The socioeconomic correlates of global complication prevalence in type 1 diabetes (T1D): A multinational comparison

https://doi.org/10.1016/j.diabres.2005.03.026Get rights and content

Abstract

We sought to determine the extent to which the geographic variation in the complications of type 1 diabetes (T1D) may reflect the socioeconomic status (SES) conditions and health care performance (HCP) of countries around the world. The World Health Organization (WHO) DiaMond complications study (DiaComp) is a multinational, cross-sectional study of complications in T1D. Information on complications was identified for 892 subjects from 14 clinical centers in 12 countries. All participants were diagnosed with diabetes in childhood (<15 years of age) and had disease duration of 5–24 years. Complications were assessed by self-report, and by clinical exam, with microalbuminuria identified by Micral II dipstick, neuropathy by the Michigan Neuropathy Screening Instrument exam and hypertension using the HDFP protocol. These data were linked to center-specific information on the local social and economic landscape, health care access and diabetes management practices and health care costs. Country-specific indicators of social and economic development were also linked to the complications data. Both diabetes complications and economic and health care factors vary widely across the DiaComp centers. Health system performance, as measured by disability adjusted life expectancy (DALE), gross national investment (GNI) per capita and purchasing power all showed strong consistent correlations with complications, and significant independent associations with complication prevalence after controlling for HbA1c and hypertension. In conclusion, health system performance, social distribution of wealth and purchasing power may play important roles in explaining the geographic variation of diabetes complications.

Section snippets

Research design and methods

The DiaComp study is a multi-centre study based on the WHO DiaMond study of T1D incidence registries and supplemented with the inclusion of populations of T1D subjects with longer disease duration. Inclusion criteria for subjects were T1D diagnosis <15 years of age and diabetes duration between 5 and 24.9 years. The DiaComp study collected information on complications from subjects and participating centers at two levels. Level 1 consisted of an interviewer-administered survey to subjects to

Results

Table 1 lists the prevalence of complications in DiaComp as assessed at Level 2. In the short duration group (5–14 years), reported retinopathy was high in Lithuania, Romania and Slovakia and also showed considerable variation, ranging from 0 in the UK and Italy (Ancona) to 35% in Slovakia (Bratislava), while a history of laser treatment showed similar variation. Reported and examined neuropathy were high in the central European centers of Lithuania and Romania, but also in Puerto Rico for

Discussion

This report examines the ecologic relationship between diabetes complications and several social and economic variables. It suggests that economic and health care system influences may play an important role in the global distribution of type 1 diabetes complications and diabetes care practices. To our knowledge, this is the first assessment of the association between geographically varied, population-based TID complication prevalence and the existing socioeconomic and health care conditions

Acknowledgements

This study was made possible by the volunteer efforts of the investigators listed below and their colleagues, diabetes nurses and patients, for which we are deeply grateful. We also thank Dr. S. Kelsey for statistical advice and Drs. P. Bennett, L. Franco and N. Tajima for serving on the steering committee. In addition, we would like to thank Novo Nordisk for financial and administrative support, and Bayer and Roche Diagnostics for laboratory contribution.

References (12)

  • M.G. Walsh, J. Zgibor, K. Borch-Johnsen, T.J. Orchard, on behalf of all DiaComp Investigators, A Multinational...
  • E.T. Lee et al.

    Follow-up of the WHO multinational study of vascular disease in diabetes: general description and morbidity

    Diabetologia

    (2001)
  • J. Stephenson et al.

    Microvascular and acute complications in IDDM patients: the EURODIAB IDDM complications study

    Diabetologia

    (1994)
  • A.F. Brown et al.

    Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature

    Epidemiol. Rev.

    (2004)
  • A. Nicolucci et al.

    Stratifying patients at risk of diabetic complications

    Diab. Care

    (September 1998)
  • The Economist, The Big Mac Index, available at http://www.economist.com/markets/bigmac/, September...
There are more references available in the full text version of this article.

Cited by (15)

  • Socioeconomic status. The relationship with health and autoimmune diseases

    2014, Autoimmunity Reviews
    Citation Excerpt :

    Even at a national level, SES modifications represent a change in disease incidence [164]. Non-Caucasian ancestry and low SES were associated with low incidence [165,166], but long term complications related to poor metabolic control were present in these populations [167–169]. The presence of ketoacidosis at onset of T1D in Latin Americans is notable and has been attributed, in part, to difficulties in health care access and low SES [170].

  • The assessment of clinical distal symmetric polyneuropathy in type 1 diabetes: A comparison of methodologies from the Pittsburgh Epidemiology of Diabetes Complications Cohort

    2011, Diabetes Research and Clinical Practice
    Citation Excerpt :

    However, DSP demonstrated only a sensitivity of 0.54 compared to NC-stat (SNAP), while NC-stat had a sensitivity of 0.79 for DSP. While this is consistent with NC-stat (SNAP) detecting participants with underlying disease some of whom have yet to detect symptoms, this does raise the issue as to whether nerve conduction abnormalities are always followed by significant clinical disease [33–40]. Previous NC-stat study populations have consisted of very few type 1 diabetes participants, which may account for the disparity of the results.

  • Influence of socioeconomic and psychological factors in glycemic control in young children with type 1 diabetes mellitus

    2019, Jornal de Pediatria
    Citation Excerpt :

    Haller et al.19,20 have stressed how the health team should aim beyond the measurement of blood glucose levels and preventing complications, considering also the social, economic, and psychological conditions, as well as child development. Interestingly, socioeconomic status was not a significant predictor of HbA1c; nonetheless, the present study identified an association between low economic status and poor glycemic control; the economic problems of developing countries, such as Brazil, should be considered an obstacle to intensive treatment of T1DM.20 Moreover, Walsh et al.20 found that investment and per capita spending on healthcare has an inverse correlation with levels of HbA1c and complications.

View all citing articles on Scopus
1

A list of DiaComp Investigators is provided in the Appendix A.

View full text