristics of municipalities were obtained from government statistics. We calculated the standardized mortality ratio (SMR) of diabetes for each municipality using the empirical Bayes method and represented geographic differences in SMRs in a map of Japan. Multiple linear regression was conducted to identify the socioeconomic factors affecting differences in SMR. Statistically significant socioeconomic factors were further assessed by calculating the relative risk of mortality of quintiles of municipalities classified according to the degree of each socioeconomic factor using Poisson regression analysis.

RESULTS

The geographic distribution of diabetes mortality differed by gender. Of the municipality-specific socioeconomic factors, high rates of single-person households and unemployment and a high number of hospital beds were associated with a high SMR for men. High rates of fatherless households and blue-collar workers were associated with a high SMR for women, while high taxable income per-capita income and total population were associated with low SMR for women. Quintile analysis revealed a complex relationship between taxable income and mortality for women. The mortality risk of quintiles with the highest and lowest taxable per-capita income was significantly lower than that of the middle-income quintile.

CONCLUSIONS

Socioeconomic factors of municipalities in Japan were found to affect geographic differences in diabetes mortality.

Questionnaire-based Survey of Demographic and Clinical Characteristics, Health Behaviors, and Mental Health of Young Korean Adults with Early-onset Diabetes

BACKGROUND

The incidence of early-onset diabetes is increasing among young adults. However, there are limited data on the characteristics and management of young Korean adults with diabetes. This study assessed the clinical and demographic characteristics, health behaviors, and mental health among young Korean adults with diabetes mellitus.

METHODS

This cross-sectional study included young Korean adults with diabetes (n = 225) with an onset age of 20-39 years from four university hospitals. Demographic characteristics, management of diabetes, and mental health were assessed using a questionnaire survey.

RESULTS

Type 2 diabetes was the most common type (73.3%), and 13.8% of participants were classified as other types or unknown. Approximately, 64.7% of participants had a strong family history of diabetes, and 76% had treatment within three months of diagnosis. Approximately, 11.1% of participants had diabetic complications; 39.1% of participants received insulin injections, including oral anti-diabetic medications. Additionally, 30.4% were smokers, and only 28% had active physical activity; 26.5% of participants had >3 hours of screen time. One third of participants never had breakfast, and 60.5% went out to eat at least three times a week. Half of the participants showed moderate to severe stress perception, and 21.4% of patients had moderate to severe levels of depression based on the Korean version of Beck Depression Inventory score.

CONCLUSION

Early-onset diabetes was associated with a strong family history and early insulin treatment. Young adults with diabetes had poor health behaviors and frequent mental depression. These findings suggest the necessity of health policies for improving health behaviors and mental distress.

Socioeconomic inequalities, modifiable lifestyle risk factors, and retinal vessel calibers: The African-PREDICT Study

OBJECTIVE

Lifestyle risk factors vary between socioeconomic status (SES) groups and may influence cardiovascular function differently. The retinal microvasculature allows for monitoring early changes in cardiovascular health, and therefore, we investigated whether retinal vessel calibers associate differently with modifiable risk factors in different SES groups.

METHODS

We included 1064 young adults (aged 20-30 years) grouped by low and high SES. The central retinal artery and vein equivalents (CRAE, CRVE) were determined from fundus images captured using the Dynamic Retinal Vessel Analyzer (Imedos Systems GmbH, Jena, Germany). We collected anthropometry, self-reported alcohol consumption, and biochemical data.

RESULTS

Retinal vessel calibers did not differ between SES groups (p ≥ .80) after adjusting for sex and ethnicity. Unique independent associations were observed in the low SES group, where CRAE (β = 0.08, p = .042) and CRVE (β = .14, p = .001) associated positively with cotinine and body mass index, respectively. In the high SES group, CRAE (β = -0.09, p = .027) associated negatively with alcohol consumption.

CONCLUSION

At young ages, retinal vessel calibers associated differently with modifiable lifestyle risk factors within each SES group. Our data highlight the importance of detecting adverse lifestyle risk factors among young adults from diverse socioeconomic settings to improve prevention of cardiovascular disease.

Development and Validation of a Machine Learning Model Using Administrative Health Data to Predict Onset of Type 2 Diabetes

Importance

Systems-level barriers to diabetes care could be improved with population health planning tools that accurately discriminate between high- and low-risk groups to guide investments and targeted interventions.

Objective

To develop and validate a population-level machine learning model for predicting type 2 diabetes 5 years before diabetes onset using administrative health data.

Design, Setting, and Participants

This decision analytical model study used linked administrative health data from the diverse, single-payer health system in Ontario, Canada, between January 1, 2006, and December 31, 2016. A gradient boosting decision tree model was trained on data from 1 657 395 patients, validated on 243 442 patients, and tested on 236 506 patients. Costs associated with each patient were estimated using a validated costing algorithm. Data were analyzed from January 1, 2006, to December 31, 2016.

Exposures

A random sample of 2 137 343 residents of Ontario without type 2 diabetes was obtained at study start time. More than 300 features from data sets capturing demographic information, laboratory measurements, drug benefits, health care system interactions, social determinants of health, and ambulatory care and hospitalization records were compiled over 2-year patient medical histories to generate quarterly predictions.

Main Outcomes and Measures

Discrimination was assessed using the area under the receiver operating characteristic curve statistic, and calibration was assessed visually using calibration plots. Feature contribution was assessed with Shapley values. Costs were estimated in 2020 US dollars.

Results

This study trained a gradient boosting decision tree model on data from 1 657 395 patients (12 900 257 instances; 6 666 662 women [51.7%]). The developed model achieved a test area under the curve of 80.26 (range, 80.21-80.29), demonstrated good calibration, and was robust to sex, immigration status, area-level marginalization with regard to material deprivation and race/ethnicity, and low contact with the health care system. The top 5% of patients predicted as high risk by the model represented 26% of the total annual diabetes cost in Ontario.

Conclusions and Relevance

In this decision analytical model study, a machine learning model approach accurately predicted the incidence of diabetes in the population using routinely collected health administrative data. These results suggest that the model could be used to inform decision-making for population health planning and diabetes prevention.

Comparison of prevalence of diabetes complications in Brazilian and Mexican adults: a cross-sectional study

BACKGROUND

Type 2 diabetes is more frequent in Latin American people than in non-Hispanic whites due to a combination of genetic and lifestyle risk factors. Brazil and Mexico are the most populous countries in Latin America. The present study aimed to compare the results of the National Health Survey "PNS" in Brazil and the National Survey Health and Nutrition "ENSANUT" in Mexico regarding the prevalence, complications and healthcare issues of diabetes in both countries.

METHODS

A cross-sectional study was conducted with data from the National Health Survey (PNS) of 2013 in Brazil and the National Survey of Health and Nutrition (ENSANUT) of 2018 in Mexico. The prevalence of diabetes, complications and risk factors related to developing diabetes were considered.

RESULTS

The respondents included 3636 individuals in Brazil and 4555 individuals in Mexico. There were significant differences in age and time living with diabetes between the two countries. Mexican people had twice as likely as Brazilian people to have a complication (p < 0.0001). The principal risk factor (OR 2.47; p ≤ 0.0001) for developing any diabetic complication was living with diabetes for more than 15 years. Visual impairment was the most frequent complication in both countries, but it was more prevalent in Mexico (p ≤ 0.001).

CONCLUSIONS

Diabetes complications are important health problems in Brazil and Mexico. Visual impairment was the principal complication in both countries. Several factors, such as access to and type of health system, living in a rural area, treatment, BMI and performing preventive actions, affected the risk of developing a complication. However, living with diabetes for more than 15 years was the principal risk factor. National health surveys have added significant information on the impact of diabetes in these Latin American populations. This comparison of data could provide valuable information to guide national policies and program decisions in both countries.

Predicting adverse outcomes due to diabetes complications with machine learning using administrative health data

Across jurisdictions, government and health insurance providers hold a large amount of data from patient interactions with the healthcare system. We aimed to develop a machine learning-based model for predicting adverse outcomes due to diabetes complications using administrative health data from the single-payer health system in Ontario, Canada. A Gradient Boosting Decision Tree model was trained on data from 1,029,366 patients, validated on 272,864 patients, and tested on 265,406 patients. Discrimination was assessed using the AUC statistic and calibration was assessed visually using calibration plots overall and across population subgroups. Our model predicting three-year risk of adverse outcomes due to diabetes complications (hyper/hypoglycemia, tissue infection, retinopathy, cardiovascular events, amputation) included 700 features from multiple diverse data sources and had strong discrimination (average test AUC = 77.7, range 77.7-77.9). Through the design and validation of a high-performance model to predict diabetes complications adverse outcomes at the population level, we demonstrate the potential of machine learning and administrative health data to inform health planning and healthcare resource allocation for diabetes management.

The Association between Social Determinants of Health and Self-Reported Diabetic Retinopathy: An Exploratory Analysis

One-third of Americans with diabetes will develop diabetic retinopathy (DR), the leading cause of blindness in working-age Americans. Social determinants of health (SDOHs) are conditions in a person’s environment that may impact health. The objective of this study was to determine whether there is an association between SDOHs and DR in patients with type II diabetes. This cross-section study used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). This study included people with self-reported diabetes in the US in 2018 (n = 60,703). Exposure variables included homeownership, marital status, income, health care coverage, completed level of education, and urban vs. rural environment. The outcome variable was DR. Logistic regression analysis were applied to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Alaskan Native/Native American (OR 2.11; 95% CI: 1.14–3.90), out of work (OR 2.82; 95% CI: 1.62–4.92), unable to work (OR 2.14; 95% CI: 1.57–2.91), did not graduate high school (OR 1.91; 95% CI: 1.30–2.79), only graduated high school (OR 1.43; 95% CI 1.08–1.97), or only attended college or technical school without graduating (OR 1.42; 95% CI: 1.09–1.86) were SDOHs associated with DR in patients with diabetes. Health care providers should identify these possible SDOHs affecting their diabetic patients.

Optical coherence tomography-based diabetic macula edema screening with artificial intelligence

BACKGROUND

Optical coherence tomography (OCT) is considered as a sensitive and noninvasive tool to evaluate the macular lesions. In patients with diabetes mellitus (DM), the existence of diabetic macular edema (DME) can cause significant vision impairment and further intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF) is needed. However, the increasing number of DM patients makes it a big burden for clinicians to manually determine whether DME exists in the OCT images. The artificial intelligence (AI) now enormously applied to many medical territories may help reduce the burden on clinicians.

METHODS

We selected DME patients receiving IVI of anti-VEGF or corticosteroid at Taipei Veterans General Hospital in 2017. All macular cross-sectional scan OCT images were collected retrospectively from the eyes of these patients from January 2008 to July 2018. We further established AI models based on convolutional neural network architecture to determine whether the DM patients have DME by OCT images.

RESULTS

Based on the convolutional neural networks, InceptionV3 and VGG16, our AI system achieved a high DME diagnostic accuracy of 93.09% and 92.82%, respectively. The sensitivity of the VGG16 and InceptionV3 models was 96.48% and 95.15%., respectively. The specificity was corresponding to 86.67% and 89.63% for VGG16 and InceptionV3, respectively. We further developed an OCT-driven platform based on these AI models.

CONCLUSION

We successfully set up AI models to provide an accurate diagnosis of DME by OCT images. These models may assist clinicians in screening DME in DM patients in the future.

Influence of sociodemographic characteristics on the preferred format of health education delivery in individuals with type 2 diabetes mellitus and or cardiovascular disease: a questionnaire study

AIM

To examine the influence of sociodemographic factors of interest on preference for a particular health education format among people with type 2 diabetes and/or cardiovascular disease.

METHODS

A questionnaire was used to collect information on the influence of six sociodemographic factors of interest on the preference for health education formats in people with type 2 diabetes and/or cardiovascular disease. Chi-squared tests were used to examine the distribution of preferences between groups. The characteristics of the population preferring the online format were then examined in more detail using logistic regression.

RESULTS

Responses were received from 1559 participants. Overall the preferred health education format was one-to-one learning from a doctor or nurse (67%). Age, gender, diagnosis and educational level all affected the preferences expressed. The characteristics showing most consistent and significant influence were age and educational level. Overall, 29% ranked the online format highly (scores 1 or 2). This group were more likely to be aged < 65 years (P < 0.001) and to have a higher level of educational attainment (upper secondary education or higher; P < 0.001).

CONCLUSIONS

Significant differences between sociodemographic groups exist in preferences for health education formats among people with type 2 diabetes and/or cardiovascular disease. Preferences should be considered when designing educational interventions to ensure they are accessible to the target group and to avoid increases in health inequality.

Effects of Socioeconomic Status on Alzheimer Disease Mortality in Taiwan

OBJECTIVE

The combined effects of individual and neighborhood socioeconomic status (SES) on survival rates of patients with Alzheimer's disease (AD) remain unclear.

DESIGN

Retrospective cohort study.

SETTING

National Health Insurance Bureau of Taiwan data (2003-2012).

PARTICIPANTS

Patients with AD.

MEASUREMENTS

The authors aimed to analyze the effects of neighborhood and individual SES on the 5-year survival rates of patients with AD. The author defined individual and neighborhood SES based on income-related insurance payment amounts and residence in advantaged versus disadvantaged areas and compared survival rates using the Cox proportional hazards model after adjusting for risk factors.

RESULTS

A total of 1,754 patients with AD were identified. Each patient was followed for 5 years or censored. The 5-year overall survival rates were worst for those with a low individual SES in a disadvantaged area. After adjustment for sex, age, and comorbidities, patients with a low individual SES living in disadvantaged areas had the worse survival rate than those with a high SES (hazard ratio: 2.19; 95% confidence interval [CI]: 1.53-3.13). In contrast, after the adjustment for characteristics, patients with a high individual SES in disadvantaged areas had a similar mortality rate to those with a high individual SES in advantaged areas (hazard ratio: 0.93; 95% CI: 0.64-1.35).

CONCLUSION

Despite universal health coverage, patients with AD and a low individual SES in disadvantaged areas exhibited the worst survival rate. The socioeconomic survival gradient among patients with AD in Taiwan may result from differences in major attributes of individual and neighborhood SES.

Role of Air Pollution and rs10830963 Polymorphism on the Incidence of Type 2 Diabetes: Tehran Cardiometabolic Genetic Study

Diabetes mellitus (DM) is considered one of the leading health issues that are egregiously threatening human life throughout the world. Several epidemiological studies have examined the relationship of a particular matter < 10 μm (PM10) exposure and with type 2 diabetes mellitus (T2DM) prevalence and incidence. Accordingly, the current study is a study investigating the independent influence of air pollution (AP) and rs10830963 on the incidence of T2DM. A total number of 2428 adults over 20 years of age participated in a prospective cohort (TCGS) during a 9-year follow-up phase. The concentration of AP was measured, and the obtained values were considered the mean level in three previous years since the exposure concentration took the people living in that location. The COX regression model was employed to determine the influence of AP and rs10830963 on the incidence of T2DM in adjustment with covariate factors. Among the 392 T2DM, 230 cases (58.7%) were female diabetics, and 162 (41.3%) were male diabetics. According to the multivariable-adjusted model, exposure to PM10 (per 10 μm/m3), associated with the risk of T2DM, although just a borderline (p = 0.07) was found in the multivariable model (HR; 1.50, 95% CI; 1-2.32). The rs10830963 was directly associated with the incidence of diabetes, and the GG genotype increased the T2DM rate by 113% (more than two times) (HR; 2.134, 95% CI; 1.42-3.21, p ≤ 0.001) and GC increased it by 65% (HR; 1.65, 95% CI; 1.24-2.21, p ≤ 0.001). Long-term exposure to PM10 was associated with an increased risk of diabetes. Thus, it is suggested that the individuals with variant rs10830963 genotypes fall within a group susceptible to an increased risk of T2DM arising from AP.

Prevalence of Type 1 and Type 2 Diabetes-Related Complications and Their Association With Determinants Identified in Canada's Survey on Living With Chronic Diseases-Diabetes Component

OBJECTIVES

In this study, we estimated the prevalence of diabetes-related complications and the factors associated with them in Canadian patients with diabetes.

METHODS

Data from the 2011 Survey on Living with Chronic Diseases in Canada---Diabetes Component (SLCDC-DM-2011) were used to calculate the weighted prevalence of 16 diabetes-related complications. A multivariable, sex-stratified logistic regression model was used to examine the association between each diabetes-related complication and select determinants.

RESULTS

Among Canadian patients who self-reported having diabetes, 80.26% reported having at least 1 type of diabetes-related complication. The most frequently reported complications were high blood pressure (54.65%), cataracts (29.52%) and poor circulation (21.68%). Male patients were more associated to have at least 1 complication if they had an inappropriate body mass index (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.39 to 6.23) and had a high level of glycated hemoglobin (OR, 2.32; 95% CI, 1.05 to 5.13), were older (OR, 6.92; 95% CI, 1.82 to 24.74) and had diabetes for a longer period of time (OR, 3.42; 95% CI, 1.71 to 6.85). Among the female patients, a longer duration diabetes was found to have a significant association with complications (OR, 2.00; 95% CI, 1.05 to 3.81).

CONCLUSIONS

Our findings suggest that socioeconomic factors, including marital status, income and education, have a significant association with most types of complications. Our findings also confirm that low levels of physical activity and high levels of glycated hemoglobin were major determinants in many diabetes-related complications.

Long working hours and skipping breakfast concomitant with late evening meals are associated with suboptimal glycemic control among young male Japanese patients with type 2 diabetes

AIMS/INTRODUCTION

To assess the associations of working conditions, eating habits and glycemic control among young Japanese workers with type 2 diabetes.

MATERIALS AND METHODS

This hospital- and clinic-based prospective study included 352 male and 126 female working patients with diabetes aged 20-40 years. Data were obtained from June to July 2012 and June to July 2013. Logistic regression analysis was used to estimate multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for suboptimal glycemic control (glycosylated hemoglobin level of ≥7%) obtained from June to July 2013.

RESULTS

Multivariable logistic regression analysis showed that disease duration of ≥10 years (OR 2.43, 95% CI 1.02-5.80), glycosylated hemoglobin level of ≥7% in 2012 (OR 8.50, 95% CI 4.90-14.80), skipping breakfast and late evening meals (OR 2.50, 95% CI 1.25-5.00) and working ≥60 h/week (OR 2.92, 95% CI 1.16-7.40) were predictive of suboptimal glycemic control in male workers, whereas a glycosylated hemoglobin level of ≥7% in 2012 (OR 17.96, 95% CI 5.93-54.4), oral hyperglycemic agent therapy (OR 12.49, 95% CI 2.75-56.86) and insulin therapy (OR 11.60, 95% CI 2.35-57.63) were predictive of suboptimal glycemic control in female workers.

CONCLUSIONS

Working ≥60 h/week and habitual skipping breakfast concomitant with late evening meals might affect the ability of young male workers with type 2 diabetes to achieve and maintain glycemic control.

Socioeconomic differences among community-dwelling diabetic adults screened for diabetic retinopathy and nephropathy: The 2015 Korean Community Health Survey

We investigated the association between socioeconomic status (SES) and screening for diabetic retinopathy (DR) and diabetic nephropathy (DN) in community-dwelling diabetics. We analyzed data from 22,134 people with diabetes aged ≥19 years at the time of the nationwide 2015 Korean Community Health Survey. Multiple logistic regression analysis was used to explore the relationship between SES and screening for DR and DN both before and after adjustment for health behaviors, comorbidities, and educational level. Of all diabetic subjects, 33.9% and 38.1% underwent DR and DN screening, respectively. In the fully adjusted model, the extent of the DR and DN screening trended significantly lower as the educational level fell. Monthly household income was positively associated with DR screening, but a lower odds ratio (OR) for DN screening was evident only when the lowest and highest income groups were compared. Compared with managers/professionals, agricultural/forestry/fishery workers (OR 0.81, 95% confidence interval [CI] 0.69-0.96) and mechanical/manual laborers (OR 0.83, 95% CI 0.71-0.97) had lower ORs for DN screening. Residents in rural (compared with urban) areas and widows/widowers (compared with members of couples) were significantly less likely to undergo screening for DR and DN. Similar findings were obtained when the analysis was limited to those who had been educated about diabetes. In conclusion, socioeconomic inequalities were evident in terms of screening for DR and DN in community-dwelling Korean diabetics, regardless of whether they had reported receiving diabetes education. Tailored public health policies (and societal attention) are required to aid the socioeconomically disadvantaged.

Aralia elata inhibits neurodegeneration by downregulating O-GlcNAcylation of NF-κB in diabetic mice

AIM

To investigate the role of O-GlcNAcylation of nuclear factor-kappa B (NF-κB) in retinal ganglion cell (RGC) death and analysedthe effect of Aralia elata (AE) on neurodegeneration in diabetic mice.

METHODS

C57BL/6mice with streptozotocin-induced diabetes were fed daily with AE extract or control (CTL) diet at the onset of diabetes mellitus (DM). Two months after injection of streptozotocin or saline, the degree of cell death and the expression of O-GlcNAc transferase (OGT), N-acetyl-b-D-glucosaminidase (OGA), O-GlcNAcylated proteins, and O-GlcNAcylation of NF-κB were examined.

RESULTS

AE did not affect the metabolic status of diabetic mice. The decrease in the inner retinal thickness (P<0.001 vs CTL, P<0.01 vs DM) and increases in RGCs with terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling (P<0.001 vs CTL, P<0.0001 vs DM), glial activation, and active caspase-3 (P<0.0001 vs CTL, P<0.0001 vs DM) were blocked in diabetic retinas of AE extract-fed mice. Expression levels of protein O-GlcNAcylation and OGT were increased in diabetic retinas (P<0.0001 vs CTL), and the level of O-GlcNAcylation of the NF-κB p65 subunit was higher in diabetic retinas than in controls (P<0.0001 vs CTL). AE extract downregulated O-GlcNAcylation of NF-κB and prevented neurodegeneration induced by hyperglycemia (P<0.0001 vs DM).

CONCLUSION

O-GlcNAcylation of NF-κB is concerned in neuronal degeneration and that AE prevents diabetes-induced RGC apoptosis via downregulation of NF-κB O-GlcNAcylation. Hence, O-GlcNAcylation may be a new object for the treatment of DR, and AE may have therapeutic possibility to prevent diabetes-induced neurodegeneration.

Socioeconomic characteristics and comorbidities of diverticular disease in Sweden 1997-2012

PURPOSE

This study aimed to evaluate the association of socioeconomic status and comorbidities with uncomplicated and complicated diverticular disease (DD) in Sweden.

METHODS

We identified all individuals aged ≥30 years in Sweden diagnosed with DD between 1997 and 2012 using the Swedish National Population and Housing Census and the Hospital Discharge Register. Data were analyzed by multivariable logistic regression, with individual-level characteristics as covariates.

RESULTS

A total of 79,481 patients (median age 66 [range 30-86] years) were hospitalized for DD, 15,878 (20%) of whom for complicated DD. Admissions for both uncomplicated and complicated DD were more common in women (p < 0.001). A low education level was identified as a risk factor for uncomplicated (unadjusted hazard ratio [HR] 1.79, 95% confidence interval [CI] 1.75-1.82; adjusted HR 1.22, 95% CI 1.19-1.24) and complicated DD (unadjusted HR 1.84, 95% CI 1.77-1.92; adjusted HR 1.26, 95% CI 1.21-1.32). Patients with the lowest income had a lower risk of hospitalization for uncomplicated (adjusted HR 0.94, 95% CI 0.91-0.96) and complicated DD (adjusted HR 0.87, 95% CI 0.83-0.92) than those with the highest income. The correlation coefficient between income and education was 0.25. Diabetes and cardiovascular disease were identified as protective factors against uncomplicated DD (adjusted HR 0.68, 95% CI 0.66-0.69 and HR 0.79, 95% CI 0.74-0.84, respectively).

CONCLUSIONS

Patients with the lowest education level had an increased risk of hospitalization for DD. Further studies are needed to explore the association of diabetes and cardiovascular disease with uncomplicated DD.