Prevalence of diabetes across different immigrant groups in North-eastern Italy

A randomized trial to evaluate a complex, co-created, culture-sensitive intervention to promote healthy lifestyles and compliance to therapy in immigrants with type 2 diabetes: A protocol of a multicenter Italian study

INTRODUCTION

The active involvement of end users may overcome socio-economic, cultural and context-related barriers that may reduce health promotion effectiveness in type 2 diabetes control and prevention. The "Cardio-metabolic diseases in immigrants and ethnic minorities: from epidemiology to new prevention strategies" (DIABETHIC) project funded by the European Union through the Italian Ministry of Health includes a multicentre randomised controlled trial (RCT) aimed to assess the effectiveness of a co-created health promotion intervention for immigrants affected by type 2 diabetes. This protocol describes the co-creation process and methodological challenges in evaluating co-created health promotion interventions.

METHODS AND ANALYSIS

Between November 2023 and July 2024, four Italian primary care centres will recruit 200 immigrants with type 2 diabetes that will be randomised to usual health promotion practice or to the experimental health promotion intervention developed through a participatory process. Endpoints are changes in glycated haemoglobin, Body Mass Index, diet, physical activity and therapeutic adherence at 12 months after recruitment. Qualitative research experts supported the participatory process at local and national levels. According to available evidence and recommendations, the participatory process focused on the three pillars of type 2 diabetes control (diet, physical activity, and therapeutic adherence). To co-create the intervention, interviews, focus groups and role-plays were conducted with patients and immigrants, healthcare workers and representatives of social services. Identified barriers were ranked according to priority and actionability. Given different health promotion practice in the four centres, the intervention was standardised by function (dietary counselling, culturally tailored information materials, access to cultural mediation, training in effective and reflective communication, individual and group meetings) rather than by form (operators involved, protocols and timeframes), which was defined locally by feasibility and by contrasting usual health promotion. (Trial registration: ClinicalTrials.gov ID NCT06131411).

Assessment of health literacy among migrant populations in Southern Spain: A cross-sectional study

AIM

The aim of this study was to measure of health literacy in the migrant population and establish a type of immigrant profile with a higher risk of presenting low levels of health literacy.

DESIGN

A cross-sectional descriptive study.

METHODS

Health literacy was measured in a total of 278 immigrants using HLS-EU-Q16. An inferential descriptive and multiple regression analysis was carried out.

RESULTS

65.1% having inadequate and problematic health literacy. Significant correlations were found between health literacy and length of stay in Spain (r = .398), age (r = .178p) and perceived social status (r = .151). Participants with shorter length of stay (β = .405 1), without health sciences education (β = .205) and low education level (β = .182) had limited health literacy.

A Cohort Study on Diabetic Undocumented Migrants in Italy: Can Charitable Organizations Contribute to Higher Adherence?

The increasing presence of documented and undocumented migrants increases the commitment of the Italian National Health Service to their health needs, following its founding principle of equity. In particular, chronic diseases, such as diabetes, represent a crucial area where patients' health is affected by their adherence to care pathways, for which the recent literature has reported alarming low levels. In the case of migrants, obstacles to adherence, such as language or organizational barriers, could be overcome thanks also to charitable organizations providing healthcare services. In this study, we aimed to compare the adherence among documented and undocumented migrants who received healthcare services in Milan, Italy, either from the National Health Service (NHS) or from a charitable organization. We identified a cohort of newly taken into care diabetic patients composed of two groups: (i) documented migrants that attend the NHS; and (ii) undocumented migrants that attend a charity. Information was tracked by merging two datasets: the regional healthcare information system of Lombardy, and a unique dataset that collects data on specialistic visits and pharmaceutical prescriptions for all people visiting one of the most prominent charitable organizations in Italy. The annual diabetologist visit was used as the measure of adherence. The probability of being adherent was compared among the two groups by using a multivariate log-binomial regression model, considering a set of personal characteristics that may impact health behaviors. The cohort comprised 6429 subjects. The percentage of adherence was 52% among the documented migrants, and 74% among the undocumented. Regression results confirmed this pattern: undocumented patients have an increased probability of being adherent by 1.19 times (95% CI: 1.12 to 1.26) compared to documented ones. Our study revealed the potentiality of charitable organizations in guaranteeing continuity of care to undocumented migrants. We argue that this mechanism would benefit from central coordination by the government.

Risk factors, awareness of disease and use of medications in a deprived population: differences between indigent natives and undocumented migrants in Italy

BACKGROUND

Undocumented migrants experience many health problems; a comparison with a suitable control group of natives living in the same socio-economic conditions is still lacking.

METHODS

Demographic data and data on risk factors, chronic conditions and dietary habits were obtained for 6933 adults (2950 Italians and 3983 undocumented migrants) receiving medical assistance from 40 non-governmental organizations all over the country.

RESULTS

Attributed to the fact that these were unselected groups, differences were found in their demographic features, the main ones being their marital status (singles: 50.5% among Italians and 42.8% among migrants; P < 0.001). Smokers were more frequent among Italians (45.3% versus 42.7% P = 0.03); the same happened with hypertension (40.5% versus 34.5% P < 0.001). Migrants were more often overweight (44.1% versus 40.5% P < 0.001) and reporting a chronic condition (20.2% versus 14.4% P < 0.001). Among those on medications (n = 1354), Italians were fewer (n = 425) and on different medications. Differences emerged also in dietary habits.

CONCLUSIONS

Differences in health conditions exist between native-borns and undocumented migrants, not because of a bias related to socio-economic conditions. Further studies are needed to design sustainable health policies and tailored prevention plans.

Outcomes of Culturally Tailored Dietary Intervention in the North African and Bangladeshi Diabetic Patients in Italy

Immigrants show higher adjusted diabetes prevalence than Italians, especially among South-East Asians followed by North and Sub-Saharan Africans. Diabetes progression is influenced by food behaviors, and diet control is a critical aspect in disease management. Food habits have many cultural and symbolic implications. Guidelines recommend that every patient should receive appropriate self-management education according to cultural and socioeconomic characteristics. This study aims to test whether a customized diet and transcultural mediator’s support can improve immigrants’ food habits. A pre-post quali-quantitative study was conducted among 20–79-year-old Bangladeshi and North African diabetic immigrants. The INMP transcultural mediator, an expert in the social and health care field, actively participates in clinical activity by decoding linguistic and cultural needs expressed by the foreigner patient. Five culturally tailored dietary profiles were designed according to international diabetes guidelines and adjusted to traditional food habits. Data were collected with two different semi-structured questionnaires. Changes in food consumption were assessed through McNemar’s test, while paired Wilcoxon Signed-Rank test was used to analyze pre and post intervention. Fifty-five patients were enrolled. At follow-up, cereals, meat, and potatoes intake significantly improved, and the number of adequate dietary habits for each patient increased significantly. Transcultural mediator support was 90% positively evaluated. Adherence to dietary control is favorably influenced by a transcultural intervention, which is based on clinical and socio-cultural criteria, in compliance with patient’s lifestyles.

Current Pharmacological Treatment of Type 2 Diabetes Mellitus in Undocumented Migrants: Is It Appropriate for the Phenotype of the Disease?

Type 2 diabetes is increasingly recognized as a spectrum of metabolic disorders sharing chronic hyperglycaemia. In Europe, the continually growing number of migrants from developing countries could affect diabetes phenotypes. We evaluated a population of 426 Italians and 412 undocumented migrants. Using 17 variables (with the exclusion of ethnic origin) we performed a multiple component analysis to detect potential clusters, independently from ethnicity. We also compared the two groups to evaluate potential ethnicity associated differences. We found five clusters of patients with different disease phenotypes. Comparing Italians with undocumented migrants, we noted that the first had more often cardiovascular risk factors and neurologic involvement, while the latter had a higher frequency of diabetic ulcers and renal involvement. Metformin was used in a comparable percentage of patients in all clusters, but other antidiabetic treatments showed some differences. Italians were more often on insulin, due to a larger use of long acting insulin, and received a larger number of oral antidiabetics in combination. Pharmacological treatment of comorbidities showed some differences too. We suggest that type 2 diabetes should be considered as a spectrum of diseases with different phenotypes also in heterogeneous populations, and that this is not due only to ethnic differences.

Will undocumented migrants contribute to change epidemiology, presentation and pharmacologic treatment of diabetes in Western countries?

AIMS

Migrants from countries in which health and social conditions are unsatisfactory, and their offspring, are becoming a growing component of the western population. Available health data show that their morbidity is at least comparable to that of the host country population, with a significant contribution of chronic diseases as diabetes. The possibility that diabetes shows different features in undocumented migrants is the hypothesis that we tried to investigate in this study.

METHODS

We retrospectively analysed the data of 413 patients with type 2 diabetes mellitus (T2DM): 222 patients followed in a diabetes clinic at a University Hospital and 191 undocumented migrants cared for by a Charity in Milan, Italy.

RESULTS

We found that the onset of the disease was earlier in migrants; they showed a significant lower body mass index (BMI) and had lower socioeconomic conditions. They had a worse glycaemic control. The pattern of complications was also different between the two groups, with cardiovascular complications more frequent in Italians. Finally, also pharmacologic treatment differed significantly.

CONCLUSIONS

Age of onset, clinical manifestations and complications of T2DM in undocumented migrants and natives may show significant differences. This is important for both epidemiological and clinical reasons. If these preliminary observations are confirmed by larger studies, we can conclude that undocumented migrants should be screened for T2DM earlier than natives, and that therapies should be tailored to the specific features of their disease.

Exploring the Experiences of West African Immigrants Living with Type 2 Diabetes in the UK

The increasing prevalence and poorer management of Type 2 diabetes among West African immigrants in the UK is a public health concern. This research explored the experiences of West African immigrants in the management of Type 2 diabetes in the UK using a constructivist grounded theory approach. In-depth individual interviews were conducted with thirty-four West African immigrants living with Type 2 diabetes in the London area. Fifteen male and nineteen female adult West African immigrants with age range from 33-82 years participated in the study. Participants were recruited from five diabetes support groups and community settings. Initial, focused and theoretical coding, constant comparison and memos were used to analyse collected data. Three concepts emerged: Changing dietary habits composed of participants' experiences in meeting dietary recommendations, improving physical activity concerned with the experience of reduced physical activity since moving to the UK and striving to adapt which focus on the impact of migration changes in living with Type 2 diabetes in the UK. These address challenges that West African immigrants experience in the management of Type 2 diabetes in the UK. The findings of this research provide a better understanding of the influencing factors and can be used to improve the support provided for West Africans living with Type 2 diabetes in the UK, presenting a deeper understanding of socio-cultural factors that contribute to supporting individuals from this population.

Insulin Glargine U100 Utilization in Patients with Type 2 Diabetes in an Italian Real-World Setting: A Retrospective Study

BACKGROUND

This study is aimed at estimating the proportion of type 2 diabetes mellitus (T2DM) patients treated with basal insulin (insulin glargine U100) and at evaluating daily insulin dose, treatment pattern, and adherence to treatment of these patients.

METHODS

Data from administrative and laboratory databases of 3 Italian Local Health Units were retrospectively collected and analyzed. All patients with a diagnosis of T2DM between 01/01/2012 and 31/12/2012 were considered, and those with at least a prescription of insulin glargine between 01/01/2013 and 31/12/2014 were included and followed up for one year. For each patient, we evaluated HbA1c levels both at baseline and during the follow-up period and the daily average dose of insulin. Medication adherence was defined by using medication possession ratio (MPR) and reported as proportion of patients with MPR ≥ 80%.

RESULTS

7,422 T2DM patients were available for the study. According to the antidiabetic medication prescribed, patients were categorized into four groups: insulin glargine only, insulin glargine plus oral glucose-lowering drugs, insulin glargine plus rapid-acting insulin, and insulin glargine plus DPP-4 inhibitors. Median daily dose of insulin among insulin glargine only patients was higher than in other groups (35 IU vs. 20 IU, p < 0.05), and a higher percentage of them achieved a target HbA1c value of less than 7.0% (53.8% vs. 30%, p < 0.001). Adherence to insulin treatment was lowest (41%) in the insulin glargine only group compared to other groups (ranging from 58.4% to 64.4%), p < 0.001.

CONCLUSIONS

A large proportion of T2DM patients treated with insulin fail in achieving the glycemic target of HbA1c level < 7%, irrespective of treatment regimen; however, basal insulin only is associated with lower therapeutic unsuccess. Adherence to antidiabetes medications is also suboptimal in these patients and should be addressed to improve long-term outcomes of reducing and preventing microvascular and macrovascular complications.

Prevalence and management of diabetes in immigrants resident in the Lombardy Region: the importance of ethnicity and duration of stay

AIMS

To describe the prevalence and management of diabetes among immigrants according to ethnic group and duration of stay, compared to Italian citizens.

METHODS

Diabetic immigrant and Italian residents aged 20-69 years in the administrative database of the Lombardy Region. Immigrants were classified by region of origin and as long-term residents (LTR) and short-term residents (STR). Age- and sex-adjusted prevalence and indicators of diabetes management were calculated for immigrants by region of origin and by length of stay using Cox proportional models.

RESULTS

In 2010 19,992 immigrants (mean age 49.1 ± 10.8, 53.7% males) and 195,049 Italians (mean age 58.7 ± 9.3, 61.1 males) with diabetes were identified. Immigrants had a higher adjusted diabetes prevalence than Italians (OR 1.48; 95% CI 1.45-1.50). STR received significantly fewer recommended cardiovascular drugs (antiplatelets, statins and ACE-inhibitors/ARBs) than Italians, although prescription was higher among LTR from some ethnic groups. Immigrants were less likely to be seen by a diabetologist and to do at least one HbA1c test per year. Although the recommended tests/visits were more often done for the LTR than the STR, in the majority of ethnic groups these indicators were still far from optimal.

CONCLUSION

The prevalence and management of diabetes differ between immigrants and Italians, although some improvement can be seen among LTR.

Ethnic inequalities in acute myocardial infarction hospitalization rates among young and middle-aged adults in Northern Italy: high risk for South Asians

The knowledge of ethnic-specific health needs is now essential to design effective health services and population-based prevention strategies. However, data on migrant populations living in Southern Europe are limited. The study is designed to investigate ethnic inequalities in hospitalization for acute myocardial infarction (AMI) in the Veneto region (Italy). Hospital admissions for AMI in Veneto for the whole resident population aged 20-59 years during 2008-2013 were studied. Age and gender-specific AMI hospitalization rates for immigrant groups (classified by country of origin according to the United Nations geoscheme) and Italians were calculated. The indirect standardization method was used to estimate standardized hospitalization ratios (SHR) for each immigrant group, with rates of Italian residents as a reference. Overall, 8200 AMI events were retrieved, 648 among immigrants. The highest risk of AMI is seen in South Asians males (SHR 4.2, 95% CI 3.6-4.9) and females (SHR 2.5, 95% CI 1.4-4.5). AMI rates in South Asian males sharply increase in the 30-39 years age class. Other immigrant subgroups (Eastern Europe, North Africa, Sub-Saharan Africa, other Asian countries, Central-South America, high-income countries) displayed age- and gender-adjusted hospitalization rates similar to the native population. Present findings stress the urgent need for implementation of ethnic-specific health policies in Italy. The awareness about the high cardiovascular risk in subjects from South Asia must be increased among general practitioners and immigrant communities.

Plasma Cholesteryl Ester Fatty Acids do not Mediate the Association of Ethnicity with Type 2 Diabetes: Results From the HELIUS Study

SCOPE

Ethnic minority groups have a higher risk of type 2 diabetes (T2D) than the host population. Our aim is to identify whether plasma cholesteryl ester fatty acids (CEFA) mediate the ethnic differences in type 2 diabetes.

METHODS AND RESULTS

We included 202 Dutch, 206 South-Asian Surinamese, 205 African Surinamese, 215 Turkish, and 213 Moroccan origin participants of the HELIUS study (Amsterdam, the Netherlands). Logistic regression is used to determine the associations between plasma CEFA and T2D. Mediation analysis is used to identify whether CEFA contributed to the association between ethnicity and T2D. We adjusted for ethnicity, age, sex, smoking, physical activity, and BMI. Associations between plasma CEFA and T2D were similar across all ethnic groups. Although differences in plasma CEFA across ethnic groups were observed, CEFA did not mediate the differences in T2D prevalence between ethnic groups.

CONCLUSION

Although ethnic differences in plasma CEFA are found and CEFA are associated with T2D, CEFA does not contribute to the difference in T2D prevalence between ethnic groups. If confirmed, this implies that maintenance of the more beneficial CEFA profiles in the non-Dutch ethnic groups may be encouraged to prevent an even higher prevalence of T2D in these groups.

Diverging patterns of cardiovascular diseases across immigrant groups in Northern Italy

BACKGROUND

Only fragmentary data are available on the burden of non-communicable diseases among immigrants in Europe, mostly limited to mortality by cause. Aim of the study is to investigate the prevalence of cardiovascular diseases across different immigrant groups in the Veneto Region (North-Eastern Italy).

METHODS

The resident population aged 20-59 was classified according to country of citizenship. The Adjusted Clinical Groups System was adopted to identify selected cardiovascular conditions by linkage of Hospital Discharge Records, Emergency Room visits, Chronic disease registry for copayment exemptions, the Home care database, and drugs reimbursed by the Regional Health Service. Age standardized prevalence rates were compared across population groups, and rate ratios (RR) with 95% confidence intervals (CI) were computed taking the Italian population as reference.

RESULTS

The prevalence of diabetes was higher across all immigrant groups compared to Italians. Specific risk patterns could be identified associated to different ethnicities: South Asian immigrants were at very high risk of diabetes, dyslipidemia, and ischemic heart disease (males RR 2.3, CI 1.9-2.8; females RR 2.0, CI 1.2-3.5). Immigrants from Africa were affected by high rates of hypertension, cerebrovascular diseases, and heart failure, with a more pronounced unfavorable profile among females (hypertension RR 3.0, CI 2.6-3.3; cerebrovascular diseases RR 1.7, CI 1.1-2.7).

CONCLUSIONS

Wide differences in the prevalence of cardiovascular diseases could be detected across immigrant groups. These findings represent a first step towards systematic chronic disease surveillance by ethnicity, a fundamental tool for shaping culturally-tailored prevention strategies.

Lifestyle-tailored interventions for South Asians with type 2 diabetes living in high-income countries: a systematic review

AIM

To summarize evidence on the effectiveness of educational interventions for type 2 diabetes control in South Asians living in high-income countries.

METHODS

We systematically searched PubMed, EMBASE, Cinahl and the Cochrane Library, using Medical Subject Heading and free-text terms. The considered outcomes were: mortality, morbidity, glycaemic control, blood pressure, practice (diet, physical activity and self-care), attitudes/awareness and knowledge. Papers published up to July 2015 were considered. Two reviewers independently screened the title and abstract and then read the full text of selected papers.

RESULTS

Nine studies were included, four non-randomized studies of interventions and five randomized controlled trials. All studies except one were conducted in the UK. Target population ranged from 39 to 1486 individuals; the follow-up ranged from 1 to 24 months. The interventions were mostly based on a tailored educational package, individually or group administered, conducted by lay link workers, health professionals or both. No study measured mortality or morbidity. An effect on glycaemic control was observed only in before/after studies, while a randomized study showed a non-significant improvement (percentage of glycated haemoglobin -0.15, P = 0.11). Two randomized studies found a reduction in blood pressure. Changes in practice and attitudes showed heterogeneous results, mostly favouring intervention.

CONCLUSIONS

There was weak evidence that interventions using link workers and tailored education can modify attitudes, self-care skills and blood pressure in South Asian migrants to industrialized countries. Only one larger trial, with adequate follow-up, showed a small non-significant improvement of glycaemic control.