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AIMS: Development of non-invasive and minimally invasive glucose monitoring devices (NI-MI-GMDs) generally takes place in high-income countries (HICs), with HIC's attributes guiding product characteristics. However, people living with diabetes (PLWD) in low-income and middle-income countries (LMICs) encounter different challenges to those in HICs. This study aimed to define requirements for NI-MI-GMDs in LMICs to inform a target product profile to guide development and selection of suitable devices. METHODS: This was a multiple-methods, exploratory, qualitative study conducted in Kyrgyzstan, Mali, Peru and Tanzania. Interviews and group discussions/activities were conducted with healthcare workers (HCWs), adults living with type 1 (PLWD1) or type 2 diabetes (PLWD2), adolescents living with diabetes and caregivers. RESULTS: Among 383 informants (90 HCW, 100 PLWD1, 92 PLWD2, 24 adolescents, 77 caregivers), a range of differing user requirements were reported, including preferences for area of glucose measurement, device attachment, data display, alert type and temperature sensitivity. Willingness to pay varied across countries; common requirements included ease of use, a range of guiding functions, the possibility to attach to a body part of choice and a cost lower than or equal to current glucose self-monitoring. CONCLUSIONS: Ease-of-use and affordability were consistently prioritised, with broad functionality required for alarms, measurements and attachment possibilities. Perspectives of PLWD are crucial in developing a target product profile to inform characteristics of NI-MI-GMDs in LMICs. Stakeholders must consider these requirements to guide development and selection of NI-MI-GMDs at country level, so that devices are fit for purpose and encourage frequent glucose monitoring among PLWD in these settings.
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Países em Desenvolvimento , Diabetes Mellitus Tipo 2 , Adulto , Adolescente , Humanos , Diabetes Mellitus Tipo 2/terapia , Tanzânia , Quirguistão , Mali , Peru , Automonitorização da Glicemia , GlicemiaRESUMO
INTRODUCTION: SARS-CoV-2 has impacted globally the care of chronic diseases. However, direct evidence from certain vulnerable communities, such as Indigenous communities in Latin America, is missing. We use observational data from a health district that primarily serves people of Maya K'iche' ethnicity to examine the care of type 2 diabetes in Guatemala during the pandemic. METHODS: We used a parallel convergent mixed methods design. Quantitative data (n=142 individuals with diabetes) included glycated haemoglobin (HbA1c), blood pressure, body mass index and questionnaires on diabetes knowledge, self-care and diabetes distress. Quantitative data was collected at two points, at baseline and after COVID restrictions were lifted. For quantitative outcomes, we constructed multilevel mixed effects models with multiple imputation for missing data. Qualitative data included interviews with providers, supervisors and individuals living with diabetes (n=20). We conducted thematic framework analysis using an inductive approach. RESULTS: Quantitative data was collected between June 2019 and February 2021, with a median of 487 days between data collection points. HbA1c worsened +0.54% (95% CI, 0.14 to 0.94) and knowledge about diabetes decreased -3.54 points (95% CI, -4.56 to -2.51). Qualitatively, the most important impact of the pandemic was interruption of the regular timing of home visits and peer group meetings which were the standard of care. CONCLUSIONS: The deterioration of diabetes care was primarily attributed to the loss of regular contact with healthcare workers. The results emphasize the vulnerability of rural and Indigenous populations in Latin America to the suspension of chronic disease care.
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COVID-19 , Diabetes Mellitus Tipo 2 , Humanos , COVID-19/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/terapia , SARS-CoV-2 , Hemoglobinas Glicadas , Guatemala/epidemiologiaRESUMO
OBJECTIVES: Over 40 million people in low-income and middle-income countries (LMICs) experience serious health-related suffering (SHS) annually and require palliative care. Patient and caregiver experiences of SHS in LMICs are understudied despite their importance in guiding palliative care provision. Diabetes and cancer are the second-leading and third-leading causes of death in Mexico, causing a significant SHS burden on patients, families and health systems. This study examines SHS and palliative care from the point of view of patients with cancer and diabetes and their caregivers. DESIGN: A qualitative descriptive study based on in-depth telephone interviews was conducted between August 2021 and February 2022. Data were analysed through inductive thematic analysis. PARTICIPANTS: Overall, 20 patients with end-stage cancer, 13 patients with diabetes and 35 family caregivers were interviewed individually. SETTING: Participants were recruited from two family medicine clinics and a pain clinic in Mexico City. RESULTS: Seven themes emerged: (1) suffering as a multifaceted phenomenon, (2) diversity in perceptions of suffering, (3) different coping strategies, (4) need and perceived importance of relief from suffering, (5) barriers to accessing services to relieve suffering, (6) demand for the health sector's active and humane role in addressing suffering and (7) preferences and need for comprehensive care for relief from suffering. The primary coping strategies included family companionship, protective buffering and faith-based support. Participants lacked knowledge of palliative care. They expressed the importance of relief from suffering, viewing it as the health sector's responsibility and requesting more humane, personalised care and access to medicines and pain clinics. CONCLUSIONS: The multifaceted nature of SHS highlights the health system's responsibility to provide high-quality palliative care. Policies to enhance access to palliative care should integrate it into primary care, redesigning services towards patient and caregiver biopsychosocial and spiritual needs and ensuring access to medicines and competent health personnel.
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Diabetes Mellitus , Neoplasias , Humanos , Cuidados Paliativos/métodos , Cuidadores/psicologia , México , Motivação , Pesquisa Qualitativa , Neoplasias/terapia , Diabetes Mellitus/terapiaRESUMO
OBJECTIVE: COVID-19 would kill fewer people if health programmes can predict who is at higher risk of mortality because resources can be targeted to protect those people from infection. We predict mortality in a very large population in Mexico with machine learning using demographic variables and pre-existing conditions. DESIGN: Cohort study. SETTING: March 2020 to November 2021 in Mexico, nationally represented. PARTICIPANTS: 1.4 million laboratory-confirmed patients with COVID-19 in Mexico at or over 20 years of age. PRIMARY AND SECONDARY OUTCOME MEASURES: Analysis is performed on data from March 2020 to November 2021 and over three phases: (1) from March to October in 2020, (2) from November 2020 to March 2021 and (3) from April to November 2021. We predict mortality using an ensemble machine learning method, super learner, and independently estimate the adjusted mortality relative risk of each pre-existing condition using targeted maximum likelihood estimation. RESULTS: Super learner fit has a high predictive performance (C-statistic: 0.907), where age is the most predictive factor for mortality. After adjusting for demographic factors, renal disease, hypertension, diabetes and obesity are the most impactful pre-existing conditions. Phase analysis shows that the adjusted mortality risk decreased over time while relative risk increased for each pre-existing condition. CONCLUSIONS: While age is the most important predictor of mortality, younger individuals with hypertension, diabetes and obesity are at comparable mortality risk as individuals who are 20 years older without any of the three conditions. Our model can be continuously updated to identify individuals who should most be protected against infection as the pandemic evolves.
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COVID-19 , Hipertensão , Humanos , Adulto , Adulto Jovem , SARS-CoV-2 , México/epidemiologia , Estudos de Coortes , Obesidade , Análise Fatorial , Hipertensão/epidemiologia , Aprendizado de MáquinaRESUMO
OBJECTIVE: Overweight and obesity are important contributors to the non-communicable disease burden. The consumption of sugar-sweetened beverages (SSBs) has been associated with an increased risk of type 2 diabetes mellitus (T2DM), cardiovascular disease, cancer and other conditions. The objective of this study was to estimate the burden of disease attributable to the consumption of SSBs and the costs to the healthcare systems in Argentina, Brazil, El Salvador, and Trinidad and Tobago. DESIGN: Following a systematic review of models, a comparative risk assessment framework was developed to estimate the health and economic impact associated with the consumption of SSBs. SETTING: Argentina, Brazil, El Salvador, and Trinidad and Tobago. PARTICIPANTS: Overall population. PRIMARY AND SECONDARY OUTCOME MEASURES: The model estimated the effects of SSB consumption on health through two causal pathways: one mediated by body mass index (BMI) and health conditions associated with BMI and another that reflected the independent effects of SSB consumption on T2DM and cardiovascular diseases. RESULTS: The model results indicated that for all four countries, in 1 year, SSB consumption was associated with 18 000 deaths (3.2% of the total disease-related deaths), seven million disease events (3.3% of the total disease-related events), a half-million DALYs and US$2 billion in direct medical costs. This included 1.5 million cases of overweight and obesity in children/adolescents (12% of the excess weight cases) and 2.8 million cases in adults (2.8%); 2.2 million cases of type 2 diabetes (19%); 200 000 cases of heart disease (3.8%); 124 000 strokes (3.9%); 116 000 cases of musculoskeletal disease (0.2%); 102 000 cases of kidney disease (0.9%); and 45 000 episodes of asthma (0.4%). The Trinidad and Tobago population were the most affected by disease events. CONCLUSIONS: The study results indicate that the consumption of SSBs is associated with a significant burden of disease and death in Latin America and the Caribbean.
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Diabetes Mellitus Tipo 2 , Obesidade Infantil , Bebidas Adoçadas com Açúcar , Adulto , Criança , Adolescente , Humanos , Bebidas Adoçadas com Açúcar/efeitos adversos , Diabetes Mellitus Tipo 2/epidemiologia , América Latina , Sobrepeso , Efeitos Psicossociais da Doença , BebidasRESUMO
OBJECTIVE: The burden of diabetes mellitus is increasing in low-income and middle-income countries (LMICs). Few studies have explored pathways to care among individuals with diabetes in LMICs. This study evaluates care trajectories among adults with diabetes in rural Guatemala. DESIGN: A qualitative investigation was conducted as part of a population-based study assessing incidence and risk factors for chronic kidney disease in two rural sites in Guatemala. A random sample of 807 individuals had haemoglobin A1c (HbA1c) screening for diabetes in both sites. Based on results from the first 6 months of the population study, semistructured interviews were performed with 29 adults found to have an HbA1c≥6.5% and who reported a previous diagnosis of diabetes. Interviews explored pathways to and experiences of diabetes care. Detailed interview notes were coded using NVivo and used to construct diagrams depicting each participant's pathway to care and use of distinct healthcare sectors. RESULTS: Participants experienced fragmented care across multiple health sectors (97%), including government, private and non-governmental sectors. The majority of participants sought care with multiple providers for diabetes (90%), at times simultaneously and at times sequentially, and did not have longitudinal continuity of care with a single provider. Many participants experienced financial burden from out-of-pocket costs associated with diabetes care (66%) despite availability of free government sector care. Participants perceived government diabetes care as low-quality due to resource limitations and poor communication with providers, leading some to seek care in other health sectors. CONCLUSIONS: This study highlights the fragmented, discontinuous nature of diabetes care in Guatemala across public, private and non-governmental health sectors. Strategies to improve diabetes care access in Guatemala and other LMICs should be multisectorial and occur through strengthened government primary care and innovative private and non-governmental organisation care models.
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Diabetes Mellitus , Humanos , Adulto , Guatemala/epidemiologia , Hemoglobinas Glicadas , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Fatores de Risco , Pesquisa QualitativaRESUMO
INTRODUCTION: The Food Frequency Questionnaire is one of the most widely used tools for estimating nutritional intake in epidemiological studies. No study has been systematically performed to comprehensively explore Food Frequency Questionnaires designed, developed and validated specifically for the diabetic population (FFQs-DDV-DiaP). Therefore, a systematic review and meta-analysis will be carried out in order to identify and describe FFQs-DDV-DiaP; to examine their design, development, validity and reproducibility; as well as to estimate the overall degree of correlation and agreement; and to evaluate the factors that affect them. METHODS AND ANALYSIS: A systematic literature review will be performed in PubMed/MEDLINE, Scopus and Web of Science to find potentially relevant studies. Original studies related to the design, development, as well as the assessment of the validity and reproducibility of FFQs-DDV-DiaP; reported in English or Romance languages will be selected. Independent reviewers will select studies, extract relevant data and assess FFQs-DDV-DiaP quality. Data will be pooled using the generic inverse-variance method with random-effects models and expressed as correlation coefficients or mean differences with 95% CIs to examine the global validity and reproducibility of FFQs-DDV-DiaP. Heterogeneity will be evaluated by the Cochran Q-statistic and quantified by the I2 statistic. Stratified analyses and random-effects meta-regressions will be performed to explore heterogeneity and whether any covariate influences the effect sizes. Finally, publication bias will be assessed through the Begg's and Egger's tests. ETHICS AND DISSEMINATION: This systematic review and meta-analysis will not use confidential personal data. Therefore, the requirement of ethical approval or informed consent is not necessary. The results of this review will be disseminated only in peer-reviewed publications or at relevant scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42021268575.
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Diabetes Mellitus , Humanos , Metanálise como Assunto , Reprodutibilidade dos Testes , Literatura de Revisão como Assunto , Inquéritos e Questionários , Revisões Sistemáticas como AssuntoRESUMO
OBJECTIVES: Assess values, preferences and burden of treatment that patients with type 2 diabetes consider when initiating glucagon-like peptide-1 receptor agonists (GLP-1 RA) or sodium-glucose cotransporter-2 inhibitors (SGLT-2i) compared with other glucose-lowering options. METHODS: Paired reviewers independently included studies reporting quantitative or qualitative methods to assess values, preferences and burden of treatment reported by patients with type 2 diabetes regarding the initiation of GLP-1 RA or SGLT-2i over other alternatives. A systematic search in MEDLINE, Scopus, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials from inception until May 2020 was performed by an experienced librarian. Risk of bias was assessed with a specifically designed tool for values and preferences studies. RESULTS: 17 studies (7296 patients) proved eligible. Studies fulfilling criteria for SGLT-2i were not identified. Five studies (2662 patients) evaluated preferences for GLP-1 RA compared with other glucose-lowering medications. 12 studies (4634 patients) evaluated preferences between, at least, two kinds of GLP-1 RA or their injection devices based on the following attributes: efficacy, dose, application frequency, device characteristics. Among studies comparing GLP-1 RA to other glucose-lowering medications, some preferences were observed for dypeptil peptidase-4 inhibitors compared with once daily liraglutide. Comparing different attributes of GLP-1 RA drugs and devices, cardiovascular risk reduction, glucose lowering potential, once weekly and simple administered regimens were the most preferred. CONCLUSIONS: As no evidence for preferences on SGLT-2i was available, only preferences for GLP-1 RA were assessed; however, evidence is still limited for the latter. Studies comparing preferences for GLP1-RA to other glucose-lowering alternatives only included twice daily or once daily injection regimens of GLP-1 RA drugs. According to our findings, once weekly alternatives are widely preferred than the formers. The extent to which patients with type 2 diabetes value reduced adverse cardiovascular and kidney outcomes, weighed benefits against harms and burden of treatment is limited and with very low certainty. PROSPERO REGISTRATION NUMBER: CRD42020159284.
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Diabetes Mellitus Tipo 2 , Preparações Farmacêuticas , Inibidores do Transportador 2 de Sódio-Glicose , Adulto , Diabetes Mellitus Tipo 2/tratamento farmacológico , Receptor do Peptídeo Semelhante ao Glucagon 1 , Humanos , Hipoglicemiantes/uso terapêutico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêuticoRESUMO
OBJECTIVES: Our study aimed to assess social inequality trends for hypertension, diabetes mellitus, smoking and obesity from 2007 to 2018 in adults from Brazilian capitals. SETTING: Data from the Surveillance of Risk and Protection Factors for Chronic Diseases by Telephone Survey study, a cross-sectional telephone survey, conducted annually from 2007 to 2018. PARTICIPANTS: We used data from 578 977 Brazilian adults (≥18 years). DESIGN: Cross-sectional surveys conducted annually from 2007 to 2018. PRIMARY OUTCOME MEASURES: Participants responded to a questionnaire about medical diagnosis of hypertension and diabetes, smoking status, weight and height. Educational inequalities (0-3, 4-8, 9-11 and 12 or more years of study) by sex and skin colour were assessed trough absolute, Slope Index of Inequality (SII) and relative measures of inequality, Concentration Index and trends were tested by Prais-Winsten. RESULTS: All outcomes were more prevalent in the least educated. The largest absolute educational inequality was observed for hypertension (SIItotal=-37.8 in 2018). During 2007-2018, the total educational disparity remained constant for hypertension, increased for diabetes and smoking, and decreased for obesity. Overall, inequality was higher among women and non-whites, compared with men and whites. We found a reduction in absolute inequality for hypertension among non-whites, an increase for diabetes in all strata, and an increase for smoking in women and non-whites. The relative inequality decreased in women and whites and increased for smoking in all strata, except among men. CONCLUSION: The educational inequality reduced for obesity, remained constant for hypertension and increased for diabetes and smoking from 2007 to 2018 in Brazilian adults.
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Diabetes Mellitus , Hipertensão , Adulto , Brasil/epidemiologia , Estudos Transversais , Diabetes Mellitus/epidemiologia , Escolaridade , Feminino , Disparidades nos Níveis de Saúde , Humanos , Hipertensão/epidemiologia , Masculino , Obesidade/epidemiologia , Prevalência , Fumar/epidemiologia , Fatores SocioeconômicosRESUMO
OBJECTIVES: Diabetes is increasing rapidly in low-income and middle-income countries. We aimed to estimate the prevalence of diabetes, describe its correlates and its associated dietary intake in urban adults from Colombia. SETTING: The Colombian Study of Nutritional Profiles was a population-based, cross-sectional, multi-stage probabilistic sampling survey designed to represent the five main Colombian cities. PARTICIPANTS: Between June and November 2018, we studied 736 non-pregnant participants aged 18 or older. Diabetes was defined as a random plasma glucose ≥200 mg/dL, self-reported prior diagnosis of diabetes or use of any oral or injectable antidiabetic medication(s). Participants also fulfilled a detailed 157-item food-frequency questionnaire. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of diabetes, dietary intake of key nutrients, achievement of dietary goals among individuals with diabetes. RESULTS: The overall estimated prevalence of diabetes was 10.1%, with no difference by sex (9.6% in women, 10.8% in men, p=0.43). The association between diabetes and education level depended on sex, diabetes was more prevalent among more educated men and less educated women. Abdominal obesity was associated with a 65% increase in diabetes prevalence among men, and a 163% increase in women. Individuals with diabetes reported lower mean consumption of all nutrients, but after adjustment by sex, age, socioeconomic level (SEL) and body mass index, only their lower sodium consumption remained significant (p=0.013). The proportion of non-achievement of dietary intake goals among participants with diabetes was 94.4% for saturated fats, 86.7% for sodium, 84.4% for fibre and 80% for trans fats. In multivariate logistic regression models, age was the strongest independent correlate of diabetes. CONCLUSIONS: Diabetes by self-report, random plasma glucose or medication use was highly prevalent among Colombian adults. There were large differences by abdominal obesity status, region of residence, SEL and educational level. The proportion of individuals with diabetes meeting dietary recommendations was alarmingly low.