Rural-Urban Differences in Diabetes Care and Control in 42 Low- and Middle-Income Countries: A Cross-sectional Study of Nationally Representative Individual-Level Data

Association between diabetes phenotypes with hypertension and cardiovascular diseases, using single-sample confirmatory testing: a national study

AIM

To investigate, for the first time, the association between undiagnosed diabetes-using a single-sample confirmatory definition-and prevalent hypertension and cardiovascular diseases (CVD) in an Iranian national population. A few studies on this topic have been limited to Western populations.

METHODS

The study included 16328 adults aged ≥ 30 years. Diabetes phenotypes were classified as: 1-no diabetes: fasting plasma glucose (FPG) < 7 mmol/L (126 mg/dL) and glycated hemoglobin (HbA1c) < 6.5% (48 mmol/mol), as reference; 2-unconfirmed undiagnosed diabetes: having elevated levels of either FPG or HbA1c; 3-confirmed undiagnosed diabetes: having elevated levels of both tests; 4-known diabetes: self-reported history of glucose-lowering medications. Hypertension was defined using American Heart Association criteria. Self-reported history of CVD is defined as prevalent CVD. Multivariable logistic regression models were applied to estimate the odds ratio (OR) and 95% confidence interval (CI) of the association between diabetes phenotypes with hypertension and CVD.

RESULTS

Prevalence of unconfirmed undiagnosed-, confirmed undiagnosed-, and known -diabetes was calculated as 2.70, 3.10, and 5.64%, respectively. Unconfirmed undiagnosed-, confirmed undiagnosed-, and known -diabetes were associated with hypertension with corresponding OR were, 1.30, 1.37, and 1.62; the related values for CVD were 1.80, 1.61, and 2.38; and for the coexistence of CVD and hypertension were 1.86, 1.79, and 2.80, respectively (all P values < 0.05). Furthermore, isolated HbA1c elevation was significantly associated with prevalent CVD [2.04 (1.20-3.45)], and coexistence of hypertension and CVD [1.89 (1.00-3.55)].

CONCLUSIONS

Both unconfirmed- and confirmed- undiagnosed -diabetes were significantly associated with hypertension and CVD, the issue that was mainly attributable to high HbA1c.

Characteristics associated with optimal blood sugar in individuals living with type 2 diabetes in hard-to-reach rural communities: results of a cross-sectional study in Esmeraldas, Ecuador

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a pressing public health challenge in Latin America, with an increasing prevalence and negative impacts on population health. Achieving optimal blood glucose levels is critical for preventing complications, yet significant socioeconomic inequities persist in disease management and optimal glucose control. We aimed to investigate the patient characteristics associated with optimal fasting capillary glucose in individuals living with T2DM in a hard-to-reach setting in Esmeraldas, Ecuador.

METHODS

We carried out a cross-sectional study of individuals with T2DM in the Eloy Alfaro health district of Esmeraldas, using a complex sample design with some limitations. Data collection took place between October 2020 and May 2022 and involved face-to-face interviews to collect sociodemographic and clinical data and a Fasting Capillary Blood Glucose test. Perceived social support was measured with the Multidimensional Scale of Perceived Social Support (MSPSS). We estimated the prevalence of optimal glucose levels according to patient characteristics and calculated odds ratios (OR) with 95% confidence intervals using multivariable logistic regression.

RESULTS

Of the 474 participants surveyed, only 18.1% (86; 95%CI: 14.9-21.9) had optimal fasting capillary glucose levels. In this sample, optimal glucose was nearly four times more frequent among men compared to women (aOR = 3.92, 95%CI: 2.08-7.40, p < 0.001). Furthermore, older age (aOR = 1.03, 95%CI: 1.01-1.05, p = 0.006), living in an urbanised setting (aOR = 2.04, 95%CI: 1.22-3.40, p = 0.006) and unemployment (aOR = 0.48, 95%CI: 0.25-0.94, p = 0.031) were also linked to optimal blood glucose levels. While perceived social support in this population was moderate (median = 2.33, on a scale of 1 to 4), high family support appeared to reduce optimal glycaemic levels (aOR = 0.35, 95%CI: 0.18-0.70, p = 0.003).

CONCLUSIONS

The intricate interplay of factors influencing diabetes management and optimal blood sugar suggests that targeted, context-specific and gender-sensitive public health strategies may be needed to address diabetes disparities in vulnerable populations.

Glycemic control is worse in rural compared to urban type 2 diabetes in Bangladesh, irrespective of food security status

BACKGROUND

Food insecurity (FIS) affects around 25% of Bangladesh's population, and data from developed nations report higher FIS rates among individuals with type 2 diabetes (T2D), potentially worsening glycemic control. The importance of FIS to T2D has not been studied in developing countries such as Bangladesh, with substantial disparities in healthcare access, especially between rural and urban areas. We evaluated the relationships between food insecurity and glycemic control in the context of area of residence among individuals with T2D in Bangladesh.

METHODS

A total of 849 individuals with T2D attending diabetes clinics in four districts of Bangladesh completed a validated questionnaire to assess the FIS (a score ≥ 3 is indicative of FIS), which was compared with their sociodemographic and biochemical data. Two-way anova and multiple linear and binary logistic regression analyses were performed.

RESULTS

Both HbA1c levels (10.8% vs 9.5, P < 0.001) and the prevalence of FIS (45.8% vs 31.4%, P < 0.001) were higher in rural areas. According to two-way anova (0.87-1.78% mean difference, P < 0.05) and multiple linear regression model (β = 1.4, P < 0.001), HbA1c levels were also higher among rural than urban dwellers, irrespective of their FIS status. Rural dwellers were also more than twice as likely to have suboptimal glycemic control (HbA1c ≥7%; AOR: 2.26 (1.35-3.97), P < 0.05), irrespective of their food security status (AOR: 1.19 (0.78-1.84, P > 0.05)).

CONCLUSIONS

In Bangladesh, rural residence is associated with poor glycemic control, irrespective of food security status, and thus is an important social determinant of diabetes care that warrants further exploration.

Identify unmet needs in diabetes care in Shandong, China: a secondary analysis of a cross-sectional study using cascade of care framework

BACKGROUND

The continuum management of diabetes remains under-evaluated in China. This study aimed to estimate the proportions of diabetes adults at each stage of the cascade of care framework in Shandong, China.

METHODS

We conducted a secondary analysis using the 2018 China Adult Chronic Disease and Nutrition Surveillance (CACDNS) data in Shandong. This nationwide cross-sectional survey was conducted between September and November 2018, investigating the major chronic diseases among Chinese adults through interviews, physical examinations, and laboratory tests. We employed the cascade model to examine the proportion of diabetes adults, including both type 1 and type 2, from diabetes screening, diagnosis, pharmaceutical and non-pharmaceutical treatments, to single and comprehensive management targets, and quantified the attrition between each stage. Diabetes screening was defined as participants reported to have ever received a blood glucose test. Diabetes diagnosis was defined as: 1) fasting plasma glucose (FPG) ≥ 126 mg/dL, or 2) 2-h oral glucose tolerance test (2 h-OGTT) ≥ 200 mg/dL, or 3) hemoglobin A1c (HbA1c) ≥ 6.5%, or 4) self-reported diabetes. Diabetes management targets included: 1) single glycemic target of personalized HbA1c level, 2) comprehensive ABC targets of personalized HbA1c level, blood pressure (BP) < 140/80 mm Hg, and low-density lipoprotein cholesterol (LDL-c) level < 2.6 mmol/L, 3) lifestyle target of not currently smoking. The estimated proportion was calculated through self-reported diabetes status and FPG, 2h-OGTT and HbA1c. The number of diabetes cases in Shandong was extrapolated using the 2018 provincial census data for adults aged 18 years and above (N = 80.6 million). The cascade of diabetes care was further examined by age, sex, and Basic Public Health Service (BPHS) enrollment.

RESULTS

This secondary analysis included 8,462 individuals (47.8% males, median age: 49.0), among whom 12.4% had diabetes (self-reported: 4.2%, newly diagnosed: 8.2%) and 41.1% had prediabetes. In 2018, an estimated 9.2 million adults in Shandong had diabetes, with 6.4 million (69.6%) receiving diabetes screening but 6.2 million (67.7%) remaining unaware of their conditions. Among self-reported diabetes adults, 2.7 million (86.4%) and 2.8 million (89.6%) received pharmaceutical and non-pharmaceutical treatment, respectively. Of those with treatments, 1.2 million (58.2%) met personalized glycemic target. A rapid decline, however, was observed in BP (31.1%) and LDL-c (39.3%) control among diabetes patients with multimorbidity (≥ 2 diseases). Ultimately, 0.1 million self-reported diabetes adults (3.8%) achieved the ABC targets. BPHS Enrollment slightly improved comprehensive management with ABC targets.

CONCLUSIONS

A significant unmet need exists for diabetes adults from screening to management, particularly the comprehensive management of glycemia, BP and LDL-c levels among those with multimorbidity. Tailored strategies and appropriate allocation of healthcare resource is needed to addressing gaps in care continuum and reduce long-term disease burden.

Individual Characteristics in the Comprehension of Pandemic Video Communication: Randomized Controlled Between-Subjects Design

BACKGROUND

Video played an important role in health communication throughout the COVID-19 pandemic. It was used to communicate pandemic information to the public, with a variety of formats, presenters, and topics. Evidence regarding the effectiveness of video features is available, while how individual characteristics of recipients influence communication comprehension is still limited.

OBJECTIVE

This study aimed to test 6 individual characteristics and assess their effect on the comprehension of pandemic video communication.

METHODS

Short health communication videos were presented to a large sample of subjects, receiving questionnaire responses from 1194 participants. Individual characteristics consisted of age, sex, living area, education level, income level, and belief in science. Communication comprehension consisted of both perceived and objective comprehension. The data were analyzed by multiple linear regression.

RESULTS

Age had a negative effect on both perceived and objective comprehension-age was negatively associated with comprehension. There were sex differences, with higher perceived comprehension and lower objective comprehension among female than male individuals. Living in an urban or a rural area had no significant effect (all P>.05). The level of education and income had a positive effect on both subjective and objective comprehension. Finally, the belief in science had a positive effect on perceived comprehension (P<.001) but did not have a statistically significant effect on objective comprehension (P=.87).

CONCLUSIONS

The main differences between those who think they understand pandemic communication and those who comprehend it better are sex (female individuals have a higher perception of having comprehended, while male individuals have higher levels of objective comprehension) and belief in science (higher belief in science leads to higher perceived comprehension, while it does not have any impact on objectively understanding the message conveyed).

Rural versus urban healthcare through the lens of health behaviors and access to primary care: a post-hoc analysis of the Romanian health evaluation survey

BACKGROUND

Worldwide, rural populations are recognized to be exposed to increased health challenges due to their living and working environment, socioeconomic status, and access to health services. According to the Romanian Country Health Profile 2023, approximately 46% of all deaths recorded in Romania in 2019 could be attributed to behavioral risk factors such as tobacco smoking, dietary risks, alcohol consumption and low physical activity. No data on rural versus urban areas are available to date, and research is needed to document health inequalities, identify barriers to health services, and explore solutions.

METHODS

This study is an analysis of data collected during the Health Evaluation Survey carried out by the National Institute of Public Health in 2022 and aimed to reveal differences in health risk factors between rural and urban areas. The analysis was carried out under the methodological framework of the Health Evaluation Survey 2022, which is coordinated by the National Institute of Public Health.

RESULTS

Our study's objectively measured data revealed that the overall health profile of rural communities is characterized by lower education levels, lower incomes, and higher binge drinking rates than those of their urban counterparts. Additionally, rural inhabitants more often have high blood pressure, are more overweight and obese (per body mass index measurements) and have higher fasting plasma glucose. The health profile of the urban population revealed higher education levels and greater proportions of people with adequate monthly income, people with daily alcohol consumption, people who smoke, and people with hypercholesterolemia. Access to primary health care evaluated through proxy indicators was lower in rural areas but was relatively good overall.

CONCLUSIONS

Our analysis of the health profile of rural communities revealed a greater prevalence of obesity and overweight, especially among women, and an increased prevalence of heavy drinking among men. Access to primary health care evaluated through proxy indicators is lower in rural areas but is relatively good overall. Lower education levels and the possibility of lower health literacy underpin the need for targeted health education campaigns. Sustainable strategies for rural health need to be identified, especially in the field of health promotion and disease prevention programs.

TRIAL REGISTRATION

This study is observational research involving human participants where no interventions were applied to the study population.

Diabetes and all-cause mortality among middle-aged and older adults in China, England, Mexico, rural South Africa, and the United States: A population-based study of longitudinal aging cohorts

Objective

There is a need for comparable worldwide data on the impact of diabetes on mortality. This study assessed diabetes and all-cause mortality among middle-aged and older adults in five countries.

Research Design and Methods

We analyzed adults aged 51 years or older followed between 2010 and 2020 from population-based cohorts in China, England, Mexico, rural South Africa, and the United States. Diabetes was defined by self-report or an elevated diabetes blood-based biomarker meeting the clinical criteria for diabetes. All-cause mortality was assessed through linkages or informant interviews. We used Poisson regression models to estimate mortality rate ratios and mortality rate differences, comparing people with diabetes to those without diabetes. Models were adjusted for age, gender, education, smoking status, body mass index, and economic status.

Results

We included 29,397 individuals, of whom 4,916 (16.7%) died during the study period. The median follow-up time ranged from 4.6 years in South Africa to 8.3 years in China. The adjusted all-cause mortality rate ratios for people with diabetes versus those without diabetes ranged from 1.53 (95% CI: 1.39-1.68) in the United States to 2.02 (95% CI: 1.34-3.06) in Mexico. The adjusted mortality rate differences (per 1,000 person-years) for people with diabetes versus those without diabetes ranged from 11.9 (95% CI: 4.8-18.9) in England to 24.6 (95% CI: 12.2-37.0) in South Africa.

Conclusions

Diabetes was associated with increased all-cause mortality in population-based cohorts across five diverse countries. There is an urgent need to implement clinical and public health interventions to improve diabetes outcomes globally.

Awareness, treatment, and control among adults living with arterial hypertension or diabetes mellitus in two rural districts in Lesotho

In Lesotho, the hypertension and diabetes care cascades are unknown. We measured awareness, treatment, and control of hypertension and diabetes among adults ≥18 years and identified factors associated with each step of the cascade, based on data from a population-based, cross-sectional survey in 120 randomly sampled clusters in the districts of Butha-Buthe and Mokhotlong from 1st November 2021 to 31st August 2022. We used multivariable logistic regression to assess associations. Among participants with hypertension, 69.7% (95%CI, 67.2-72.2%, 909/1305) were aware of their condition, 67.3% (95%CI 64.8-69.9%, 878/1305) took treatment, and 49.0% (95%CI 46.3-51.7%, 640/1305) were controlled. Among participants with diabetes, 48.4% (95%CI 42.0-55.0%, 111/229) were aware of their condition, 55.8% (95%CI 49.5-62.3%, 128/229) took treatment, and 41.5% (95%CI 35.1-47.9%, 95/229) were controlled. For hypertension, women had higher odds of being on treatment (adjusted odds ratio (aOR) 2.54, 95% CI 1.78-3.61) and controlled (aOR 2.44, 95%CI 1.76-3.37) than men. Participants from urban areas had lower odds of being on treatment (aOR 0.63, 95% CI 0.44-0.90) or being controlled (aOR 0.63, 95% CI 0.46-0.85). Considerable gaps along the hypertension and diabetes care cascades in Lesotho indicate that access and quality of care for these conditions are insufficient to ensure adequate long-term health outcomes.

Diabetes and Technology in Romania: A Patient's Perspective

Professional medical care in the case of diabetes is of utmost importance to ensure patient health, compliance, and comfort. In the past decades, the emergence of healthcare medical devices has also brought important advancements in diabetology. However, this also raised new provocations for patients and healthcare professionals as well, regarding the acceptance, use, and contentment of sensors and pumps in the everyday lives of diabetic patients. The present study aimed to bring more evidence into the possibilities and pitfalls of these medical devices by interrogating 185 diabetic patients through online questionnaires from Romania. The results revealed that the medical devices can complement traditional medical care, and pre-, post-prandial, and nighttime glycemia can be more precisely achieved. Patients have also reported that the sensors and pumps can augment their daily decision-making about glycemic control and ease their daily routine. Contrariwise, the use of these medical devices is related to comfortlessness during sleeping and physical activity. Researchers acknowledge that patients' information, education, and diabetes management, through the opinion of the patients, can augment patient-focused decision-making in the daycare of diabetic patients.

Metabolic Score for Insulin Resistance and New-Onset Type 2 Diabetes in a Middle-Aged and Older Adult Population: Nationwide Prospective Cohort Study and Implications for Primary Care

BACKGROUND

The metabolic score for insulin resistance (METS-IR) has emerged as a noninsulin-based index for the approximation of insulin resistance (IR), yet longitudinal evidence supporting the utility of METS-IR in the primary prevention of type 2 diabetes mellitus (T2DM) remains limited.

OBJECTIVE

We aimed to investigate the longitudinal association between METS-IR, which combines fasting plasma glucose (FPG), lipid profiles, and anthropometrics that can be routinely obtained in resource-limited primary care settings, and the incidence of new-onset T2DM.

METHODS

We conducted a closed-cohort analysis of a nationwide, prospective cohort of 7583 Chinese middle-aged and older adults who were free of T2DM at baseline, sampled from 28 out of 31 provinces in China. We examined the characteristics of participants stratified by elevated blood pressure (BP) at baseline and new-onset T2DM at follow-up. We performed Cox proportional hazard regression analysis to explore associations of baseline METS-IR with incident T2DM in participants overall and in participants stratified by baseline BP. We also applied net reclassification improvement and integrated discrimination improvement to examine the incremental value of METS-IR.

RESULTS

During a mean follow-up period of 6.3 years, T2DM occurred in 527 participants, among which two-thirds (332/527, 62.9%; 95% CI 58.7%-67.1%) had baseline FPG<110 mg/dL. A SD unit increase in baseline METS-IR was associated with the first incidence of T2DM (adjusted hazard ratio [aHR] 1.33, 95% CI 1.22-1.45; P<.001) in all participants. We obtained similar results in participants with normal baseline BP (aHR 1.41, 95% CI 1.22-1.62; P<.001) and elevated baseline BP (aHR 1.29, 95% CI 1.16-1.44; P<.001). The predictive capability for incident T2DM was improved by adding METS-IR to FPG. In study participants with new-onset T2DM whose baseline FPG was <126 mg/dL and <110 mg/dL, 62.9% (332/527; 95% CI 60%-65.9%) and 58.1% (193/332; 95% CI 54.3%-61.9%) of participants had baseline METS-IR above the cutoff values, respectively.

CONCLUSIONS

METS-IR was significantly associated with new-onset T2DM, regardless of baseline BP level. Regular monitoring of METS-IR on top of routine blood glucose in clinical practice may add to the ability to enhance the early identification of primary care populations at risk for T2DM.

Inclusion of Rurality and Social Determinants of Health in Documents for the Primary Prevention of Type 2 Diabetes: A Systematic Review

Purpose: The type 2 diabetes (T2D) burden is disproportionately concentrated in low- and middle-income economies, particularly among rural populations. The purpose of the systematic review was to evaluate the inclusion of rurality and social determinants of health (SDOH) in documents for T2D primary prevention. Methods: This systematic review is reported following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We searched 19 databases, from 2017-2023, for documents on rurality and T2D primary prevention. Furthermore, we searched online for documents from the 216 World Bank economies, categorized by high, upper-middle, lower-middle, and low income status. We extracted data on rurality and the ten World Health Organization SDOH. Two authors independently screened documents and extracted data. Findings: Based on 3318 documents (19 databases and online search), we selected 15 documents for data extraction. The 15 documents applied to 32 economies; 12 of 15 documents were from nongovernment sources, none was from low-income economies, and 10 of 15 documents did not define or describe rurality. Among the SDOH, income and social protection (SDOH 1) and social inclusion and nondiscrimination (SDOH 8) were mentioned in documents for 25 of 29 high-income economies, while food insecurity (SDOH 5) and housing, basic amenities, and the environment (SDOH 6) were mentioned in documents for 1 of 2 lower-middle-income economies. For U.S. documents, none of the authors was from institutions in noncore (most rural) counties. Conclusions: Overall, documents on T2D primary prevention had sparse inclusion of rurality and SDOH, with additional disparity based on economic status. Inclusion of rurality and/or SDOH may improve T2D primary prevention in rural populations.

Primary health care preparedness to integrate diabetes care in Blantyre, Malawi: A mixed methods study

BACKGROUND

There is limited access to diabetes care services at primary care facilities in Malawi. Assessing the capacity of facilities to provide diabetes care is an initial step to integrating services at primary care.

AIM

To assess the preparedness for delivering diabetes services at primary care level within the Blantyre District Health Office (DHO) to support the response to NCD epidemic in Malawi.

SETTING

Blantyre DHO primary care facilities.

MATERIALS AND METHODS

A mixed methods approach nested in a national needs assessment for NCD response in Malawi was used. Fourteen primary healthcare facilities from Blantyre DHO were assessed. A tool adapted from the WHO rapid assessment questionnaire was used to identify human resource, equipment, supplies, and medication needed for comprehensive diabetes care. Descriptive statistics were done to analyze the quantitative data. Fisher's exact test was used to assess if there was a statistically significant difference between urban and rural facilities. Seventeen health care workers from the selected facilities participated in key informant interviews. Framework analysis method guided the qualitative data analysis. The quantitative and qualitative data were merged and displayed jointly.

RESULTS

The quantitative assessment showed that none of the facilities assessed had capacity to provide all the interventions recommended by WHO for diabetes care at primary level. Eight (57%) of the facilities had the capacity to diagnose diabetes, monitor glucose, prevent limb amputations and manage hypoglycemia and hyperglycemia. Four themes emerged from the qualitative data: differences in level of preparedness and implementation of diabetes care; disparities in resources between urban and rural facilities; low utilization of diabetes services; and strategy and policy recommendations for improvement of diabetes care.

CONCLUSION

Inadequate health financing resulted in significant disparities in the available resources between the rural and urban facilities to offer diabetes care services. There is need to develop national policies and guidelines for diabetes care to strengthen the capacity of primary care facilities to facilitate achievement of universal health coverage.

Exploring the path to optimal diabetes care by unravelling the contextual factors affecting access, utilisation, and quality of primary health care in West Africa: A scoping review protocol

BACKGROUND

The prevalence of diabetes in West Africa is increasing, posing a major public health threat. An estimated 24 million Africans have diabetes, with rates in West Africa around 2-6% and projected to rise 129% by 2045 according to the WHO. Over 90% of cases are Type 2 diabetes (IDF, World Bank). As diabetes is ambulatory care sensitive, good primary care is crucial to reduce complications and mortality. However, research on factors influencing diabetes primary care access, utilisation and quality in West Africa remains limited despite growing disease burden. While research has emphasised diabetes prevalence and risk factors in West Africa, there remains limited evidence on contextual influences on primary care. This scoping review aims to address these evidence gaps.

METHODS AND ANALYSIS

Using the established methodology by Arksey and O'Malley, this scoping review will undergo six stages. The review will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR) guidelines to ensure methodological rigour. We will search four electronic databases and search through grey literature sources to thoroughly explore the topic. The identified articles will undergo thorough screening. We will collect data using a standardised data extraction form that covers study characteristics, population demographics, and study methods. The study will identify key themes and sub-themes related to primary healthcare access, utilisation, and quality. We will then analyse and summarise the data using a narrative synthesis approach.

RESULTS

The findings and conclusive report will be finished and sent to a peer-reviewed publication within six months.

CONCLUSION

This review protocol aims to systematically examine and assess the factors that impact the access, utilisation, and standard of primary healthcare services for diabetes in West Africa.

The effects of diabetes clubs on peer-support, disclosure of diabetes status, and sources of information regarding diabetes management: results of a pilot-intervention in rural Vietnam

OBJECTIVES

To measure the effects of diabetes clubs on peer support, disclosure of diabetes status, and the source of information regarding the management of diabetes among persons living with type-2 diabetes (T2D) in rural Vietnam.

STUDY DESIGN

A pre- and post-pilot intervention study was carried out in Thai Binh Province, Vietnam (n = 222).

RESULTS

Post-intervention, 57.7 % reported using experiences shared by other persons with T2D during the diabetes club sessions. Compared to pre-intervention, there was an increase in the proportion of persons with T2D who disclosed their diabetes status to friends and/or community members (an increase of 15.3 and 13.8 percentage points, respectively). The proportion of persons who reported gathering their own information regarding diabetes management without any support from others decreased from 15.7 % to 6.3 %. Those who reported a relative inside their home or a relative outside their household as their primary source of T2D-relevant information increased from 10.8 % to 18.6 % and from 2.7 % to 9.5 %, respectively. Persons who mentioned that they did not have a need for further support for their diabetes care increased from 18.5 % to 32.0 %. Specific support regarding diabetes-related knowledge received from family members, friends, and/or community members increased from 27.5 % to 62.2 % CONCLUSIONS: These findings suggest a promising potential for the implementation of diabetes clubs to enhance diabetes-relevant knowledge and the quality of self-management among persons living with T2D diabetes in rural areas of Vietnam.

Mortality and disability-adjusted life years in North Africa and Middle East attributed to kidney dysfunction: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

The study aimed to estimate the attributable burden to kidney dysfunction as a metabolic risk factor in the North Africa and Middle East (NAME) region and its 21 countries in 1990-2019.

METHODS

The data used in this study were obtained from the Global Burden of Diseases (GBD) 2019 study, which provided estimated measures of deaths, disability-adjusted life years (DALYs), and other epidemiological indicators of burden. To provide a better insight into the differences in the level of social, cultural, and economic factors, the Socio-Demographic Index (SDI) was used.

RESULTS

In the NAME region in 2019, the number of deaths attributed to kidney dysfunction was 296 632 (95% uncertainty interval: 249 965-343 962), which was about 2.5 times higher than in the year 1990. Afghanistan, Egypt, and Saudi Arabia had the highest, and Kuwait, Turkey, and Iran (Islamic Republic of) had the lowest age-standardized rate of DALYs attributed to kidney dysfunction in the region in 2019. Kidney dysfunction was accounted as a risk factor for ischemic heart disease, chronic kidney disease, stroke, and peripheral artery disease with 150 471, 111 812, 34 068, and 281 attributable deaths, respectively, in 2019 in the region. In 2019, both low-SDI and high-SDI countries in the region experienced higher burdens associated with kidney dysfunction compared to other countries.

CONCLUSIONS

Kidney dysfunction increases the risk of cardiovascular diseases burden and accounted for more deaths attributable to cardiovascular diseases than chronic kidney disease in the region in 2019. Hence, policymakers in the NAME region should prioritize kidney disease prevention and control, recognizing that neglecting its impact on other diseases is a key limitation in its management.

How do sex-specific BMI trajectories shape diabetes risk? A longitudinal analysis of Indonesian adults

Introduction

Sex is a critical predictor of body mass index (BMI) trajectory over the life span, playing a role in disparities in the risk of diabetes. While there is some evidence of the effect of BMI on the risk of diabetes, little is known about sex differences in BMI trajectories over the life span and their later life association with diabetes, especially in low-income and middle-income settings.

Methods

Using panel data from the Indonesian Family Life Survey, this study examines the impact of an individual's BMI trajectory throughout adulthood on diabetes onset. Analysis for men and women were conducted separately. First, growth curve modelling estimates individuals' BMI trajectories over age. Second, the effect of BMI trajectories on diabetes is estimated using logistic regression adjusted for individual socioeconomic status. Finally, we perform relative dominance analysis to test the importance of BMI trajectories as a predictor of diabetes in later life against abdominal obesity measurements.

Results

BMI trajectories over adulthood strongly predict the probability of diabetes in both men and women. A rapidly increasing BMI significantly increases the probability of diabetes in men regardless of individuals' initial BMI. Among women, those who started out with an overweight/obese BMI and experienced a rapid loss in BMI over age had the highest risk of diabetes. Greater educational attainment is associated with an increase in the likelihood of diabetes in men, but higher education level is a protective factor from diabetes in women.

Conclusion

The findings suggest that maintaining BMI at normal cut-off over the life course can lower the likelihood of diabetes onset in later adulthood. This study emphasises that simple monitoring of BMI trajectory over adulthood could be a useful tool to identify the population at risk of diabetes in contexts with substantial underdiagnoses of diabetes.

Factors Influencing the Control of Diabetes Measured via Glycated Hemoglobin Concentrations in Adults with Type 1 Diabetes

Numerous complications of type 1 diabetes (T1D) may be prevented through suitable glycemic control. Glycated hemoglobin (HbA1c) may be one of the markers for the early detection of the metabolic imbalance characteristic of the disease. However, optimal control of diabetes is not achieved in a large group of patients. It was demonstrated that numerous factors (sociodemographic, psychological, and clinical) contributed to this condition. The aim of the study was to identify factors influencing the control of diabetes measured via glycated hemoglobin concentrations in people with T1D. Independent factors influencing better diabetes control measured via HbA1c in the study group included higher disease acceptance, higher nutritional adherence, lower BMI, and a lower risk of eating disorders. Describing the determinants will allow for the improvement of the system of care provided to people with T1D and for it to comprise important psychological variables related to self-care and acceptance of the disease.

Rural-urban disparities in the incidence and treatment intensity of periodontal disease among patients with diabetes

Background

Diabetes threatens population health, especially in rural areas. Diabetes and periodontal diseases have a bidirectional relationship. A persistence of rural-urban disparities in diabetes may indicate a rural-urban difference in periodontal disease among patients with diabetes; however, the evidence is lacking. This retrospective study aimed to investigate rural-urban discrepancies in the incidence and treatment intensity of periodontal disease among patients who were newly diagnosed with type 2 diabetes in the year 2010.

Methods

The present study was a retrospective cohort design, with two study samples: patients with type 2 diabetes and those who were further diagnosed with periodontal disease. The data sources included the 2010 Diabetes Mellitus Health Database at the patient level, the National Geographic Information Standardization Platform and the Department of Statistics, Ministry of Health and Welfare in Taiwan at the township level. Two dependent variables were a time-to-event outcome for periodontal disease among patients with type 2 diabetes and the treatment intensity measured for patients who were further diagnosed with periodontal disease. The key independent variables are two dummy variables, representing rural and suburban areas, with urban areas as the reference group. The Cox and Poisson regression models were applied for analyses.

Results

Of 68,365 qualified patients, 49% of them had periodontal disease within 10 years after patients were diagnosed with diabetes. Compared to urban patients with diabetes, rural (HR = 0.83, 95% CI: 0.75-0.91) and suburban patients (HR = 0.86, 95% CI: 0.83-0.89) had a lower incidence of periodontal disease. Among 33,612 patients with periodontal disease, rural patients received less treatment intensity of dental care (Rural: RR = 0.87, 95% CI: 0.83, 0.92; suburban: RR = 0.93, 95% CI: 0.92, 0.95) than urban patients.

Conclusion

Given the underutilization of dental care among rural patients with diabetes, a low incidence of periodontal disease indicates potentially undiagnosed periodontal disease, and low treatment intensity signals potentially unmet dental needs. Our findings provide a potential explanation for the persistence of rural-urban disparities in poor diabetes outcomes. Policy interventions to enhance the likelihood of identifying periodontal disease at the early stage for proper treatment would ease the burden of diabetes care and narrow rural-urban discrepancies in diabetes outcomes.

Aspirin for Secondary Prevention of Cardiovascular Disease in 51 Low-, Middle-, and High-Income Countries

Importance

Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD.

Objective

To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries.

Design, Setting, and Participants

Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years.

Exposures

Countries' per capita income levels and world region; individuals' socioeconomic demographics.

Main Outcomes and Measures

Self-reported use of aspirin for secondary prevention of CVD.

Results

The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries.

Conclusion and Relevance

Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

Cardiovascular health metrics in low and middle-income countries: A scoping review

BACKGROUND

In 2010 the American Heart Association defined the concept of ideal cardiovascular health to renew the focus on primordial prevention for cardiovascular disease. Evidence primarily from high-income countries suggests ideal CVH prevalence is low and decreases with age, with vulnerable populations differentially affected. We aimed to identify and characterize the evidence relevant to CVH metrics in low- and middle-income countries (LMICs).

METHODS

We followed the Joanna Briggs Institute guideline for the conduct of this scoping review. We searched MEDLINE, Embase, LILACS and study registers from inception to 14 March 2022. We included cross-sectional and cohort studies in populations representing a geographically-defined unit (urban or rural) in LMICs, and with data on CVH metrics i.e. all health or clinical factors (cholesterol, blood pressure, glycemia and body mass index) and at least one health behavior (smoking, diet or physical activity). We report findings following the PRISMA-Scr extension for scoping reviews.

RESULTS

We included 251 studies; 85% were cross-sectional. Most studies (70.9%) came from just ten countries. Only 6.8% included children younger than 12 years old. Only 34.7% reported seven metrics; 25.1%, six. Health behaviors were mostly self-reported; 45.0% of studies assessed diet, 58.6% physical activity, and 90.0% smoking status.

CONCLUSIONS

We identified a substantial and heterogeneous body of research presenting CVH metrics in LMICs. Few studies assessed all components of CVH, especially in children and in low-income settings. This review will facilitate the design of future studies to bridge the evidence gap. This scoping review protocol was previously registered on OSF: https://osf.io/sajnh.

Guidelines, position statements, and advisories for the primary prevention of type 2 diabetes, hypertension, and cardiovascular disease in rural populations: A systematic review protocol

INTRODUCTION

Globally, noncommunicable diseases (NCDs), which include type 2 diabetes (T2D), hypertension, and cardiovascular disease (CVD), are associated with a high burden of morbidity and mortality. Health disparities exacerbate the burden of NCDs. Notably, rural, compared with urban, populations face greater disparities in access to preventive care, management, and treatment of NCDs. However, there is sparse information and no known literature synthesis on the inclusion of rural populations in documents (i.e., guidelines, position statements, and advisories) pertaining to the prevention of T2D, hypertension, and CVD. To address this gap, we are conducting a systematic review to assess the inclusion of rural populations in documents on the primary prevention of T2D, hypertension, and CVD.

METHODS AND ANALYSIS

This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 19 databases including EMBASE, MEDLINE, and Scopus, from January 2017 through October 2022, on the primary prevention of T2D, hypertension, and CVD. We conducted separate Google® searches for each of the 216 World Bank economies. For primary screening, titles and/or abstracts were screened independently by two authors (databases) or one author (Google®). Documents meeting selection criteria will undergo full-text review (secondary screening) using predetermined criteria, and data extraction using a standardized form. The definition of rurality varies, and we will report the description provided in each document. We will also describe the social determinants of health (based on the World Health Organization) that may be associated with rurality.

ETHICS AND DISSEMINATION

To our knowledge, this will be the first systematic review on the inclusion of rurality in documents on the primary prevention of T2D, hypertension, and CVD. Ethics approval is not required since we are not using patient-level data. Patients are not involved in the study design or analysis. We will present the results at conferences and in peer-reviewed publication(s).

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42022369815.

Economic Burden of Diabetic Mellitus Among Patients on Follow-up Care in Hospitals of Southwest Shewa Zone, Central Ethiopia

BACKGROUND

Diabetes has emerged as one of the most serious health issues of the twenty-first century. Diabetes and its complications expose individuals and their families to catastrophic healthcare costs, which have a severe impact on the country's economy. Though the prevalence of diabetes is rising quicker in Ethiopia, little is known about its economic impact. Hence, this study aimed to determine the total cost of diabetic mellitus and associated factors among patients attending hospitals in Southwest Shewa zone, Central Ethiopia.

METHODS

The study was conducted among diabetes patients who were on care and treatment from September to October 2020. Direct costs were calculated using the micro-costing technique, while indirect costs were calculated using the human capital approach. The statistical significance of cost difference between the groups of patient characteristics was determined using Wilcoxon and Kruskal-Wallis mean rank sum tests, and the factors associated with a total cost of illness were identified with Generalized Linear Model (GLM).

RESULTS

Out of the planned patients, 398 have responded and were included in the analysis; making a response rate of 98.5%. The mean monthly total cost of diabetic mellitus was US$ 37.7(95% CI, 23.45-51.95). Direct and indirect costs constituted 76.2% and 23.8% of the total cost, respectively. The mean direct and indirect cost of diabetic mellitus per patient per month was US$ 28.73(95% CI, 17.17-40.29) and US$ 9.50 (95% CI, 1.99-16.99) respectively. Statistical mean cost differences were observed by gender, age groups, family size, and comorbidities. The total cost of illness was associated with residence (p=0.007), family size (p=0.001), presence of co-morbidities (p=0.04), and history of ever-stopping treatments (p<0.0001).

CONCLUSIONS

The total cost of diabetes condition was relatively high compared to other related literatures. The medical expenditures accounted for most direct costs for diabetic patients. As a result, the government should provide sufficient resources to safeguard patients against catastrophic medical costs. Efforts should be made to enhance access to diabetes care, and the supply of diabetic medications at all levels of health facilities.