Prevalence of diabetes in a large, nationally representative population sample in Hungary

diabetes research and clinical practice 81 (2008) e5–e8

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Prevalence of diabetes in a large, nationally representative population sample in Hungary Eszter P. Vamos a,b, Maria S. Kopp a, Andras Keszei a, Marta Novak a,b,c, Istvan Mucsi a,b,d,* a

Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary 1st Department of Internal Medicine, Semmelweis University, Budapest, Hungary c Department of Psychiatry, University Health Network, University of Toronto, Toronto, Canada d Hungarian Academy of Sciences-Semmelweis University Research Group for Pediatrics and Nephrology, Budapest, Hungary b

article info

abstract

Article history:

We examined the prevalence of diabetes in a large, Hungarian, nationally representative

Received 25 March 2008

adult population sample. The overall prevalence of diabetes was 6.2% (95% CI: 5.7–6.6).

Accepted 29 April 2008

Increasing age and body mass index (BMI), male gender, physical inactivity, lower self-

Published on line 9 June 2008

reported financial status, hypertension and non-smoking were independently associated with diabetes. # 2008 Elsevier Ireland Ltd. All rights reserved.

Keywords: Diabetes Epidemiology Prevalence Adult Population based

1.

Introduction

Diabetes is recognized as one of the most burdensome and costly chronic diseases with increasing public health significance [1,2]. Epidemiological data on diabetes is essential for the assessment of public health impact and economic burden of the disease, identification of high-risk groups, development of prevention and screening programs and for the evaluation of disease prevention and intervention. To date no nationally representative data have been reported in Hungary and only a very few representative surveys were conducted in Eastern and Central Europe on the epidemiology of diabetes.

The purpose of the present survey was to estimate the prevalence of diabetes in Hungary in a nationally representative sample. Our secondary aim was to identify sociodemographic, medical and lifestyle factors associated with the disease.

2.

Methods

Hungarostudy 2002 was a cross-sectional survey enrolling a large, nationally representative sample of the Hungarian population over the age of 18 [3]. Participants were randomly

* Corresponding author at: Institute of Behavioral Sciences, Semmelweis University, Budapest Nagyvarad ter 4., Budapest H-1089, Hungary. Tel.: +36 1 266 0926/6457; fax: +36 1 210 1220. E-mail address: [email protected] (I. Mucsi). 0168-8227/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2008.04.022

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diabetes research and clinical practice 81 (2008) e5–e8

selected from the National Population Register by a clustered, stratified sampling procedure. All Hungarian settlements with a population of over 10,000 were included; smaller settlements were randomly sampled. For each refusal, another person was selected with similar sampling characteristics. The overall refusal rate was 17.7%. The final sample included 12,643 adults, representing 0.16% of the Hungarian population by age, gender and geographic regions. The study protocol was approved by the Ethics Committee of the Semmelweis University, Budapest. Demographic, lifestyle and self-reported medical history details were obtained in a structured home-interview. Body mass index (BMI) was classified as normal, underweight (<25 kg/m2), overweight (25 and <30 kg/m2) and obese (30 kg/m2) [4]. Alcohol consumption was estimated by the WHO’s AUDIT questionnaire (Alcohol Use Disorders Identification Test); a score of 8 indicated hazardous alcohol use [5]. Self-reported leisure time physical activity (classified as inactive, moderately active and active), smoking status (current smoker vs. non-smoker) and self-reported financial status (lower than average, average and higher than average) were also tabulated.

3.

Statistical analysis

Patient characteristics are described as frequencies or means  S.D. Group differences were compared using Pearson’s chi-square test for categorical, t-tests for normally distributed and Mann–Whitney test for skewed continuous variables. We used multivariate logistic regression model to identify risk factors of diabetes. The final model was adjusted for age, gender, BMI, hypertension, education level, self-

reported financial status, alcohol consumption, smoking, physical activity and residence. All variables in the final model contributed to the models and were retained. Statistical analyses were performed using SPSS statistical software (SPSS Inc., Version 13.0).

4.

Results

A total of 12,643 participants (5661 (44.8%) men and 6982 (55.2%) women) were included in this analysis. The overall prevalence of diabetes was 6.2% (95% confidence interval (CI): 5.7–6.6). The prevalence increased markedly with age, reached its peak in the age group of 65–74 years and decreased slightly after the age of 75 years. Elderly individuals over 60 years accounted for 59.8% and subjects over 70 years for 34.6% of all diabetic patients. Although the prevalence was similar among men and women (6.1 and 6.3%, respectively, NS), diabetes was more common in men between 35 and 64 years of age. Table 1 presents the characteristics of the survey population by sex and diabetes. People with diabetes were more likely to be overweight or obese and physically inactive, more likely to have hypertension and less likely to be smokers and hazardous alcohol users. Frequency of diabetes showed an increasing trend across tertiles of BMI (2.1, 5.5 and 10.9%, respectively). Women with better self-reported financial position and people with higher education were less likely to report diabetes. The prevalence of diabetes was similar among individuals living in urban and rural areas (6.1% vs. 6.2%, respectively, NS) regardless of sex. In multivariate logistic regression analysis, increasing age (OR(95% CI) 1.04(1.03–1.04), p < 0.001) and BMI (OR(95% CI) 1.09(1.07–1.11), p < 0.001), male gender (OR(95% CI) 1.33(1.12–

Table 1 – Characteristics of survey population by diabetes in 2002 Men, n = 5661 Diabetic Age, mean  S.D. 2

60  13.6

Women, n = 6982

Non-diabetic p-Value

Diabetic

Total, n = 12,643

Non-diabetic p-Value

45.1  16.8

<0.001

63.6  13.6

47.8  18.2

<0.001

47.6  17.8

BMI (kg/m ), mean  S.D. Normal or underweight (%) Overweight (%) Obese (%)

29.2  4.9 17.8 40.9 41.5

26.2  4.2 42.0 40.1 17.9

<0.001 <0.001

28.8  4.8 21.6 39.8 38.6

25.3  5 51.4 31.2 17.4

<0.001 <0.001

25.9  4.7 45.5 35.5 19.0

Hypertension (%) Hazardous alcohol use (%) Current smoking (%)

56.0 7.0 20.7

18.8 12.5 35.7

<0.001 0.004 <0.001

65.7 0.5 10.9

25.1 0.7 23.6

<0.001 NS <0.001

24.7 5.7 28.2

Physical activity (%) Inactive Moderately active Active

64.3 22.0 13.7

44.4 29.7 25.9

79.5 8.6 11.9

51.5 25.6 23.0

Years in education (%) 8 years 9–12 years >12 years

32.6 50.0 17.4

23.9 62.5 13.7

60.3 33.6 6.0

33.8 51.7 14.5

Self-assessed financial status (%) Lower than average Average Higher than average Urban residence (%)

41.5 45.9 12.6 63.8

38.0 46.6 15.4 61.2

50.2 45.6 4.2 60.6

40.5 47.3 12.2 63.4

<0.001

<0.001

<0.001

<0.001

NS

NS

49.8 26.6 23.6

30.6 55.5 13.9 <0.001

NS

39.9 46.9 13.2 62.5

diabetes research and clinical practice 81 (2008) e5–e8

1.58), p = 0.001), hypertension (OR(95% CI) 2.60(2.19–3.09), p < 0.001), non-smoking (OR(95% CI) 1.28(1.02–1.62), p = 0.03), physical inactivity (vs. active OR(95% CI) 1.31(1.01–1.69, p = 0.04) and worse self-reported financial status (vs. better OR(95% CI) 1.55(1.13–2.11), p = 0.006) were associated with diabetes after adjustment for education, alcohol consumption and residence. When introducing interaction terms to the logistic model, we found significant effect modification between gender and self-reported financial status ( p = 0.04). In a separate analysis, worse financial status was associated with diabetes in women (OR(95% CI) 2.2(1.31–3.84), p = 0.003), but not in men (OR(95% CI) 1.3(0.87–1.95), p = 0.2).

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has been demonstrated in several studies [18]. We did not distinguish different types of diabetes; our results are more representative of the prevalence of type 2 diabetes. The main implication of our study is that the prevalence of diabetes in Hungarostudy 2002 was much higher than previous estimations from international data predicted. Since up to half of diabetic patients may be undiagnosed, the true burden of diabetes is even larger than suggested by our results. We strongly suggest that comprehensive nationwide programs be implemented to target populations at risk and modifiable risk factors to halt the epidemic of diabetes and to improve health outcomes of the population.

Acknowledgements 5.

Discussion

The results of Hungarostudy 2002 provide the first population based, nationally representative estimates for the prevalence of diabetes in the Hungarian adult population. The few earlier studies reporting prevalence or incidence estimates of diabetes in Hungary focused on specific age groups or distinct geographic areas [6–8]. Differences in methodology, diagnostic and temporal variations make it difficult to compare our results with international data. Nevertheless, the prevalence of diabetes estimated in Hungarostudy 2002 is considerably higher than earlier extrapolations suggested, and also higher than prevalence reported from several Western- and Eastern-European populations [9–12]. Diabetes was more frequent in middle-aged men and male gender was associated with diabetes in multiple logistic regression analysis. This could be partly explained by the different distribution of risk factors between genders and the higher premature mortality of men above 65 years. Similar results were found in a primary care-based survey conducted in four Hungarian counties in 2005 [6]. Half (49.8%) of the survey population was physically inactive and 54.5% was overweight or obese. Consistent with earlier studies, these unfavorable lifestyle factors were independently associated with diabetes [13–15]. Our data call attention to the urgent need of public health prevention programs addressed to persons at risk and modifiable risk factors. People with diabetes were 2.6-fold more likely to have hypertension compared to non-diabetic individuals. Hypertension often precedes diabetes and evidence suggests that hypertension is an important risk factor for diabetes independently of adiposity [16]. Worse self-reported financial status was associated with diabetes in women but not in men. It has been suggested that self-reported financial situation is a powerful predictor of selfrated health and socioeconomic position, particularly in women [17]. Strengths of our survey include the large, non-institutionalized, nationally representative population sample, face-toface interviews and the availability of data on several key risk factors. Limitations include that all health-related estimates were based on self-report and the prevalence of these factors may be underestimated, although the accuracy of self-reports

The authors would like to thank to the other members of the ‘‘Hungarostudy 2002’’ team (Csilla Csoboth, Gyo¨rgy Gyukits, Katalin Hajdu´, Ja´nos Lo˝ ke, Andrea Odor, Ja´nos Re´thelyi, ´ rpa´d Skrabski, Adrienne Stauder, Andra´s Sa´ndor Ro´zsa, A Sze´kely and La´szlo´ Szu˝ cs) for their work and also to the network of community nurses for the home interviews, and for the National Population Register for the sample selection. Funding: This study was supported by the NKFP 1/002/2001 project, by the United Nation Development Program (UNDP) (project no. HUN/00/002/A/01/99), and the National Research Fund (OTKA) (projects no.: T-32974 (2000) and TS-040889).

Conflict of interest There are no conflicts of interest.

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