Impact of applying a diabetes risk score in primary care on change in physical activity: a pragmatic cluster randomised trial

AIM

There is little evidence of the impact of diabetes risk scores on individual diabetes risk factors, motivation for behaviour changes and mental health. The aim of this study was to investigate the effect of applying a noninvasive diabetes risk score in primary care as component of routine health checks on physical activity and secondary outcomes.

METHODS

Cluster randomised trial, in which primary care physicians (PCPs), randomised (1:1) by minimisation, enrolled participants with statutory health insurance without known diabetes, ≥ 35 years of age with a body mass index ≥ 27.0 kg/m². The German Diabetes Risk Score was applied as add-on to the standard routine health check, conducted in the controls. Primary outcome was the difference in participants' physical activity (International Physical Activity Questionnaire) after 12 months. Secondary outcomes included body mass index, perceived health, anxiety, depression, and motivation for lifestyle change. Analysis was by intention-to-treat principle using mixed models.

RESULTS

36 PCPs were randomised; remaining 30 PCPs (intervention: n = 16; control: n = 14) recruited 315 participants (intervention: n = 153; controls: n = 162). A slight increase in physical activity was observed in the intervention group with an adjusted mean change of 388 (95% confidence interval: - 235; 1011) metabolic equivalents minutes per week. There were no relevant changes in secondary outcomes.

CONCLUSIONS

The application of a noninvasive diabetes risk score alone is not effective in promoting physical activity in primary care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT03234322, registration date: July 31, 2017).

Socio-economic inequalities in glycaemic control in recently diagnosed adults with type 1 and type 2 diabetes

BACKGROUND AND AIMS

It is unclear whether socio-economic status (SES) is associated with glycaemic control in people with recently diagnosed diabetes. The aim was to investigate whether SES is related to haemoglobin A1c (HbA1c) during the first year after diagnosis in people with type 1 and type 2 diabetes and if metabolic, quality of care or mental factors may explain the association.

METHODS

In the German Diabetes Study, people with type 1 (n = 274, median age 36 [25th; 75th percentile: 28; 48] years) and type 2 diabetes (n = 424, 54 [47; 60] years) underwent detailed metabolic characterisation within the first year after diagnosis. SES was documented using a standardised questionnaire. Associations between SES and HbA1c were assessed using multivariable linear regression and restricted cubic spline regression analyses. Additional covariables were patient characteristics, laboratory measurements, health behaviour, quality of care and depression variables. Models were separately fitted for diabetes type, SES and its dimensions (income, education, occupation).

RESULTS

Higher SES score was associated with lower HbA1c (-0.7 mmol/mol per unit increase in SES, 95% CI: -1.1; -0.2 mmol/mol [-0.1%, 95% CI: -0.1; 0.0%]) in people with type 1 diabetes. Included covariates did not attenuate this association. In people with type 2 diabetes, effect estimates were close to zero indicating no relevant difference.

CONCLUSION

Socio-economic inequalities in HbA1c already exist during the first year after diagnosis in people with type 1 diabetes. The absence of association between glycaemic control and SES in type 2 diabetes could be due to the lower complexity of diabetes therapy compared to type 1 diabetes.

Educational Level, but Not Income or Area Deprivation, is Related to Macrovascular Disease: Results From Two Population-Based Cohorts in Germany

Objectives: An inverse relationship between education and cardiovascular risk has been described, however, the combined association of education, income, and neighborhood socioeconomic status with macrovascular disease is less clear. The aim of this study was to evaluate the association of educational level, equivalent household income and area deprivation with macrovascular disease in Germany.

Methods: Cross-sectional data from two representative German population-based studies, SHIP-TREND (n = 3,731) and KORA-F4 (n = 2,870), were analyzed. Multivariable logistic regression models were applied to estimate odds ratios and 95% confidence intervals for the association between socioeconomic determinants and macrovascular disease (defined as self-reported myocardial infarction or stroke).

Results: The study showed a higher odds of prevalent macrovascular disease in men with low and middle educational level compared to men with high education. Area deprivation and equivalent income were not related to myocardial infarction or stroke in any of the models.

Conclusion: Educational level, but not income or area deprivation, is significantly related to the macrovascular disease in men. Effective prevention of macrovascular disease should therefore start with investing in individual education.

Estimating the impact of tax policy interventions on the projected number and prevalence of adults with type 2 diabetes in Germany between 2020 and 2040

INTRODUCTION

As a population-wide intervention, it has been proposed to raise taxes on unhealthy products to prevent diseases such as type 2 diabetes. In this study, we aimed to estimate the effect of tax policy interventions in 2020 on the projected prevalence and number of people with type 2 diabetes in the German adult population in 2040.

RESEARCH DESIGN AND METHODS

We applied an illness-death model and the German Diabetes Risk Score (GDRS) to project the prevalence and number of adults with type 2 diabetes in Germany under a base case scenario and under a tax policy intervention scenario. For the base case scenario, we assumed constant age-specific incidence rates between 2020 and 2040. For the intervention scenario, we assumed a 50% price increase for sugar-sweetened beverages, tobacco and red meat products in the year 2020. Based on price elasticities, we estimated the impact on these risk factors alone and in combination, and calculated subsequent reductions in the age-specific and sex-specific GDRS. These reductions were used to determine reductions in the incidence rate and prevalence using a partial differential equation.

RESULTS

Compared with the base case scenario, combined tax interventions in 2020 resulted in a 0.95 percentage point decrease in the prevalence of type 2 diabetes (16.2% vs 17.1%), which corresponds to 640 000 fewer prevalent cases of type 2 diabetes and a relative reduction by 6%.

CONCLUSIONS

Taxation of sugar-sweetened beverages, tobacco products and red meat by 50% modestly lowered the projected number and prevalence of adults with type 2 diabetes in Germany in 2040. Raising taxes on unhealthy products as a stand-alone measure may not be enough to attenuate the future rise of type 2 diabetes.