Management of Diabetes and Associated Cardiovascular Risk Factors in Seven Countries: A Comparison of Data from National Health Examination surveys/Traitement Du Diabete et Des Facteurs De Risque Cardiovasculaire Associes Dans Sept Pays: Comparaison Des Donnees D'enquetes Nationales De Sante Par examen/Tratamiento
Gakidou, Emmanuela, Mallinger, Leslie, Abbott-Klafter, Jesse, Guerrero, Ramiro, Villalpando, Salvador, Ridaura, Ruy Lopez, Aekplakorn, Wichai, Naghavi, Mohsen, Lim, Stephen, Lozano, Rafael, Murray, Christopher J. L., Bulletin of the World Health Organization
The estimated global prevalence of diabetes is around 6.4% and more than 280 million people in the world have diabetes. Of those affected, the majority live in the developing world. (1) Projections for 2010 were that diabetes would account for almost 4 million deaths worldwide. (2) The burden of diabetes will only continue to grow, since the number of adults with diabetes in developing countries is projected to rise by more than two-thirds between 2010 and 2030. (1) Previous studies have documented significant deficits in the management of individuals with diabetes. (3-8)
Five strategies can help reduce the burden of diabetes at the population level: (i) case prevention through reductions in modifiable risk factors such as obesity; (ii) screening coupled with pharmacological or lifestyle interventions targeting individuals with pre-diabetes; (9,10) (iii) improved diagnosis and control of blood glucose among individuals with diabetes; (11-13) (iv) improved management of microvascular complications, including renal disease, retinopathy, diabetic foot and other neuropathies; (l4,15) and (v) improved management of associated cardiovascular risks. (13,16) It is essential to understand how well health systems are performing in terms of these five strategies and the role of health system and individual attributes such as physical access, financial access, provider quality and patient education and motivation.
While diabetes care under specific providers is extensively examined in the literature, (17-19) there is only one previous comparative analysis of how health systems overall are responding to diabetes? In this paper we expand the range of comparisons by analysing in a consistent way surveys conducted in three developed and four developing settings. We focus the analysis on the two strategies for which data are available: (i) diagnosis and control of blood glucose, and (ii) the management of arterial blood pressure and serum cholesterol in individuals with diabetes. We explore the relationship between socioeconomic status, financial access to diabetes care and place of residence with effective management of diabetes.
Our selection of countries was opportunistic. We searched extensively for nationally representative health examination surveys that included measurements of fasting plasma glucose or glycosylated haemoglobin or haemoglobin Aic (HbA1c) as well as arterial blood pressure and serum cholesterol. We downloaded publicly available data sets from England, Scotland and the United States of America. For other countries we requested data and collaboration on this project from the institution that conducted the survey and were able to include surveys from Colombia, the Islamic Republic of Iran, Mexico and Thailand. Table 1 presents the characteristics of each survey. For all surveys except the one conducted in the Islamic Republic of Iran, sampling weights were available and were taken into account in the analysis.
Table 2 summarizes the definitions, diagnostic parameters and treatment targets for all the conditions under study. We followed the International Diabetes Federation (IDF) guidelines (26) for diagnosis and treatment values in all cases except for serum cholesterol, for which we used the guidelines of the National Institute for Health and Clinical Excellence (NICE). (27) Individuals with diabetes were categorized into four mutually exclusive groups: (i) undiagnosed, (ii) diagnosed but untreated, (iii) treated but not controlled (not meeting treatment targets), and (iv) treated and controlled (meeting treatment targets) for blood glucose, blood pressure and serum cholesterol. Our analysis was limited to medical treatment as lifestyle interventions, such as dietary changes, are not measured consistently in the household surveys.
Analysis of determinants
We used logistic regression to explore the determinants of being diagnosed, treated and controlled among individuals with diabetes, separately for each survey. …