Non-financial social determinants of diabetes among public assistance recipients in Japan: A cohort study

Social determinants of health and type 2 diabetes in Asia

Type 2 diabetes mellitus (T2DM) is a major global public health challenge driven by a complex interplay of genetic, environmental, and social factors. This review highlights the effects of social determinants of health (SDOH) on T2DM in Asia, where rapid urbanization, worsening air pollution, and distinct socioeconomic structures uniquely influence disease outcomes. Key SDOH domains, socioeconomic status (education, income, and occupation), physical environment, food environment, healthcare access, and social context, were analyzed for their associations with T2DM prevalence, progression, and management. Among these, environmental and lifestyle shifts have emerged as particularly influential factors in Asia. Air pollution, particularly fine particulate matter, has been increasingly linked to insulin resistance and diabetes risk in Asian populations. Additionally, rapid urbanization and changing food environments contribute to rising T2DM incidence through shifts in lifestyle and dietary patterns. Across the diverse healthcare systems of Asian countries, primary care remains a universally critical component in addressing T2DM issues. Additionally, social capital and cohesion serve as protective factors, whereas social isolation heightens vulnerabilities. These insights underscore the importance of addressing SDOH in public health strategies to combat T2DM in Asia. Future research should prioritize longitudinal studies and culturally tailored interventions to reduce the region's diabetes burden.

Public assistance and survival equality in patients with EGFR mutation-positive lung cancer

BACKGROUND

Disparities in public assistance or the urbanization level of a residential region can affect cancer treatment outcomes. This study aimed to investigate whether these factors affect the overall survival (OS) of patients with epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC) using Tokushukai REAL World Data.

METHODS

We analyzed the clinical data of consecutive patients with NSCLC receiving EGFR-tyrosine kinase inhibitors between April 2010 and March 2020 at 46 Tokushukai Medical Group hospitals in Japan. The patient's insurance coverage status was extracted from electronic medical records, and the urbanization level of residential regions was classified as megalopolis or other according to the secondary medical region. Univariate and multivariate Cox regression analyses were performed to examine the associations between OS and patient/tumor/treatment/socioeconomic-related factors.

RESULTS

In total, 758 patients (58.5% females) were included in the study; 41 patients (5.4%) received public assistance, and 442 patients (58.3%) were categorized under megalopolis in the secondary medical regions. In multivariate Cox regression analyses, there was no significant difference in the OS between non-recipients of public assistance and recipients [hazard ratio (HR) 1.084; 95% confidence intervals (CIs), 0.674-1.744]. There was also no significant difference in the OS between megalopolis and other regions in the secondary medical regions (HR 1.143; 95% CIs, 0.914-1.428).

CONCLUSIONS

Our findings suggest that neither the use of public assistance nor the urbanization level in the residential region significantly impacts the prognosis of Japanese patients with EGFR mutation-positive NSCLC.

The impact of war on people with type 2 diabetes in Ukraine: a survey study

Background

Although the number of studies reporting war-induced effects on the health of the Ukrainian population has been growing, there are still little data on assessing patients with type 2 diabetes (T2D) during the war. This study aimed to evaluate the impact of war on T2D patients' health to define key risk factors promoting disease progression.

Methods

A survey covering various aspects of T2D patients' experience and glycemic control data was conducted from June 2022 to February 2024. Overall, 1193 patients from all regions of Ukraine were enrolled in the study. According to the difference between the initial and current levels of HbA1c, all the respondents were subdivided into two categories: progressors (with HbA1c levels greater than 5% of the initial value) and stable (patients with stable HbA1c levels). Next, the impact of intrinsic and war-related factors on T2D progression was assessed via logistic regression analysis and machine learning tools.

Findings

Two years of war experience was associated with significant increase in the median HbA1c from 7.8% (7.0-8.93) to 8.4% (7.4-9.9; p < 0.001), with the highest value occurring in eastern and northern Ukraine. HbA1c levels demonstrated a time-dependent pattern of growth, reflecting the cumulative effect of war-related factors on T2D patients' health. Witnesses of armed attacks and occupation aggravated the T2D course. Experience with military actions (p = 0.002), occupation (p = 0.001), internal displacement (p = 0.018) and family member injury or death (p = 0.031) increased HbA1c. In addition, lack of regular glucose monitoring (p < 0.001), consultation by endocrinologists (p < 0.001), diet inconsistency (p = 0.017) and scarcity of physical activity (p = 0.047) affected the HbA1c parameters.

Interpretation

This study demonstrated a dramatic cumulative effect of the war on T2D patients' health. Uncovered direct and indirect war-related risk factors can guide further adjustment of diabetic care in Ukraine to improve T2D patient support.

Funding

National Research Foundation of Ukraine (grant number 2022.01/0089).

Understanding the daily life needs of older public assistance recipient subgroups in Japan: A qualitative study

Transition from individual-level treatment to social-level intervention should be made to improve peoples daily living conditions for reducing health inequality, which is a major global public health concern. Older public assistance recipients in Japan are socially vulnerable and require healthcare, long-term care, daily living, and social care support. Understanding the diverse daily living needs among public assistance recipient subgroups would prompt the development of novel support measures in the welfare sector. Therefore, this study aimed to understand the daily life needs of older recipient subgroups (segments) created quantitatively in our previous study. We interviewed four caseworkers at municipal welfare offices in 2021; the interview data were analyzed using a qualitative descriptive method to describe the daily life needs of the five older recipient segments for each sex. Five themes of daily life needs were demonstrated: i) housing, ii) financial, iii) welfare service, iv) healthcare, and v) no daily life needs. Consequently, we identified the daily life needs of some older recipient segments, indicating the necessity for support interventions. Future research would help interview other professionals from various backgrounds to further understand the daily life needs of older recipient segments.

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

Background

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

Methods

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

Results

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

Conclusions

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

Diabetes control in public assistance recipients and free/low-cost medical care program beneficiaries in Japan: a retrospective cross-sectional study

Introduction

Previous research has highlighted the association between socioeconomic factors and diabetes management. This study aimed to elucidate the blood glucose control status among individuals with low income (ie, recipients of public assistance (PARs) and free/low-cost medical care (FLCMC) programme beneficiaries) and to investigate the effects of public subsidies for medical expenses on treatment adherence among low-income patients with diabetes.

Methods

We conducted a secondary analysis of medical records from 910 outpatients with diabetes who underwent pharmacological treatment for >90 days. Data on predictive variables, such as glycated haemoglobin (HbA1c) level and control variables, including sex, age and insurance type, were obtained retrospectively. The HbA1c levels among public health insurance (PHI)-only beneficiaries, FLCMC programme beneficiaries and PARs were compared using logistic regression analysis.

Results

The analysis included 874 individuals, among whom the majority were men (61.7%) and aged≥65 years (58.4%). Logistic regression analysis revealed that among individuals aged ˂65 years, the adjusted ORs for HbA1c levels above 9% were significantly higher in FLCMC programme beneficiaries (OR=5.37, 95% CI: 2.23 to 12.82) and PARs (OR=5.97, 95% CI: 2.91 to 12.74) than in PHI-only beneficiaries. Among patients aged ˂65 years with HbA1c levels above 7%, the adjusted OR was significantly higher in FLCMC programme beneficiaries (OR=3.82, 95% CI: 1.65 to 10.43) than in PHI-only beneficiaries. Additionally, the adjusted OR was significantly higher in FLCMC programme beneficiaries aged ˂65 years (OR=2.57, 95% CI: 1.02 to 7.44) than in PARs.

Conclusions

This study highlights the predictive value of public assistance or the FLCMC programme for poor blood glucose control and suggests the inadequacy of current medical expense subsidies to eliminate health disparities in diabetes control.

Mortality from major causes and lifestyles by proportions of public assistance recipients among 47 prefectures in Japan: Ecological panel data analysis from 1999 to 2016

Objective

Comprehensive investigations of correlations between subnational socioeconomic factors and trends in mortality and lifestyle are important for addressing public health problems.

Methods

Forty-seven prefectures in Japan were divided into quartiles based on the proportion of public assistance recipients (PPAR). Age-standardized mortality from all causes, cancer, heart disease, and stroke in each prefecture were averaged for these quartiles in 2000, 2005, 2010, and 2015. Data from the National Health and Nutrition Survey were obtained for the following periods: 1999-2001, 2003-2005, 2007-2009, 2012, and 2016. Body mass index (BMI), intake of total energy, vegetable and salt, step count, and prevalence of current smoking and drinking for individuals aged 40-69 years age range were standardized for each prefecture and averaged by quartile. A two-way analysis of variance was used to assess differences in mortality and lifestyle across different years or periods, and quartiles.

Results

Mortality rates decreased, with the first (lowest) quartile showing the lowest rates, across all causes, cancer and heart diseases in both sexes. BMI exhibited an increase in men, whereas, BMI in women and other lifestyle factors in both sexes, excluding smoking and drinking in women, exhibited a decrease. BMI, vegetable and salt intake, total energy intake in men, and smoking in women varied across quartiles. Lower quartiles exhibited lower BMI and smoking prevalence but higher energy, vegetables, and salt intake.

Conclusions

PPAR exhibited favorable trends and significant differences in mortality related to all causes, cancer and heart disease across both sexes, along with BMI among women.

Living alone increases the risk of developing type 2 diabetes mellitus: A systematic review and meta-analysis based on longitudinal studies

BACKGROUND

Living alone is a prevalent psychological issue that has been found to have significant implications for lifestyle and health status. While considerable research has been conducted to explore the relationship between living alone and the risk of developing type 2 diabetes mellitus (T2DM), the majority of studies have been cross-sectional, leaving direct correlations elusive. Therefore, this study aims to analyze data from longitudinal studies to determine whether living alone increases the risk of T2DM.

METHODS

A comprehensive search was conducted in the PubMed, Cochrane, and Embase databases to identify studies examining the association between living alone and T2DM risk. The search encompassed studies published until September 2023. Pooled analysis utilized the random-effects model with inverse variance and included adjusted hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs).

RESULTS

The meta-analysis comprised a total of 8 studies, which consisted of 5 prospective cohort studies and 3 retrospective cohort studies. The total population under consideration included 11,686,677 individuals without T2DM, of whom 54.3% were female. Among this population, 396,368 individuals developed T2DM. To account for heterogeneity, a random-effects model was employed. Overall, the pooled data demonstrated a significant association between living alone and an increased risk of T2DM when compared to living with others (HR 1.24, 95% CI 1.06-1.46). Subgroup analysis revealed that this risk was not statistically significant for either males (HR 1.28, 95% CI 0.93-1.76) or females (HR 1.06, 95% CI 0.84-1.33), nor in prospective cohort studies (HR 1.26, 95% CI 0.91-1.74) or retrospective cohort studies (HR 1.26, 95% CI 0.91-1.74).

CONCLUSION

Individuals living alone faced a significantly higher risk of developing diabetes compared to those who did not live alone. However, no significant difference in this risk was observed between genders and study types. Further high-quality studies are necessary in the future to elucidate this causal association.

Polypharmacy prevalence and associated factors in patients with systemic lupus erythematosus: A single-centre, cross-sectional study

OBJECTIVES

This study aimed to clarify factors associated with polypharmacy among patients with systemic lupus erythematosus.

METHODS

This single-centre cross-sectional study was conducted by reviewing the medical records and questionnaire data of 261 systemic lupus erythematosus patients at a teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as the regular administration of five or more oral medications; excessive polypharmacy consisted of the regular use of 10 or more oral medications. This study investigated (1) the prevalence of polypharmacy and excessive polypharmacy, (2) the distribution of medication types, and (3) the factors associated with polypharmacy and excessive polypharmacy.

RESULTS

The proportions of patients who exhibited polypharmacy and excessive polypharmacy were 70% and 19%, respectively. Polypharmacy was associated with older age, long duration of systemic lupus erythematosus, high disease activity, and administration of glucocorticoids or immunosuppressive agents. Excessive polypharmacy was associated with a higher updated Charlson comorbidity index, history of visits to multiple internal medicine clinics, and presence of public assistance.

CONCLUSIONS

Polypharmacy and excessive polypharmacy in patients with systemic lupus erythematosus are related to medical aspects such as disease severity and comorbidities in addition to social aspects such as hospital visitation patterns and economic status.

Identifying meaningful subpopulation segments among older public assistance recipients: a mixed methods study to develop tailor-made health and welfare interventions

BACKGROUND

Public assistance recipients have diverse and complex needs for health and social support in addition to financial support. Segmentation, which means dividing the population into subgroups (segments) with similar sociodemographic characteristics, is a useful approach for allocating support resources to the targeted segments. Clustering is a commonly used statistical method of segmentation in a data-driven marketing approach. This explanatory sequential mixed methods study applied a clustering technique, aiming to identify segments among older public assistance recipients quantitatively, and assess the meaningfulness of the identified segments in consultation and support activities for older recipients qualitatively.

METHODS

We identified the segments of older recipients in two municipalities using probabilistic latent semantic analysis, a machine learning-based soft clustering method. Semi-structured interviews were subsequently conducted with caseworkers to ask whether the identified segments could be meaningful for them in practice and to provide a reason if they could not think of any older recipients from the segment.

RESULTS

A total of 3,165 older people on public assistance were included in the analysis. Five distinct segments of older recipients were identified for each sex from 1,483 men and 1,682 women. The qualitative findings suggested most of identified segments reflected older recipients in practice, especially two of them: female Cluster 1 (facility residents aged over 85 years with disability/psychiatric disorder), and female Cluster 2 (workers). Some caseworkers, however, did not recall older recipients in practice when working with certain segments.

CONCLUSIONS

A clustering technique can be useful to identify the meaningful segments among older recipients and can potentially discover previously unrecognized segments that may not emerge through regular consultation practices followed by caseworkers. Future research should investigate whether tailored support interventions for these identified segments are effective.

Socioeconomic Level and the Relationship in Glycemic Behavior in the Mexican Population. A Nutritional Alternative Focused on Vulnerable Populations

In this study, numerical approximations were generated to analyze the behavior of glycemic variations in the non-diabetic population of the Mexican republic. The main objective of this work is to obtain an overview of the glycemic variations in the non-diabetic population from different socioeconomic statuses in Mexico (Medium-high, medium, and low). Thus, evaluating the effect on the glucose level under a healthy diet considering the socioeconomic capabilities of the population. Through the national health and nutrition survey of Mexico 2020 and the Mexican food base, 1420 virtual patients were proposed (522 low status, 485 medium status and 413 Medium-High status) focused on simulating the glycemic behavior in each of the survey participants. Considering that the average food expenditure of the Mexican population is $107.00 MXN, and the cost of a healthy diet is $66.50 MXN, the economic sustainability of the Mexican population to adopt a healthy diet is revealed. The particularity of this work is focused on obtaining diverse data that are difficult to access in the development of population analyses. Such is the case of the approach proposed for different socioeconomic statuses. In this way, the proposed methodology provides a framework for complementary research contributions to the subject.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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