Diabetes, its treatment, and catastrophic medical spending in 35 developing countries

Duration of type 2 diabetes and liver-related events in nonalcoholic fatty liver disease: A landmark analysis

BACKGROUND AND AIMS

We aimed to determine the impact of the duration of type 2 diabetes (T2D) on the risk of liver-related events and all-cause mortality in patients with NAFLD.

APPROACH AND RESULTS

We conducted a territory-wide cohort study of adult patients with NAFLD diagnosed between January 1, 2000, and July 31, 2021, in Hong Kong. T2D was defined by the use of any antidiabetic agents, laboratory tests, and/or diagnosis codes. The primary endpoint was liver-related events, defined as a composite endpoint of HCC and cirrhotic complications. To conduct a more granular assessment of the duration of T2D, we employed landmark analysis in four different ages of interest (biological age of 40, 50, 60, and 70 years). By multivariable analysis with adjustment of non-liver-related deaths, compared with patients without diabetes at age 60 (incidence rate of liver-related events: 0.70 per 1,000 person-years), the adjusted subdistribution HR (SHR) of liver-related events was 2.51 (95% CI: 1.32-4.77; incidence rate: 2.26 per 1,000 person-years) in patients with T2D duration < 5 years, 3.16 (95% CI: 1.59-6.31; incidence rate: 2.54 per 1,000 person-years) in those with T2D duration of 6-10 years, and 6.20 (95% CI: 2.62-14.65; incidence rate: 4.17 per 1000 person-years) in those with T2D duration more than 10 years. A similar association between the duration of T2D and all-cause mortality was also observed.

CONCLUSIONS

Longer duration of T2D is significantly associated with a higher risk of liver-related events and all-cause mortality in patients with NAFLD.

Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania

COVID-19 disrupted health care provision and access and reduced household income. Households with chronically ill patients are more vulnerable to these effects as they access routine health care. Yet, a few studies have analysed the effect of COVID-19 on household income, health care access costs, and financial catastrophe due to health care among patients with type 2 diabetes (T2D), especially in developing countries. This study fills that knowledge gap. We used data from a cross-sectional survey of 500 people with T2D, who were adults diagnosed with T2D before COVID-19 in Tanzania (March 2020). Data were collected in February 2022, reflecting the experience before and during COVID-19. During COVID-19, household income decreased on average by 16.6%, while health care costs decreased by 0.8% and transport costs increased by 10.6%. The overall financing burden for health care and transport relative to household income increased by 32.1% and 45%, respectively. The incidences of catastrophic spending above 10% of household income increased by 10% (due to health care costs) and by 55% (due to transport costs). The incidences of catastrophic spending due to health care costs were higher than transport costs, but the relative increase was higher for transport than health care costs (10% vs. 55% change from pre-COVID-19). The likelihood of incurring catastrophic health spending was lower among better educated patients, with health insurance, and from better-off households. COVID-19 was associated with reduced household income, increased transport costs, increased financing burden and financial catastrophe among patients with T2D in Tanzania. Policymakers need to ensure financial risk protection by expanding health insurance coverage and removing user fees, particularly for people with chronic illnesses. Efforts are also needed to reduce transport costs by investing more in primary health facilities to offer quality services closer to the population and engaging multiple sectors, including infrastructure and transportation.

Investigating the effects of Ceylon cinnamon water extract on HepG2 cells for Type 2 diabetes therapy

Cinnamon and its extracts have been used as herbal remedies for many ailments, including for reducing insulin resistance and diabetes complications. Type 2 diabetes mellitus (T2DM) is a rapidly growing health concern around the world. Although many drugs are available for T2DM treatment, side effects and costs can be considerable, and there is increasing interest in natural products for managing chronic health conditions. Cinnamon may decrease the expression of genes associated with T2DM risk. The purpose of this study was to evaluate the effects of cinnamon water extract (CWE) compared with metformin on T2DM-related gene expression. HepG2 human hepatoma cells, widely used in drug metabolism and hepatotoxicity studies, were treated with different concentrations of metformin or CWE for 24 or 48 h. Cell viability was assessed by MTT (3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium) assay and glucose uptake was compared in untreated and CWE- or metformin-treated cells under high-glucose conditions. Finally, total RNA was extracted and analyzed by RNA sequencing (RNA-seq), and bioinformatics analyses were performed to compare the transcriptional effects of CWE and metformin. We found cell viability was better in cells treated with CWE than in metformin-treated cells, demonstrating that CWE was not toxic at tested doses. CWE significantly increased glucose uptake in HepG2 cells, to the same degree as metformin (1.4-fold). RNA-seq data revealed CWE and metformin both induced significantly increased (1.3- to 1.4-fold) glucose uptake gene expression compared with untreated controls. Transcriptional differences between CWE and metformin were not significant. The effects of 0.125 mg mL^-1 CWE on gene expression were comparable to 1.5 mg mL^-1 (9.5 mM) metformin. In addition, gene expression at 0.125 mg mL^-1 CWE was comparable to 1.5 mg mL^-1 (9.5 mM) metformin. Our results reveal that CWE's effects on cell viability, glucose uptake, and gene expression in HepG2 cells are comparable to those of metformin, suggesting CWE may be an effective dietary supplement for mitigating T2DM-related metabolic dysfunction.

Economic burden of type 2 diabetes in Iran: A cost-of-illness study

Background and Aims

Type 2 diabetes mellitus (T2DM) is a prevalent public health problem worldwide, and the economic burden of the disease poses one of the main challenges for health systems in low- and middle-income countries. This study aimed to estimate the economic burden of T2DM in Iran, in 2018.

Methods

This was a cost-of-illness study. Three hundred and seventy-five patients with T2DM who were referred to Imam Reza and Sina's educational and therapeutic centers and Asad Abadi clinic in Tabriz, Iran, in 2018 were included. A researcher-constructed checklist was used for data collection. Data were analyzed using EXCEL and SPSS software version 22.

Results

Total economic burden of diabetes was estimated at 152,443,862,480.3 (purchasing power parity [PPP], Current International $) (approximately 7.69% of GDP, PPP, Current International $). The mean total direct and indirect costs were 11,278.68 (PPP) (62.35% of mean total cost) and 6808.88 (PPP, Current International $) (37.64% of the total cost), respectively. The mean total direct medical cost and the direct nonmedical cost were 10,819.43 (PPP, Current International $) (59.81% of mean total cost) and 459.24 (PPP, Current International $) (2.53% of mean total cost) per patient, respectively. Besides, the mean direct medical cost was 6.18 times the total per capita expenditure on health, and the total direct medical cost was 8.9% times the total expenditure on health.

Conclusion

Diabetes imposes a substantial economic burden on patients, health systems, and the whole economy. Besides, since the cost of the disease in patients treated with insulin and those with diabetes complications is significantly higher, the reinforcement of self-care measures and focusing on modifying lifestyle (dietary modification and physical activity) in patients with T2DM can significantly reduce the costs of the disease.

Cost-Effectiveness of Dulaglutide Versus Liraglutide for Management of Type 2 Diabetes Mellitus in Iran

OBJECTIVES

Diabetes mellitus (DM), as one of the most common metabolic diseases, is the ninth leading cause of death globally and imposes heavy costs on the health systems including both costs of treatment and management of secondary complications. This study intended to investigate the cost-effectiveness of dulaglutide compared with liraglutide in the management of patients with type 2 DM in Iran.

METHOD

We conducted a cost-utility analysis using a 5-state Markov model from the health system perspective, over a 10-year time horizon, in 2018 in Iran. Sensitivity of the model has been evaluated through tornado diagram and using one-way sensitivity analysis. In addition, probabilistic sensitivity analysis has been accomplished using Monte Carlo simulation.

RESULTS

The average costs of treatment of patients with type 2 DM using the dulaglutide and liraglutide treatment regimens are 17 577.09 and 18 517.54 US dollars per patient, respectively, over a 10-year time horizon. In terms of effectiveness, the average discounted quality-adjusted life-year rates are estimated at 5.560 and 5.403 for the dulaglutide and liraglutide treatment regimens, respectively. The model is mostly sensitive to the price of dulaglutide and liraglutide, the hemoglobin A1c reduction of liraglutide, and the utility resulting from less injection frequency of dulaglutide, respectively.

CONCLUSION

Dulaglutide, in addition to being more effective, providing 0.156 more quality-adjusted life-years for the patients, reduces costs by 940.45 US dollars per patient over a 10-year time horizon. Therefore, due to the greater effectiveness and lower cost, it is concludable that dulaglutide is the cost-effective (incremental cost-effectiveness ratio = -6028.52) treatment alternative from the health system perspective.

Development and validation of a model to predict cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke in patients with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease

Background

Among individuals with atherosclerotic cardiovascular disease (ASCVD), type 2 diabetes mellitus (T2DM) is common and confers increased risk for morbidity and mortality. Differentiating risk is key to optimize efficiency of treatment selection. Our objective was to develop and validate a model to predict risk of major adverse cardiovascular events (MACE) comprising the first event of cardiovascular death, myocardial infarction (MI), or stroke for individuals with both T2DM and ASCVD.

Methods

Using data from the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), we used Cox proportional hazards models to predict MACE among participants with T2DM and ASCVD. All baseline covariates collected in the trial were considered for inclusion, although some were excluded immediately because of large missingness or collinearity. A full model was developed using stepwise selection in each of 25 imputed datasets, and comprised candidate variables selected in 20 of the 25 datasets. A parsimonious model with a maximum of 10 degrees of freedom was created using Cox models with least absolute shrinkage and selection operator (LASSO), where the adjusted R-square was used as criterion for selection. The model was then externally validated among a cohort of participants with similar criteria in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial. Discrimination of both models was assessed using Harrell’s C-index and model calibration by the Greenwood-Nam-D’Agostino statistic based on 4-year event rates.

Results

Overall, 1491 (10.2%) of 14,671 participants in TECOS and 130 (9.3%) in the ACCORD validation cohort (n = 1404) had MACE over 3 years’ median follow-up. The final model included 9 characteristics (prior stroke, age, chronic kidney disease, prior MI, sex, heart failure, insulin use, atrial fibrillation, and microvascular complications). The model had moderate discrimination in both the internal and external validation samples (C-index = 0.65 and 0.61, respectively). The model was well calibrated across the risk spectrum—from a cumulative MACE rate of 6% at 4 years in the lowest risk quintile to 26% in the highest risk quintile.

Conclusion

Among patients with T2DM and prevalent ASCVD, this 9-factor risk model can quantify the risk of future ASCVD complications and inform decision making for treatments and intensity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01603-8.

Comparative Health Systems Analysis of Differences in the Catastrophic Health Expenditure Associated with Non-Communicable Versus Communicable Diseases Among Adults in Six Countries

The growing burden of non-communicable diseases (NCDs) in low- and middle-income countries may have implications for health system performance in the area of financial risk protection, as measured by catastrophic health expenditure (CHE). We compare NCD CHE to the CHE cases caused by communicable diseases (CDs) across health systems to examine whether: (1) disease burden and CHE are linked, (2) NCD CHE disproportionately affects wealthier households and (3) whether the drivers of NCD CHE differ from the drivers of CD CHE. We used the Study on Global Aging and Adult Health survey, which captured nationally representative samples of 44 089 adults in China, Ghana, India, Mexico, Russia and South Africa. Using two-part regression and random forests, we estimated out-of-pocket spending and CHE by disease area. We compare the NCD share of CHE to the NCD share of disability-adjusted life years (DALYs) or years of life lost to disability and death. We tested for differences between NCDs and CDs in the out-of-pocket costs per visit and the number of visits occurring before spending crosses the CHE threshold. NCD CHE increased with the NCD share of DALYs except in South Africa, where NCDs caused more than 50% of CHE cases but only 30% of DALYs. A larger share of households incurred CHE due to NCDs in the lowest than the highest wealth quintile. NCD CHE cases were more likely to be caused by five or more health care visits relative to communicable disease CHE cases in Ghana (P = 0.003), India (P = 0.004) and China (P = 0.093). Health system attributes play a key mediating factor in how disease burden translates into CHE by disease. Health systems must target the specific characteristics of CHE by disease area to bolster financial risk protection as the epidemiological transition proceeds.

Who determines United States Healthcare out-of-pocket costs? Factor ranking and selection using ensemble learning

PURPOSE

Healthcare out-of-pocket (OOP) costs consist of the annual expenses paid by individuals or families that are not reimbursed by insurance. In the U.S, broadening healthcare disparities are caused by the rapid increase in OOP costs. With a precise forecast of the OOP costs, governments can improve the design of healthcare policies to better control the OOP costs. This study designs a purely data-driven ensemble learning procedure to achieve a collection of factors that best predict OOP costs.

METHODS

We propose a voting ensemble learning procedure to rank and select factors of OOP costs based on the Medical Expenditure Panel Survey dataset. The method involves utilizing votes from the base learners forward subset selection, backward subset selection, random forest, and LASSO.

RESULTS

The top-ranking factors selected by our proposed method are insurance type, age, asthma, family size, race, and number of physician office visits. The predictive models using these factors outperform the models that employ the factors commonly considered by the literature through improving the prediction error (test MSE of the OOP costs' log-odds) from 0.462 to 0.382.

CONCLUSION

Our results indicate a set of factors which best explain the OOP costs behavior based on a purely data-driven solution. These findings contribute to the discussions regarding demand-side needs for containing rapidly rising OOP costs. Instead of estimating the impact of a single factor on OOP costs, our proposed method allows for the selection of arbitrary-sized factors to best explain OOP costs.

Estimated effect of increased diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among low-income and middle-income countries: a microsimulation model

BACKGROUND

Given the increasing prevalence of diabetes in low-income and middle-income countries (LMICs), we aimed to estimate the health and cost implications of achieving different targets for diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among LMICs.

METHODS

We constructed a microsimulation model to estimate disability-adjusted life-years (DALYs) lost and health-care costs of diagnosis, treatment, and control of blood pressure, dyslipidaemia, and glycaemia among people with diabetes in LMICs. We used individual participant data-specifically from the subset of people who were defined as having any type of diabetes by WHO standards-from nationally representative, cross-sectional surveys (2006-18) spanning 15 world regions to estimate the baseline 10-year risk of atherosclerotic cardiovascular disease (defined as fatal and non-fatal myocardial infarction and stroke), heart failure (ejection fraction of <40%, with New York Heart Association class III or IV functional limitations), end-stage renal disease (defined as an estimated glomerular filtration rate <15 mL/min per 1·73 m2 or needing dialysis or transplant), retinopathy with severe vision loss (<20/200 visual acuity as measured by the Snellen chart), and neuropathy with pressure sensation loss (assessed by the Semmes-Weinstein 5·07/10 g monofilament exam). We then used data from meta-analyses of randomised controlled trials to estimate the reduction in risk and the WHO OneHealth tool to estimate costs in reaching either 60% or 80% of diagnosis, treatment initiation, and control targets for blood pressure, dyslipidaemia, and glycaemia recommended by WHO guidelines. Costs were updated to 2020 International Dollars, and both costs and DALYs were computed over a 10-year policy planning time horizon at a 3% annual discount rate.

FINDINGS

We obtained data from 23 678 people with diabetes from 67 countries. The median estimated 10-year risk was 10·0% (IQR 4·0-18·0) for cardiovascular events, 7·8% (5·1-11·8) for neuropathy with pressure sensation loss, 7·2% (5·6-9·4) for end-stage renal disease, 6·0% (4·2-8·6) for retinopathy with severe vision loss, and 2·6% (1·2-5·3) for congestive heart failure. A target of 80% diagnosis, 80% treatment, and 80% control would be expected to reduce DALYs lost from diabetes complications from a median population-weighted loss to 1097 DALYs per 1000 population over 10 years (IQR 1051-1155), relative to a baseline of 1161 DALYs, primarily from reduced cardiovascular events (down from a median of 143 to 117 DALYs per 1000 population) due to blood pressure and statin treatment, with comparatively little effect from glycaemic control. The target of 80% diagnosis, 80% treatment, and 80% control would be expected to produce an overall incremental cost-effectiveness ratio of US$1362 per DALY averted (IQR 1304-1409), with the majority of decreased costs from reduced cardiovascular event management, counterbalanced by increased costs for blood pressure and statin treatment, producing an overall incremental cost-effectiveness ratio of $1362 per DALY averted (IQR 1304-1409).

INTERPRETATION

Reducing complications from diabetes in LMICs is likely to require a focus on scaling up blood pressure and statin medication treatment initiation and blood pressure medication titration rather than focusing on increasing screening to increase diabetes diagnosis, or a glycaemic treatment and control among people with diabetes.

FUNDING

None.

Predictors of poor glycemic control among type 2 diabetes mellitus patients treated with antidiabetic medications: A cross-sectional study in China

This study aimed to clarify of the predictors of poor glycemic control in type 2 diabetes mellitus (T2DM) patients treated with antidiabetic medications in China.This study was a retrospective, cross-sectional study based on SuValue database. T2DM patients aged 18 years or older performing glycosylated hemoglobin A1c (HbA1c) examinations from January 1st, 2018 to December 31st, 2018 were included and have been treated with antidiabetic medications for at least 6 months. HbA1c < 7.0% was defined as adequate glycemic control. Multivariate analysis was performed for the factors associated with poor glycemic control.A total of 13972 T2DM patients were included in this study. The adequate glycemic control rate was 44.04% (n = 6153). In the multivariate analysis, predictors of poor glycemic control include longer T2DM duration (5-10 years vs <5 years and >10 years vs <5 years, odds ratio [OR] = 1.499 and 1.581, P < .001 and P = .008), myocardial infarction (OR = 1.141, P = .041), diabetic neuropathy (OR = 1.409, P < .001), secondary hospital (OR = 1.877, P < .001), underdeveloped regions (OR = 1.786, P < .001), insulin only (OR = 3.912, P < .001), combination of oral antidiabetic agents and/or insulin use (P < .001).In conclusion, longer T2DM duration, secondary hospital, myocardial infarction, diabetic neuropathy, undeveloped regions and use of polypharmacy and insulin were associated with poor glycemic control among T2DM patients treated with antidiabetic medications. Patient education and training of health care providers may be short-term strategy to achieve adequate glycemic control.

The impacts of health insurance on financial strain for people with chronic diseases

Background

Due to ongoing expenses for both short-term and long-term needs for health services, people with chronic diseases tend to struggle with financial hardship. Health insurance is employed as a useful tool in aiding people to solve such financial strain. This study aims to examine and compare the impacts of public and private health insurance on solving financial barriers for people with chronic diseases.

Methods

This research obtained an outpatient sample consisted of 1739 individuals and an inpatient sample consisted of 1034 individuals. We employed a Chi-square test and a two-sample T-test to explore differences in financial strain and insurance status between people with chronic diseases and those without. Then we adopted binary logistic regression technique to assess the impacts of different types of health insurance on outpatient and inpatient financial strain for people with chronic diseases.

Results

Our research has five key findings: first, people with chronic diseases were more likely to experience both the outpatient and inpatient financial strain (P < 0.01); second, public health insurance was found to reduce the outpatient financial strain; third, private health insurance was found to positively associate with inpatient financial barriers; fourth, Urban Employment Insurance (UEI) was expected to reduce both the outpatient and inpatient financial barriers, while self-paid private insurance (SPI) was positively associated with inpatient financial barriers; and fifth, income was identified as a positive predictor of having outpatient and inpatient financial strain.

Conclusions

Public health insurance has the potential to reduce the outpatient financial strain for people with chronic diseases. Private health insurance was identified as a positive predictor of inpatient financial strain for people with chronic diseases. Policy should be proposed to promote the capacity of public health insurance and explore the potential effects of private health insurance on solving the inpatient financial barriers faced by people with chronic diseases in China.

Glycemic Control and Prevention of Diabetic Complications in Low- and Middle-Income Countries: An Expert Opinion

INTRODUCTION

Trends on glycemic control and diabetes complications are known for high-income countries, but comprehensive data from low- and middle-income countries (LMIC) are lacking.

METHODS

This is an expert opinion based on two retrospective studies. Here we examine the recent subset analysis of relevant data from the IDMPS Wave 7 (International Diabetes Management-Practices Study, 2015-2016) and the GOAL study conducted in multiple LMICs.

RESULTS

Wave 7 sub-analysis was performed in 6113 people with type 2 diabetes from 24 LMIC. Poorly controlled diabetes (hemogloblin A1c [HbA1c] ≥ 7%) was found in 58.6, 73.0 and 78.3% of participants with diabetes duration of < 5, 5-12 and > 12 years, respectively (in association with a high prevalence of macro- and microvascular complications). Moreover, 37.7% of participants with diabetes duration of 5-12 years were treated only with oral antihyperglycemic drugs. The GOAL study investigated the efficacy of insulin in 2704 poorly controlled participants (mean HbA1c 9.7%; diabetes duration 10.1 ± 6.7 years; 10 LMIC). A significant 2% reduction in mean HbA1c levels was observed after 12 months of treatment. Only 7.2% of participants experienced a symptomatic episode of hypoglycemia (nocturnal or severe hypoglycemia events were infrequent).

CONCLUSION

The rate of well-controlled participants (HbA1c < 7.0%) in the Wave 7 sub-analysis was lower than that observed in the USA (NHANES survey) or in European countries (GUIDANCE study), and the incidence of microvascular complications was higher. The GOAL study showed that insulin treatment improves glycemic control and reduces this gap. The Expert Panel recommends intensifying diabetes treatment as soon as possible, as well as patients' education and other preventive measures, initiatives which require modest costs compared to hospitalization and treatment of diabetes complications.

Are Ethiopian diabetic patients protected from financial hardship?

Background

Globally, diabetes mellitus exerts an economic burden on patients and their families. However, the economic burden of diabetes mellitus and its associated factors were not well studied in Ethiopia. Therefore, the aim of this study is to assess the economic burden of diabetes mellitus and its associated factors among diabetic patients in public hospitals of Bahir Dar city administration, Ethiopia.

Methods

Across sectional study was conducted on 422 diabetic patients. The patients were selected by simple random sampling method. The prevalence-based model was used to estimate the costs on patients’ perspective. Bottom up and human capital approaches were used to estimate the direct and indirect costs of the patients respectively. Wealth index was constructed using principal component analysis by SPSS. Forty percent of nonfood threshold level was used to measure catastrophic diabetic care expenditure of diabetic patients. Whereas, the World Bank poverty line (the $1.90-a-day poverty line) was used to measure impoverishment of patients due to expenses of diabetes mellitus care. Data were entered by Epi data version 3.1and exported to SPSS version 23 for analysis. Simple and multiple logistic regressions were used.

Results

Four hundred one respondents were interviewed with response rate of 95%. We found that 239 (59.6%) diabetic patients incurred catastrophic diabetic care expenditure at 40% nonfood threshold level. Whereas, 20 (5%) diabetic patients were impoverished by diabetic care spending at the $1.90-a-day poverty line. Educational status of respondent, educational status of the head of household, occupation and wealth status were statistically associated with the catastrophic diabetic care expenditure.

Conclusions

The study revealed that the economic burden of diabetic care is very disastrous among the less privileged populations: the less educated, the poorest and unemployed. Therefore, all concerned stakeholders should design ways that can reduce the financial hardship of diabetic care among diabetic patients.

Diagnostic accuracy of tests for type 2 diabetes and prediabetes: A systematic review and meta-analysis

Aim

This systematic review aimed to ascertain the diagnostic accuracy (sensitivity and specificity) of screening tests for early detection of type 2 diabetes and prediabetes in previously undiagnosed adults.

Methods

This systematic review included published studies that included one or more index tests (random and fasting tests, HbA1c) for glucose detection, with 75-gram Oral Glucose Tolerance Test (or 2-hour post load glucose) as a reference standard (PROSPERO ID CRD42018102477). Seven databases were searched electronically (from their inception up to March 9, 2020) accompanied with bibliographic and website searches. Records were manually screened and full text were selected based on inclusion and exclusion criteria. Subsequently, data extraction was done using standardized form and quality assessment of studies using QUADAS-2 tool. Meta-analysis was done using bivariate model using Stata 14.0. Optimal cut offs in terms of sensitivity and specificity for the tests were analysed using R software.

Results

Of 7,151 records assessed by title and abstract, a total of 37 peer reviewed articles were included in this systematic review. The pooled sensitivity, specificity, positive (LR+) and negative likelihood ratio (LR-) for diagnosing diabetes with HbA1c (6.5%; venous sample; n = 17 studies) were 50% (95% CI: 42–59%), 97.3% (95% CI: 95.3–98.4), 18.32 (95% CI: 11.06–30.53) and 0.51 (95% CI: 0.43–0.60), respectively. However, the optimal cut-off for diagnosing diabetes in previously undiagnosed adults with HbA1c was estimated as 6.03% with pooled sensitivity of 73.9% (95% CI: 68–79.1%) and specificity of 87.2% (95% CI: 82–91%). The optimal cut-off for Fasting Plasma Glucose (FPG) was estimated as 104 milligram/dL (mg/dL) with a sensitivity of 82.3% (95% CI: 74.6–88.1%) and specificity of 89.4% (95% CI: 85.2–92.5%).

Conclusion

Our findings suggest that at present recommended threshold of 6.5%, HbA1c is more specific and less sensitive in diagnosing the newly detected diabetes in undiagnosed population from community settings. Lowering of thresholds for HbA1c and FPG to 6.03% and 104 mg/dL for early detection in previously undiagnosed persons for screening purposes may be considered.

Salsalate reverses metabolic disorders in a mouse model of non-alcoholic fatty liver disease through AMPK activation and caspase-6 activity inhibition

Salsalate, an ester formed by 2 salicylic acid molecules, has beneficial effect against metabolic disorders in clinical trials and in animal studies. This study focused on the mechanistic aspects of salsalate activity against non-alcoholic fatty liver disease (NAFLD). Using high-fat diet (HFD) fed mice, we showed that salsalate treatment decreased body-weight gains, reduced white adipose tissue mass and improved glycaemic control. Mice in salsalate-treated group also had reduced obese adipose tissue and hepatic macrophage infiltration and inflammation and adipogenesis gene expression. Histology analysis revealed predominant decreases in hepatosteatosis, including both macrovesicular and microvesicular steatoses. The treatment reversed AMPK activity repression that was accompanied by reduced caspase-6 activity and cleavage. Enzymatic assay and cell culture studies showed that salsalate promoted AMPK activation by directly activating AMPK. This study links salsalate effect against metabolic disorders to its activity on reversion of AMPK repression in NAFLD mice and on suppression of adipogenic gene induction.

Costs and its drivers for diabetes mellitus type 2 patients in France and Germany: a systematic review of economic studies

BACKGROUND

Type 2 diabetes represents an increasingly critical challenge for health policy worldwide. It absorbs massive resources from both patients and national economies to sustain direct costs of the treatment of type 2 diabetes and its complications and indirect costs related to work loss and wages. More recently, there are innovations based on remote control and personalised programs that promise a more cost-effective diabetes management while reducing diabetes-related complications. In such a context, this work attempts to update cost analysis reviews on type 2 diabetes, focusing on France and Germany, in order to explore most significant cost drivers and cost-saving opportunities through innovations in diabetes care. Although both countries approach care delivery differently, France and Germany represent the primary European markets for diabetes technologies.

METHODS

A systematic review of the literature listed in MEDLINE, Embase and EconLit has been carried out. It covered interventional, observational and modelling studies on expenditures for type 2 diabetes management in France or Germany published since 2012. Included articles were analysed for annual direct, associated and indirect costs of type 2 diabetes patients. An appraisal of study quality was performed. Results were summarised narratively.

RESULTS

From 1260 records, the final sample was composed of 24 papers selected according to predefined inclusion/exclusion criteria. Both France and Germany revealed a predominant focus on direct costs. Comparability was limited due to different study populations and cost categories used. Indirect costs were only available in Germany. According to prior literature, reported cost drivers are hospitalisation, prescriptions, higher HbA1c and BMI, treatment with insulin and complications, all indicators of disease severity. The diversity of available data and included costs limits the results and may explain the differences found.

CONCLUSIONS

Complication prevention and glycaemic control are widely recognized as the most effective ways to control diabetes treatment costs. The value propositions of self-based supports, such as hybrid closed-loop metabolic systems, already implemented in type 1 diabetes management, are the key points for further debates and policymaking, which should involve the perspectives of caregivers, patients and payers.

Association of early-onset diabetes, prediabetes and early glycaemic recovery with the risk of all-cause and cardiovascular mortality

AIMS/HYPOTHESIS

The increasing incidence of diabetes among young adults is a disease burden; however, the effects of early-onset diabetes, prediabetes and glycaemic recovery on CVD or mortality remain unclear. We aimed to investigate the association of these factors with 10 year all-cause mortality, CVD mortality and CVD incidence in Korean young adults.

METHODS

This large and longitudinal cohort study included data from the Korean National Health Insurance Service-National Health Information Database; 2,502,375 young adults aged 20-39 years without diabetes mellitus and CVD at baseline were included. Glycaemic status was measured twice, first in 2002-2003 and second in 2004-2005. Changes in fasting glucose levels were evaluated according to fasting glucose status: normal fasting glucose (NFG; <5.5 mmol/l), impaired fasting glucose (IFG; 5.5-6.9 mmol/l), and diabetic fasting glucose (DFG; ≥7.0 mmol/l). Primary outcomes were all-cause and CVD mortality risk. The secondary outcome was incidence of CVD, including acute myocardial infarction and stroke. All outcomes arose from the 10 year follow-up period 1 Jan 2006 to 31 December 2015.

RESULTS

Individuals with NFG at baseline, who were subsequently newly diagnosed with diabetes and prediabetes (IFG), had increased all-cause mortality (HR [95% CI] 1.60 [1.44, 1.78] and 1.13 [1.09, 1.18], respectively) and CVD incidence (1.13 [1.05, 1.23] and 1.04 [1.01, 1.07], respectively). In those with DFG at baseline, early recovery to NFG and IFG was associated with decreased all-cause mortality (0.57 [0.46, 0.70] and 0.65 [0.53, 0.81], respectively) and CVD incidence (0.70 [0.60, 0.81] and 0.78 [0.66, 0.91], respectively). Among patients with IFG at baseline, early recovery to NFG was associated with decreased CVD mortality (0.74 [0.59, 0.93]).

CONCLUSIONS/INTERPRETATION

Early-onset diabetes or prediabetes increased CVD risks and all-cause mortality after the 10 year follow-up. Furthermore, recovery of hyperglycaemia could reduce the subsequent 10 year risk for CVD incidence and all-cause mortality. Graphical abstract.

The status of diabetes and its complications in Latin-American population: A review article

The Latino population consists of distinct cultural groups, with differences in dietary habits and lifestyle that can affect the risk for type 2 diabetes. The best terminology today is Latino/Hispanic, and it should only be used as ethnicity. Latin-America has different races such as Caucasians, Native Americans, Blacks and Asians, and many mixtures of all. The leading cause of death in Latin-America is Cardiovascular diseases and the most important risk factor is diabetes mellitus (DM). According to the latest estimates from the Global Burden of Disease, the burden of DM was greater than expected in Latin America and the Caribbean region. Extensive data illustrates that lower cardiovascular disease risk in Latino group is a paradox. Instead, it is evident that the cardiovascular disease is the leading cause of mortality in Latinos.

A Systematic Review of the Economic Burden of Type 2 Diabetes in Malaysia

Diabetes causes significant disabilities, reduced quality of life and mortality that imposes huge economic burden on societies and governments worldwide. Malaysia suffers a high diabetes burden in Asia, but the magnitude of healthcare expenditures documented to aid national health policy decision-making is limited. This systematic review aimed to document the economic burden of diabetes in Malaysia, and identify the factors associated with cost burden and the methods used to evaluate costs. Studies conducted between 2000 and 2019 were retrieved using three international databases (PubMed, Scopus, EMBASE) and one local database (MyCite), as well as manual searches. Peer reviewed research articles in English and Malay on economic evaluations of adult type 2 diabetes conducted in Malaysia were included. The review was registered with PROSPERO (CRD42020151857), reported according to PRISMA and used a quality checklist adapted for cost of illness studies. Data were extracted using a data extraction sheet that included study characteristics, total costs, different costing methods and a scoring system to assess the quality of studies reviewed. The review identified twelve eligible studies that conducted cost evaluations of type 2 diabetes in Malaysia. Variation exists in the costs and methods used in these studies. For direct costs, four studies evaluated costs related to complications and drugs, and two studies were related to outpatient and inpatient costs each. Indirect and intangible costs were estimated in one study. Four studies estimated capital and recurrent costs. The estimated total annual cost of diabetes in Malaysia was approximately USD 600 million. Age, type of hospitals or health provider, length of inpatient stay and frequency of outpatient visits were significantly associated with costs. The most frequent epidemiological approach employed was prevalence-based (n = 10), while cost analysis was the most common costing approach used. The current review offers the first documented evidence on cost estimates of diabetes in Malaysia.

The household economic burden of non-communicable diseases in 18 countries

Background

Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries.

Methods

Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China.

Results

The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs.

Conclusions

Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs.

Exercise and Type 1 Diabetes

Diabetes mellitus (DM) is the most common endocrine and metabolic disease caused by absolute or insufficient insulin secretion. Under the context of an aging population worldwide, the number of diabetic patients is increasing year by year. Most patients with diabetes have multiple complications that severely threaten their survival and living quality. DM is mainly divided into type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). T1DM is caused by absolute lack of insulin secretion, so the current treatment for T1DM patients is exogenous insulin replacement therapy. At present, exercise therapy has been widely recognized in the prevention and treatment of diabetes, and regular aerobic exercise has become an important part of T1DM treatment. At the same time, exercise therapy is also used in conjunction with other treatments in the prevention and treatment of diabetic complications. However, for patients with T1DM, exercise still has the risk of hypoglycemia or hyperglycemia. T1DM Patients and specialist physician need to fully understand the effects of exercise on metabolism and implement individualized exercise programs. This chapter reviews the related content of exercise and T1DM.

Incidence and Intensity of Catastrophic Health-care Expenditure for Type 2 Diabetes Mellitus Care in Iran: Determinants and Inequality

BACKGROUND

The present study aimed to assess the prevalence and intensity of catastrophic health-care expenditures (CHE) relating to type 2 diabetes mellitus care and inequality in facing such expenditures in Iran.

METHODS

A total of 1065 type 2 diabetes patients were included in this cross-sectional study. A multistage sampling method was used to select the samples. Data on sociodemographic characteristics, economic status, health and diabetic costs were collected using a self-constructed questionnaire. We used capacity to pay (CTP) of households to calculate the incidence of CHE due to diabetic care at four different thresholds. The mean positive overshoot (MPO) and overshoot were used to assess the intensity of CHE. The relative concentration index and slope index of inequality (SII) were used to measure socioeconomic-related inequalities in incidences of CHE. In addition, decomposition methods were used to identify the main factors affecting observed inequality in CHE.

RESULTS

The incidence of CHE at the 10, 20, 30, and 40% of CTP thresholds for type 2 diabetes mellitus care was 57.5, 28.9, 16.5, and 11.4%, respectively. The results of CI and SII indices for CHE due to diabetic care indicated that the incidence of CHE was more prevalent among patients with lower socioeconomic groups. The decomposition analysis showed that the socioeconomic status, marital status and gender of patients were the main factors contributing to socioeconomic inequality in incidence of CHE among the poor.

CONCLUSION

Our study demonstrated that the incidence and intensity of CHE due to diabetic care were relatively high, particularly among socioeconomically disadvantaged patients. Modification to the present health care financing strategies is recommended in order to protect lower socioeconomic groups against the financial burden of diabetic care.

Efficacy and safety of cinnamon in type 2 diabetes mellitus and pre-diabetes patients: A meta-analysis and meta-regression

INTRODUCTION

Cinnamon has been used as a dietary component and in the management of diabetes mellitus. This study systematically reviewed and synthesized evidence on the efficacy of cinnamon for the treatment of type 2 diabetes mellitus (T2DM) and pre-diabetes patients.

METHODS

Databases of Web of Sciences, the Cochrane library, PubMed, CINAHL and SCOPUS were searched. Stata version 13 (College Station, Texas 77845 USA) and RevMan var. 5.3 software were used for meta-analysis. Heterogeneity was assessed using Chi-square and I² tests.

RESULTS

Sixteen randomized controlled studies were included in the meta-analysis. Cinnamon significantly reduced fasting blood glucose (FBG) and homeostatic model assessment for insulin resistance (HOMA-IR) level compared to placebo with weighted mean difference (WMD) of -0.545 (95% CI: -0.910, -0.18) mmol/L, I² = 83.6% and -0.714(-1.388, -0.04), I² = 84.4% respectively. There was no significant change in weighted mean difference of glycosylated hemoglobin A1C (HbA1c) % and lipid profiles (mmol/L). Meta-regression did not show any factor significantly affecting the treatment response.

CONCLUSION

Cinnamon reduced FBG and HOMA-IR, level in T2DM and pre-diabetes patients compared to placebo. High heterogeneity observed among included studies warrants further clinical trials after standardization of cinnamon formulation.

Metabolic Syndrome, Physical Activity, and Medication-Related Expenditures: A Longitudinal Analysis

Background: Metabolic syndrome (MetS) is a combination of risk factors for cardiovascular disease and type 2 diabetes mellitus. The prevalence of MetS worldwide is increasing. There is no study investigating the economic burden of MetS, especially in developing countries, on medication-related expenditure. The aim of this study was to investigate the association of medication-related expenditures with MetS and to explore how physical activity (PA) may influence this association. Methods: A total of 620 participants, 50 years or older, randomly selected in the city of Bauru, Brazil. Participants were followed from 2010 to 2014, and data on health care expenditure were collected annually. PA questionnaire was applied at baseline, 2 (2012), and 4 (2014) years later. Results: Mean age was 64.7 (95% confidence interval, 64.1–65.3). MetS was associated with higher medication expenditure related to diseases of the circulatory (P <.01) and endocrine (P <.01) systems. MetS explained 17.2% of medication-related expenditures, whereas PA slightly attenuated this association, explaining 1.1% of all health care costs. Conclusion: This study demonstrates that MetS has a significant burden on health care expenditures among adults, whereas PA seems to affect this phenomenon significantly, but in low magnitude.

Catastrophic health expenditure and impoverishment for type 2 diabetes mellitus patients in a multiethnic province in China using a Blinder-Oaxaca decomposition: A cross-sectional study

This study aimed to compare the catastrophic health expenditure (CHE) and impoverishment of type 2 diabetes mellitus (T2DM) patients between 2 ethnic groups and explore the contribution of associated factors to ethnic differences in CHE and impoverishment in Ningxia Hui Autonomous Region, China.A cross-sectional study was conducted in 2 public hospitals from October 2016 to June 2017. Data were collected by interviewing eligible Hui and Han T2DM inpatients and reviewing the hospital electronic records. Both CHE and impoverishment were measured by headcount and gap. The contributions of associated factors to ethnic differences were analyzed by the Blinder-Oaxaca decomposition technique.Both the CHE and impoverishment of Hui patients before and after reimbursement were significantly higher than those of Han patients. The ethnic differences in CHE and impoverishment headcount after reimbursement were 11.9% and 9.8%, respectively. The different distributions of associated factors between Hui and Han patients contributed to 60.5% and 35.7% of ethnic differences in CHE and impoverishment, respectively. Household income, occupation, and region were significant contributing factors.Hui T2DM patients suffered greater CHE and impoverishment than Han patients regardless of reimbursements from health insurance. Differences in socioeconomic status between Hui and Han patients were the main factors behind the ethnic differences.

Cost Effectiveness of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists, and Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: A Systematic Review

OBJECTIVE

This study aimed to systematically review cost-effectiveness studies of newer antidiabetic medications.

METHODS

The PubMed/MEDLINE, EMBASE, CINAHL Plus, Cochrane Library-NHS Economic Evaluation Database (Wiley), Cochrane Library-Health Technology Assessment Database (Wiley), Cochrane Library-Database of Abstracts of Reviews of Effects (Wiley), and the Cost-Effectiveness Analysis Registry databases (from 1 January 2000 to 1 June 2018) were searched. The search strategies included the Medical Subject Heading (MeSH) term 'economics', and the MeSH entry terms 'cost', 'cost effectiveness', 'value', and 'cost utility', as well as all names for GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors. Inclusion criteria included (1) cost-effectiveness studies of the newer antidiabetic medications, including sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase-4 (DPP-4) inhibitors; and (2) full-text publications in English. Two reviewers independently screened the titles, abstracts, and full-text articles to select studies for data extraction. Discrepancies were resolved by discussion and consensus. The quality of reporting cost-effectiveness analyses was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guideline.

RESULTS

Among 85 studies selected, 82 clearly stated the types of diabetes model used (e.g. CORE model), and 70 studied used validated diabetes models. Seventy-four (87%) studies were funded by pharmaceutical companies, and 72 (85%) studies were conducted from a payer's perspective. Seventy-six (89%) studies presented were of good quality (20-24 CHEERS items), and nine were of moderate quality (14-19 items). Thirty studies compared newer antidiabetic medications with insulin, 3 studies compared newer antidiabetic medications with thiazolidinediones (TZDs), 15 studies compared newer antidiabetic medications with sulfonylureas, 40 studies compared new antidiabetic medications with alternative newer antidiabetic medication, and 9 studies compared other antidiabetic agents that were not included above. Newer antidiabetic medications were reported to be cost-effective in 26 of 30 (87%) studies compared with insulin, and 13 of 15 (87%) studies compared with sulfonylureas.

CONCLUSIONS

Most economic evaluations of antidiabetic medications have good reporting quality and use validated diabetes models. The newer antidiabetic medications in most of the reviewed studies were found to be cost effective, compared with insulin, TZDs, and sulfonylureas.

Incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment for diabetes care in South Africa: a study at two public hospitals in Tshwane

BACKGROUND

Direct out of pocket (OOP) payments for healthcare may cause financial hardship. For diabetic patients who require frequent visits to health centres, this is of concern as OOP payments may limit access to healthcare. This study assesses the incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment amongst diabetic patients in South Africa.

METHODS

Data were taken from a cross-sectional survey conducted in 2017 at two public hospitals in Tshwane, South Africa (N = 396). Healthcare costs and transport costs related to diabetes care were classified as catastrophic if they exceeded the 10% threshold of household's capacity to pay (WHO standard method) or if they exceeded a variable threshold of total household expenditure (Ataguba method). Erreygers concentration indices (CIs) were used to assess socio-economic inequalities. A multivariate logistic regression was applied to identify the determinants of catastrophic health expenditure and impoverishment.

RESULTS

Transport costs contributed to over 50% of total healthcare costs. The incidence of catastrophic health expenditure was 25% when measured at a 10% threshold of capacity to pay and 13% when measured at a variable threshold of total household expenditure. Depending on the method used, the incidence of impoverishment varied from 2 to 4% and the concentration index for catastrophic health expenditure varied from - 0.2299 to - 0.1026. When measured at a 10% threshold of capacity to pay factors associated with catastrophic health expenditure were being female (Odds Ratio 1.73; Standard Error 0.51), being within the 3rd (0.49; 0.20), 4th (0.31; 0.15) and 5th wealth quintile (0.30; 0.17). When measured using a variable threshold of total household expenditure factors associated with catastrophic health expenditure were not having children (3.35; 1.82) and the 4th wealth quintile (0.32; 0.21).

CONCLUSION

Financial protection of diabetic patients in public hospitals is limited. This observation suggests that health financing interventions amongst diabetic patients should target the poor and poor women in particular. There is also a need for targeted interventions to improve access to healthcare facilities for diabetic patients and to reduce the financial impact of transport costs when seeking healthcare. This is particularly important for the achievement of universal health coverage in South Africa.

Economic Impact of Diabetes in South Asia: the Magnitude of the Problem

PURPOSE OF REVIEW

To critically assess and identify gaps in the current literature on the economic impact of diabetes in South Asia.

RECENT FINDINGS

The total annual (direct medical and non-medical and indirect) costs for diabetes care in South Asia range from $483-$2637 per patient, and on an average 5.8% of patients with diabetes suffer catastrophic spending i.e. when households reduce basic expenditure by 40% to cope with healthcare costs. The mean direct costs per patient are positively associated with a country's gross domestic product (GDP) per capita, although there is wide heterogeneity across South Asian countries. With an estimated 84 million people suffering from diabetes in South Asia, diabetes imposes a substantial economic burden on individuals, families, and society. Since the disease burden increasingly occurs in the most productive midlife period, it adversely affects workforce productivity and macroeconomic development. Diabetes-related complications lead to markedly higher treatment costs, causing catastrophic medical spending for many households, thus underscoring the importance of preventing diabetes-related complications.

Predominant Complications of Type 2 Diabetes in Kumasi: A 4-Year Retrospective Cross-Sectional Study at a Teaching Hospital in Ghana

Background and objectives: Diabetes mellitus type 2 (T2DM) has been associated with several microvascular and macrovascular complications. However, studies regarding the predominant complications of T2DM in Ghana have not been conducted. This study evaluated the prevalence and predominant complications of T2DM and assessed the sociodemographic factors associated with the development of diabetes-related complications in Kumasi, Ghana. Materials and Methods: This was a retrospective cross-sectional study conducted at Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. A total of 1600 Ghanaian T2DM adults were included in this study. Patients' clinical data from 2012 to 2016 were retrieved from the hospital's archive. Results: The prevalence of macrovascular and microvascular complications of T2DM was 31.8% and 35.3% respectively. The prevalence of neuropathy, nephropathy, retinopathy, sexual dysfunction, diabetic keto-acidosis (DKA), and hypoglycemia were 20.8%, 12.5%, 6.5%, 3.8%, 2.0%, and 0.8% respectively. Sexual dysfunction was significantly associated with the male gender compared to females. Being employed: Informal (aOR = 0.479, p < 0.0001), and Formal (aOR = 0.475, p = 0.0008) was associated with lower age- and sex-adjusted odds of developing T2DM-related complications while having T2DM for 5-10 years (aOR = 1.550, p = 0.0009) and more than 10 years (aOR = 2.755, p < 0.0001) was associated with increased odds of developing complications. Conclusions: Microvascular complication is the most predominant among T2DM in Kumasi, Ghana. The most prevalent T2DM-related microvascular complication in Kumasi, Ghana is neuropathy. Sexual dysfunction is associated with male compared to female T2DM patients. Being employed reduces the chance of developing T2DM-related complications while increasing DM duration increases the risk of complications.

A study to identify bacteriological profile and other risk factors among diabetic and non-diabetic foot ulcer patients in a Guyanese hospital setting

Diabetic foot infection is a global epidemic and a major public health concern. Development of microbial resistance to many antimicrobial agents in foot ulcer leads to serious complications. Therefore, the study aims to identify the microbiological profile and the potential risk factors among diabetic and non-diabetic foot ulcer patients. A prospective cross sectional study was carried out among 183 ulcer patients from diabetic foot clinic and wound dressing clinic at the public health hospital, Guyana. A total of 254 bacteria were isolated from the study with an average of 1.4 organism per lesion. Gram negative bacteria (63.0%) were prevalent than gram positive bacteria (37.0%) in this study. Among DF patients, Pseudomonas aeruginosa (18.8%) was the most common isolate followed by Escherichia coli (13.9%) among gram negative group. Were as MRSA (12.1%) followed by MSSA (7.9%) dominated among gram positive group in diabetic foot patients. Almost 42.1% (95% CI 34.8-49.6) of the infections were caused by poly-microbial. Interestingly, a stepwise logistic regression model determined increasing age and lack of health education as independent risk factor identified for acquiring an MDR wound infection (OR = 1.1; p ≥ 0.05; 95% CI 1.0-1.1). Mild, moderate and severe infection among MDR and NMDR patients were recorded as 45.3% (95% CI 32.8-58.3), 26.5% (95% CI 16.3-39.1), 28.1% (95% CI 17.6-40.8) and 51.3% (95% CI 41.9-60.5), 32.8% (95% CI 24.4-42.0), 16.0% (95% CI 9.9-23.8). Therefore, it is concluded that there's an urgent need for surveillance of resistant bacteria in diabetic foot infections to reduce the risk of major complications.

Insulclock: A Novel Insulin Delivery Optimization and Tracking System

BACKGROUND

Achieving and maintaining controlled glycemic levels are challenging in people with insulin-treated diabetes mellitus, suboptimal insulin injections being the main obstacle to treatment success.

METHODS

This research article presents the main functionalities and performance tests on Insulclock^®, an electronic device plugged into insulin pens and connected with a smartphone app to improve insulin management. Insulclock tracks the date, time of day, dose, type of insulin, temperature, and duration of insulin injections. Information is stored in the device memory and is available for analysis by patients and health care providers. Insulclock device also has a reminder system with visual and acoustic alerts to reduce insulin omissions and mistiming.

RESULTS

The main performance tests reveal that Insulclock can detect seven types of insulin pens with a 97% correct classification rate. Among 556 injections, most of the doses were accurately detected (deviation = 0), with relative errors ranging from 3% to 7% across different dosages. The duration of injections recorded by this device strongly correlated with that detected by an external chronometer (R² = 0.99, root-mean-square deviation [RMSD] = 0.39). Moreover, the precision of the temperature sensor was evidenced by high correlation of temperatures detected by Insulclock and by an external thermometer (Pearson's R² = 0.90, RMSD = 0.45).

CONCLUSIONS

Insulclock is a novel device capable of tracking dosing, timing, and missing insulin injections. The promising capabilities it offers for diabetes mellitus self-management may help health care providers, researchers, and insulin users avoid frequent errors in insulin administration.

Momordica charantia L. lowers elevated glycaemia in type 2 diabetes mellitus patients: Systematic review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Momordica charantia Linnaeus (Cucurbitaceae) has been extensively used traditionally as food and herbal medicine for type 2 diabetes mellitus in Asia, Brazil, and east Africa. In vitro and in vivo studies suggest its glycemic control potential; however, clinical studies produced conflicting results.

AIM OF THE STUDY

To evaluate the efficacy of M. charantia preparations in lowering elevated plasma glucose level in prediabetes and type 2 diabetes mellitus patients.

METHODS

Electronic search of the Cochrane library, PubMed®, CINAHL, and SCOPUS databases was done from 1st January 1960-30th April 2018 without language restriction. Two independent reviewers extracted data and assessed risk of bias of articles. Revman var. 5.3 software was used for data synthesis in meta-analysis. Heterogeneity was assessed using Chi-square and I² tests. Treatment effect was estimated using mean difference at follow up in outcome measures between M. charantia preparations and placebo or oral hypoglycemic agents control group. The protocol of this study has a registration number PROSPERO CRD42018083653.

RESULTS

Ten studies of type 2 diabetes mellitus (n = 1045) were included in the meta-analysis. They had 4-16 weeks follow up and overall moderate to high risk of bias. Compared to placebo, M. charantia monoherbal formulation significantly reduces FPG, PPG and HBA_1c with mean difference of - 0.72 mmol/L, (95% CI: -1.33, -0.12), I² = 14%, - 1.43 mmol/L, (95% CI: -2.18, -0.67), I² = 0, - 0.26%, (95% CI: -0.49, -0.03), I² = 0 respectively. M. charantia also lowered FPG in prediabetes (mean difference -0.31 mmol/L, n = 52); the evidence was downgraded to low quality because the study had unclear risk of bias and inadequate sample size. No serious adverse effects were reported.

CONCLUSION

M. charantia adjunct preparations improved glycemic control in T2DM patients. However, this conclusion is based on low to very low quality evidences for the primary outcomes and sparse data for several safety outcomes, thus, warrant further research. Particularly needed are the researches that focus on standardizing M. charantia formulation and determine its efficacy and safety in clinical trials with adequate sample size, designed with random sequence generation, allocation concealment of intervention and blinding of both research personnel and participants.

Profile of semaglutide in the management of type 2 diabetes: design, development, and place in therapy

Type 2 diabetes mellitus (T2DM) has become one of the leading causes of morbidity and mortality in developed countries. Low efficacy, weight gain, and hypoglycemia are the main pitfalls of previous treatments for T2DM. New therapies have been designed with the aim of improving the results in efficacy and quality of life. Glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1 RA) increase glucose-dependent insulin secretion, decrease gastric emptying, and reduce postprandial glucagon secretion. The last GLP-1 RA approved by the US Food and Drug Administration and European Medicines Agency was semaglutide. This review describes its pharmacology, core clinical data coming from the randomized controlled trials included in the development program, proven cardiovascular benefits, safety issues, and precautions for the use of semaglutide in special populations. Additionally, an overview of the positioning of semaglutide in T2DM therapy and practical issues regarding semaglutide initiation are offered.

Economic Impact of Diabetes in Africa

PURPOSE OF REVIEW

This review seeks to address knowledge gaps around the economic burden of diabetes in Africa. Africa is home to numerous endemic infections and also prevalent non-communicable diseases including diabetes. It is projected that the greatest increases in diabetes prevalence will occur in Africa. The importance of this review therefore lies in providing adequate knowledge on the economic challenges that diabetes poses to the continent and describe the way forward in tackling this epidemic.

RECENT FINDINGS

Diabetes contributes to a huge amount of the global health expenditure in the world. There is a dearth of information on the economic burden of diabetes in Africa with very limited number of studies in the area. Predictions do show that Africa has the greatest predicted increase in both the burden of diabetes and associated diabetic complications but yet contributes the lowest in the global annual healthcare expenses with regard to diabetes care. In 2017, the International Diabetes Federation (IDF) estimated the total health expenditure due to diabetes at $3.3 billion. In Nigeria, the national annual direct costs of diabetes was estimated in the range of $1.071 billion to $1.639 billion per year while the estimated monthly direct medical costs per individual in Cameroon stands at $148. In Sudan, the direct cost of type 2 diabetes control was $175 per year which only included the cost of medications and ambulatory care. People with diabetes are likely to experience one or more chronic illness and a significant portion of the costs associated with these complications are attributed to the underlying diabetes. The growing epidemics of diabetes and associated diabetic complications worldwide poses catastrophic financial costs, especially in Africa where most of the expenses are paid by patients and families. The most common method used for the estimation of the economic burden of a public health problem like diabetes is the cost-of-illness approach. Cost-of-illness studies traditionally divide costs into three categories: direct, indirect, and intangible. The IDF estimated the total health expenditure due to diabetes at $3.3 billion worldwide in 2017. Most of the existing studies in Africa estimated only the direct costs. The medical direct cost of type 1 diabetes was higher than type 2. However, the estimations of costs of diabetes in many countries in Africa may be underestimated due to absence of data on the relative contribution of cost of diabetes complications.

Stem cells as a potential therapy for diabetes mellitus: a call-to-action in Latin America

Latin America is a fast-growing region that currently faces unique challenges in the treatment of all forms of diabetes mellitus. The burden of this disease will be even greater in the coming years due, in part, to the large proportion of young adults living in urban areas and engaging in unhealthy lifestyles. Unfortunately, the national health systems in Latin-American countries are unprepared and urgently need to reorganize their health care services to achieve diabetic therapeutic goals. Stem cell research is attracting increasing attention as a promising and fast-growing field in Latin America. As future healthcare systems will include the development of regenerative medicine through stem cell research, Latin America is urged to issue a call-to-action on stem cell research. Increased efforts are required in studies focused on stem cells for the treatment of diabetes. In this review, we aim to inform physicians, researchers, patients and funding sources about the advances in stem cell research for possible future applications in diabetes mellitus. Emerging studies are demonstrating the potential of stem cells for β cell differentiation and pancreatic regeneration. The major economic burden implicated in patients with diabetes complications suggests that stem cell research may relieve diabetic complications. Closer attention should be paid to stem cell research in the future as an alternative treatment for diabetes mellitus.

Action to address the household economic burden of non-communicable diseases

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

Economic and social impact of diabetes mellitus in a low-income country: A case-control study in Sudan

BACKGROUND

Diabetes mellitus accounts for 11% of total health expenditure worldwide, and most people with diabetes live in low- and middle-income countries. The present study examined the economic and social effects attributed to diabetes in Sudan by calculating out-of-pocket medical expenses and the health and social effects of the disease for people with diabetes (n = 375) and their families compared with a non-diabetic control group (n = 375), matched for age, sex, and residence area.

METHODS

Data were obtained in 2013 in four states within the Sudan, via structured interviews, using instruments from the International Diabetes Federation. Descriptive statistics were used to analyze differences between case and control participants.

RESULTS

The median total annual medical expenditure was fourfold higher for people with than without diabetes (US$579 vs US$148, respectively). Annual mean expenditure was 85% higher for those with diabetes (US$1004 vs US$544). People with diabetes were also significantly more likely to suffer from serious comorbidities, such as cardiovascular disorders and foot ulcers, compared with control participants. Moreover, those with diabetes reported a higher proportion of personal adverse social effects, such as being prevented from doing paid work or participating in education, both for themselves and their families.

CONCLUSIONS

The high economic burden and adverse social effects on people with diabetes and their families in Sudan call for the development of evidence-based policy and program strategies for the prevention and management of diabetes, with an emphasis on low-resource communities.

Limited understanding, limited services, limited resources: patients' experiences with managing hypertension and diabetes in Cambodia

INTRODUCTION

Health system responses to the emergence of non-communicable diseases (NCDs) in many Southeast Asian nations, Cambodia included, have been insufficient. Little is known about how people suffering from such conditions behave in constrained contexts. We examined the experience of patients with NCDs as they seek care for their conditions and manage them.

METHODS

In-depth interviews with 28 purposively selected patients with hypertension and/or diabetes using an interview guide to capture the trajectory followed by interviewees from the development and recognition of symptoms to adherence to treatment. A general outline of major topics to be discussed was used instead of a predetermined list of specific questions.

RESULTS

All interviewees had experienced symptoms for a substantial period of time, sometimes many years, before being diagnosed. Initial treatment focused on symptoms instead of underlying conditions, often at considerable financial cost. Following diagnosis, many struggled to take medicines daily for their condition and adhering to the required behaviour changes. Many resorted to complementary medicine. Lack of financial resources was a common reason to discontinue treatment. Many reported loss of income and assets such as livestock and productive land and increasingly relied on others.

CONCLUSION

In order to assist people with NCDs in Cambodia, there is a need for a multipronged approach focusing on communities and healthcare providers. Information campaigns could focus on the timely recognition by communities of symptoms indicative of the conditions, together with instigating demand for routine screening at qualified health providers. Peer support is considerable, and locally adjusted approaches based on this principle should be considered.

Syringaresinol-4-O-β-d-glucoside alters lipid and glucose metabolism in HepG2 cells and C2C12 myotubes

Syringaresinol-4-O-β-d-glucoside (SSG), a furofuran-type lignan, was found to modulate lipid and glucose metabolism through an activity screen of lipid accumulation and glucose consumption, and was therefore considered as a promising candidate for the prevention and treatment of metabolic disorder, especially in lipid and glucose metabolic homeostasis. In this study, the effects of SSG on lipogenesis and glucose consumption in HepG2 cells and C2C12 myotubes were further investigated. Treatment with SSG significantly inhibited lipid accumulation by oil red O staining and reduced the intracellular contents of total lipid, cholesterol and triglyceride in HepG2 cells. No effect was observed on cell viability in the MTT assay at concentrations of 0.1–10 μmol/L. SSG also increased glucose consumption by HepG2 cells and glucose uptake by C2C12 myotubes. Furthermore, real-time quantitative PCR revealed that the beneficial effects were associated with the down-regulation of sterol regulatory element-binding proteins-1c, -2 (SREBP-1c, -2), fatty acid synthase (FAS), acetyl CoA carboxylase (ACC) and hydroxyl methylglutaryl CoA reductase (HMGR), and up-regulation of peroxisome proliferator-activated receptors alpha and gamma (PPARα and PPARγ). SSG also significantly elevated transcription activity of PPARγ tested by luciferase assay. These results suggest that SSG is an effective regulator of lipogenesis and glucose consumption and might be a candidate for further research in the prevention and treatment of lipid and glucose metabolic diseases.

Direct and indirect costs of diabetes mellitus in Mali: A case-control study

Background

Diabetes mellitus (DM) is one of the most burdensome chronic diseases and is associated with shorter lifetime, diminished quality of life and economic burdens on the patient and society as a result of healthcare, medication, and reduced labor market participation. We aimed to estimate the direct (medical and non-medical) and indirect costs of DM and compare them with those of people without DM (ND), as well as the cost predictors.

Methods and findings

Observational retrospective case–control study performed in Mali.

Participants were identified and randomly selected from diabetes registries. We recruited 500 subjects with DM and 500 subjects without DM, matched by sex and age. We conducted structured, personal interviews. Costs were expressed for a 90-day period. Direct medical costs comprised: inpatient stays, ICU, laboratory tests and other hospital visits, specialist and primary care doctor visits, others, traditional practitioners, and medication. Direct non-medical costs comprised travel for treatment and paid caregivers. The indirect costs include the productivity losses by patients and caregivers, and absenteeism. We estimate a two-part model by type of service and a linear multiple regression model for the total cost. We found that total costs of persons with DM were almost 4 times higher than total cost of people without DM. Total costs were $77.08 and $281.92 for ND and DM, respectively, with a difference of $204.84.

Conclusions

Healthcare use and costs were dramatically higher for people with DM than for people with normal glucose tolerance and, in relative terms, much higher than in developed countries.

Diabetes mellitus medication use and catastrophic healthcare expenditure among adults aged 50+ years in China and India: results from the WHO study on global AGEing and adult health (SAGE)

BACKGROUND

Expenditure on medications for highly prevalent chronic conditions such as diabetes mellitus (DM) can result in financial impoverishment. People in developing countries and in low socioeconomic status groups are particularly vulnerable. China and India currently hold the world's two largest DM populations. Both countries are ageing and undergoing rapid economic development, urbanisation and social change. This paper assesses the determinants of DM medication use and catastrophic expenditure on medications in older adults with DM in China and India.

METHODS

Using national standardised data collected from adults aged 50 years and above with DM (self-reported) in China (N = 773) and India (N = 463), multivariable logistic regression describes: 1) association between respondents' socio-demographic and health behavioural characteristics and the dependent variable, DM medication use, and 2) association between DM medication use (independent variable) and household catastrophic expenditure on medications (dependent variable) (China: N = 630; India: N = 439). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007-2010).

RESULTS

Prevalence of DM medication use was 87% in China and 71% in India. Multivariable analysis indicates that people reporting lifestyle modification were more likely to use DM medications in China (OR = 6.22) and India (OR = 8.45). Women were more likely to use DM medications in China (OR = 1.56). Respondents in poorer wealth quintiles in China were more likely to use DM medications whereas the reverse was true in India. Almost 17% of people with DM in China experienced catastrophic healthcare expenditure on medications compared with 7% in India. Diabetes medication use was not a statistically significant predictor of catastrophic healthcare expenditure on medications in either country, although the odds were 33% higher among DM medications users in China (OR = 1.33).

CONCLUSIONS

The country comparison reflects major public policy differences underpinned by divergent political and ideological frameworks. The DM epidemic poses huge public health challenges for China and India. Ensuring equitable and affordable access to medications for DM is fundamental for healthy ageing cohorts, and is consistent with the global agenda for universal healthcare coverage.

Resource use associated with type 2 diabetes in Africa, the Middle East, South Asia, Eurasia and Turkey: results from the International Diabetes Management Practice Study (IDMPS)

OBJECTIVE

Type 2 diabetes (T2D) and its complications form a global healthcare burden but the exact impact in some geographical regions is still not well documented. We describe the healthcare resource usage (HRU) associated with T2D in Africa, the Middle East, South Asia, Eurasia and Turkey.

RESEARCH DESIGN AND METHODS

In the fifth wave of the International Diabetes Management Practices Study (IDMPS; 2011-2012), we collected self-reported and physician-reported cross-sectional data from 8156 patients from 18 countries across 5 regions, including different types of HRU in the previous 3-6 months. Negative binomial regression was used to identify parameters associated with HRU, using incidence rate ratios (IRRs) to express associations.

RESULTS

Patients in Africa (n=2220), the Middle East (n=2065), Eurasia (n=1843), South Asia (n=1195) and Turkey (n=842) experienced an annual hospitalization rate (mean±SD) of 0.6±1.9, 0.3±1.2, 1.7±4.1, 0.4±1.5 and 1.3±2.7, respectively. The annual number of diabetes-related inpatient days (mean±SD) was 4.7±22.7, 1.1±6.1, 16.0±30.0, 1.5±6.8 and 10.8±34.3, respectively. Despite some inter-regional heterogeneity, macrovascular complications (IRRs varying between 1.4 and 8.9), microvascular complications (IRRs varying between 3.4 and 4.3) and, to a large extent, inadequate glycemic control (IRRs varying between 1.89 and 10.1), were independent parameters associated with hospitalization in these respective regions.

CONCLUSIONS

In non-Western countries, macrovascular/microvascular complications and inadequate glycemic control were common and important parameters associated with increased HRU.

The Financial Burden of Non-Communicable Chronic Diseases in Rural Nigeria: Wealth and Gender Heterogeneity in Health Care Utilization and Health Expenditures

Objectives

Better insights into health care utilization and out-of-pocket expenditures for non-communicable chronic diseases (NCCD) are needed to develop accessible health care and limit the increasing financial burden of NCCDs in Sub-Saharan Africa.

Methods

A household survey was conducted in rural Kwara State, Nigeria, among 5,761 individuals. Data were obtained using biomedical and socio-economic questionnaires. Health care utilization, NCCD-related health expenditures and distances to health care providers were compared by sex and by wealth quintile, and a Heckman regression model was used to estimate health expenditures taking selection bias in health care utilization into account.

Results

The prevalence of NCCDs in our sample was 6.2%. NCCD-affected individuals from the wealthiest quintile utilized formal health care nearly twice as often as those from the lowest quintile (87.8% vs 46.2%, p = 0.002). Women reported foregone formal care more often than men (43.5% vs. 27.0%, p = 0.058). Health expenditures relative to annual consumption of the poorest quintile exceeded those of the highest quintile 2.2-fold, and the poorest quintile exhibited a higher rate of catastrophic health spending (10.8% among NCCD-affected households) than the three upper quintiles (4.2% to 6.7%). Long travel distances to the nearest provider, highest for the poorest quintile, were a significant deterrent to seeking care. Using distance to the nearest facility as instrument to account for selection into health care utilization, we estimated out-of-pocket health care expenditures for NCCDs to be significantly higher in the lowest wealth quintile compared to the three upper quintiles.

Conclusions

Facing potentially high health care costs and poor accessibility of health care facilities, many individuals suffering from NCCDs—particularly women and the poor—forego formal care, thereby increasing the risk of more severe illness in the future. When seeking care, the poor spend less on treatment than the rich, suggestive of lower quality care, while their expenditures represent a higher share of their annual household consumption. This calls for targeted interventions that enhance health care accessibility and provide financial protection from the consequences of NCCDs, especially for vulnerable populations.

The High Cost-related Medication Non-adherence Rate Among Medicare-Medicaid Dual-Eligible Diabetes Patients

CONTEXT

Access barriers to effective medication treatment have been a persistent issue for millions of older Americans despite the establishment of Medicare Part D.

OBJECTIVE

We aimed to assess the prevalence rate of cost-related medication non-adherence (CRN) and the patterns of CRN behaviors in Medicare-Medicaid dual eligibles with diabetes.

DESIGN SETTING PATIENTS INTERVENTIONS AND MAIN OUTCOME MEASURES

We used data from the 2011 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. Multivariate logistic regression analysis was performed to assess CRN rate, controlling for demographics and types of Medicare Part D plans.

RESULTS

The CRN rate in dual-eligible diabetes patients was 21%, compared to 16% in non-dual-eligible diabetes patients (p<0.01). In 2011, the standardized prevalence rate of CRN in dual-eligible diabetes patients was 21%, of those with CRN 29% reported three or more types of CRN behaviors.

CONCLUSION

Contrary to the common belief that dual eligibles have better insurance coverage for medication due to the assistance from Medicaid to pay some of the out-of-pocket payments, the CRN rate among dual eligibles is high and patients often report multiple types of CRN behaviors. This demonstrates that cost is a significant access barrier for dual-eligible diabetes patients. More research is needed to improve the insurance benefit design and expand insurance coverage for this high-need, high-cost subpopulation.