|Year : 2022 | Volume
| Issue : 3 | Page : 161-167
Prevalence of type 2 diabetes among persons with disabilities in the South-East Asian region: A systematic review and meta-analysis
Rajeswaran Thiagesan1, Vijayaprasad Gopichandran2, Sudharshini Subramaniam3, Hilaria Soundari1, Kalpana Kosalram4
1 Centre for Applied Research, The Gandhigram Rural Institute – Deemed to be University, Dindigul, Tamil Nadu, India
2 Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India
3 Department of Community Medicine, Madras Medical College, Chennai, Tamil Nadu, India
4 School of Public Health, SRM Medical College and Hospital, SRM Institute of Science and Technology, Chengalpattu, Tamil Nadu, India
|Date of Submission||01-Mar-2022|
|Date of Decision||05-Apr-2022|
|Date of Acceptance||19-Apr-2022|
|Date of Web Publication||01-Aug-2022|
Mr. Rajeswaran Thiagesan
Centre for Applied Research, The Gandhigram Rural Institute – Deemed to be University, Gandhigram, Dindigul - 624 302, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Type 2 diabetes is a major public health burden in the South-East Asian region. Persons with disabilities have a higher predilection for developing type 2 diabetes. Objective: The objective of this study was to estimate the prevalence of type 2 diabetes among persons with physical, development, sensory, and psychiatric disabilities in the South-East Asian regional countries. Methods: The Medline database was searched through PubMed using a specifically developed search strategy to identify observational studies that looked at the prevalence of type 2 diabetes among persons with various types of disabilities. Specific inclusion–exclusion criteria were used to shortlist the most relevant studies. The AXIS tool was used to assess the risk of bias in the identified studies. Data were extracted from the final list of studies and meta-analyzed using a random-effects model. Forest plot was used to study the pooled estimate and funnel plot was studied to assess publication bias. Subgroup analysis of prevalence of diabetes among persons with psychiatric and physical disabilities was performed. Results: A total of 771 papers were identified for screening. Of them, 740 were excluded and 31 were included in the full-text review. Finally, 12 studies were included in the meta-analysis. The prevalence of type 2 diabetes among persons with disabilities was 12.8% (95% confidence interval [CI]: 8.8%–16.8%). The studies showed a wide heterogeneity. The funnel plot did not show any publication bias. Subgroup analysis showed that while the prevalence of type 2 diabetes in persons with psychiatric disabilities was 14.0% (95% CI: 9%–18.9%), it was 10.6% (95% CI: 3.6%–17.6%) among persons with other forms of physical disabilities. Conclusion: The prevalence of type 2 diabetes is high among persons with disabilities. There is a need for well-conducted systematic studies in the South-East Asian region on prevalence of type 2 diabetes among persons with disabilities.
Keywords: Disabilities, meta-analysis, prevalence, systematic review, type 2 diabetes mellitus
|How to cite this article:|
Thiagesan R, Gopichandran V, Subramaniam S, Soundari H, Kosalram K. Prevalence of type 2 diabetes among persons with disabilities in the South-East Asian region: A systematic review and meta-analysis. Curr Med Issues 2022;20:161-7
|How to cite this URL:|
Thiagesan R, Gopichandran V, Subramaniam S, Soundari H, Kosalram K. Prevalence of type 2 diabetes among persons with disabilities in the South-East Asian region: A systematic review and meta-analysis. Curr Med Issues [serial online] 2022 [cited 2022 Aug 10];20:161-7. Available from: https://www.cmijournal.org/text.asp?2022/20/3/161/352973
| Introduction|| |
Type 2 diabetes is a major public health problem in the South-East Asian Region countries. In the year 2021, close to 90 million adults with type 2 diabetes, between 20 and 79 years of age, live in the South-East Asian Region More than 50% of them are undiagnosed. The International Diabetes Federation Atlas of 2021 specifies that the age-adjusted prevalence of type 2 diabetes in this region is close to 10%. There are some unique characteristics of the epidemiology of type 2 diabetes in this South-East Asian region. This region has seen major urbanization, industrialization, and globalization in the recent years. There has been an overall increase in sedentary lifestyle and decline in food quality. These factors have contributed to the burgeoning of the epidemic of diabetes in this region. The South Asian phenotype refers to the characteristic feature of type 2 diabetes in people of this region, which presents with younger age at onset, higher levels of glycemia, early onset of complications such as neuropathy, nephropathy, and cardiovascular diseases as well as premature mortality. Taking treatment to all the people across the poor and vulnerable regions is a major challenge. Lack of adequate care and treatment predisposes these patients to higher rates of complications, morbidity, and mortality. Public health and preventive strategies are required to control the incidence and progression of diabetes in this region. This includes controlling risk factors and behavioral factors right from the preconception period, through pregnancy, childhood, adolescence, and adult life. There must be a focus on lifestyle modifications, healthy eating, staying physically active, and preventing risky behaviors such as smoking and alcohol.
Persons with disabilities form a specially vulnerable group for development of type 2 diabetes. Studies of persons with spinal cord injuries and who are immobilized have shown that they are at a higher risk of type 2 diabetes. The decreased level of physical activity and gain in weight due to spinal cord injury predisposes these patients to type 2 diabetes., There are also reports of people with intellectual disabilities having a higher risk of type 2 diabetes. Persons with mental illnesses and psychiatric disabilities also have a higher incidence of type 2 diabetes. A study from Korea showed a higher prevalence of type 2 diabetes among persons with disabilities.
Not only do persons with disabilities have a higher prevalence of diabetes, but also they suffer from difficulties in accessing health facilities for obtaining treatment for type 2 diabetes. Persons with disabilities have a higher incidence of serious health problems requiring health care, and close to 18% incidence of hospitalization, which is higher compared to the general population. Women with disabilities are particularly vulnerable and are deprived of access to health facilities for general, obstetric as well as diabetes care. Due to this lack of proper access to health care, they also suffer from higher adverse health outcomes compared to the general population.
Very little is known about the true burden of type 2 diabetes among people living with disabilities in the South-East Asian region. This information is essential to plan for diabetes care services for persons with disabilities in this region. This systematic review and meta-analysis was undertaken to estimate the prevalence of type 2 diabetes among persons with physical, development, sensory, and psychiatric disabilities in the South-East Asian regional countries.
| Methods|| |
Three of the investigators RT, VG, and SD independently searched the Medline database through PubMed to identify studies that reported the prevalence of type 2 diabetes among persons with disabilities. The search strategy used is provided in [Box 1].
Filters were later added to include only English language papers and papers within the past 20 years. All the three investigators RT, VG, and SD read the titles and abstracts of the search output obtained and assessed whether they met the inclusion and exclusion criteria. The search was conducted in January–February 2022. These criteria were as follows:
Criteria for inclusion of studies
- Community-based or hospital-based cross-sectional, case–control, retrospective, and experimental studies published between 2000 and 2021
- Studies based on data from disability registries published between 2000 and 2021
- Studies that have reported prevalence of type 2 diabetes mellitus diagnosed using either a random capillary blood, fasting blood, post glucose load plasma glucose, HbA1c, self-report of diabetes or taking medications for diabetes
- Studies conducted in the South-East Asian Region as defined by the World Health Organization regions were included. Even multicentric studies in which any SEAR country was included were also selected for inclusion in the study
- Studies that included persons with disabilities, namely physical, movement, sensory, intellectual, and mental disabilities.
Criteria for exclusion of studies
- Studies with unclear diagnostic method for the diagnosis of type 2 diabetes.
After the initial screening of titles and abstract based on these inclusion and exclusion criteria, a list of papers was prepared after reconciliation of any disagreements by HS and KK. The full-text articles of this list of papers were obtained by RT, VG, and SD and the data extraction was done. After reading the full texts of these papers, RT, VG, and SD did an assessment of risk of bias using the AXIS tool for cross-sectional studies. This tool evaluates the aims and objectives of the study, the design, sample size justification, definition of target/reference population, sampling method, categorization of nonrespondents, measurement of risk factors and outcomes, statistical analysis, and presentation of the results. We included all the extracted papers irrespective of their quality. Further, the three investigators also extracted details such as study site, country, the type of disability, severity of the disability, other risk factors for diabetes such as obesity, smoking, alcohol use, prevalence of diabetes, the 95% confidence interval (CI) of prevalence, diagnostic test used for type 2 diabetes and the total sample size that was studied. Any discrepancy in the data extraction was resolved by HS and KK.
The extracted data were entered into a Microsoft Excel spreadsheet. Using the Jamovi open source statistical software platform, the data were analyzed. Initially, the heterogeneity assessment was done by calculating Cochran's Q and I2 statistics. Based on the finding of high level of heterogeneity, a random-effects model was used to perform meta-analysis and compute the pooled estimate of prevalence of type 2 diabetes among persons with disabilities. Subgroup analysis of prevalence among persons with physical disabilities and persons with psychiatric disabilities was performed separately.
| Results|| |
The search in PubMed database returned 781 publications. Ten of them were duplicate records which were removed. Of the remaining 771 papers, 740 were excluded based on the fact that they did not report prevalence of diabetes, did not study persons with disabilities, or were not from the South-East Asian Region countries. The remaining 31 full papers were retrieved and read. Of these 31 papers, 19 did not report the prevalence of diabetes and hence were excluded. Finally, 12 papers were included in the systematic review and meta-analysis. This is shown in [Figure 1].
|Figure 1: Flowchart of article screening and inclusion in the systematic review and meta-analysis.|
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Of the 12 studies that were included, 9 were hospital based and three community based. One study was from Indonesia, one was from multiple South Asian countries, and the remaining were all studies from India. Seven were cross-sectional studies, two case–control studies, two retrospective cohort studies, and one randomized controlled trial. Only four studies measured blood glucose levels to evaluate for diabetes and the remaining studies captured either self-reported or record-based diabetes status. Eight studies were on patients with mental disabilities and four among persons with physical disabilities including rheumatoid arthritis, seizure disorders, and physical sensory and intellectual disabilities. The characteristics of the included studies are shown in [Table 1].
[Table 2] shows the risk of bias assessment of the included studies. While all studies had a clear and precisely worded research question, only two studies had a proper sample size justification. Only four studies paid attention to selecting sample in a representative manner. Nonresponse was not explored and described in any of the studies. Therefore, the risk of bias in most of the studies is high. Only three of the studies had a low risk of bias.
|Table 2: Assessment of quality of included studies using the appraisal tool for cross-sectional study tool|
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The meta-analysis using a random-effects model revealed a pooled prevalence of type 2 diabetes of 12.8% (95% CI: 8.8%–16.8%). The I2 was 97.19% indicating a very high level of heterogeneity. The Cochran's Q was 574.871, which also indicates a high level of heterogeneity.
The forest plot of the included studies is shown in [Figure 2]. [Figure 3] shows the funnel plot for assessment of publication bias. Visual inspection of the plot shows that half the studies are within the funnel and half of them outside, indicating a possibility of publication bias. However, the rank correlation test for funnel plot asymmetry showed that the Kendall's tau was 0.091 with P = 0.737. This low value indicates a lack of publication bias. The subgroup analysis of prevalence of diabetes among physical and psychiatric disabilities is shown in [Figure 4]. It is seen that while the prevalence of type 2 diabetes in persons with psychiatric disabilities was 14.0% (95% CI: 9%–18.9%), it was 10.6% (95% CI: 3.6%–17.6%) among persons with other forms of physical disabilities.
|Figure 2: Forest plot of studies reporting prevalence of type 2 diabetes among persons with disabilities.|
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|Figure 4: Subgroup analysis showing a lower prevalence of type 2 diabetes in persons with physical disabilities compared to those with psychiatric disabilities.|
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| Discussion|| |
This systematic review included 12 studies which reported type 2 diabetes among persons with disabilities. Only seven of these were cross-sectional studies and only two were community based. The other studies were not specifically designed to look at prevalence of diabetes. The number of persons experiencing diabetes was obtained from the data in the studies, but these are not necessarily prevalence studies. A detailed risk of bias assessment was performed using the AXIS tool. It was noticed that most of the studies had a high risk of bias. Therefore, the estimates are not robust. The most common methodological weaknesses in the studies were lack of proper sample size justification, lack of characterization of nonresponders, and lack of any measures to ensure representativeness of sampling. These greatly restrict the quality of the data that were available for meta-analysis.
There are some pathological mechanisms for development of metabolic abnormalities among patients who have psychiatric disabilities. A high prevalence of diabetes among persons with mental illnesses has been previously reported.,, This has been ascribed to poor dietary choices, lack of physical activity, lack of self-care among persons with serious mental illnesses as well as the metabolic effects of some medications such as antipsychotics.
Persons with physical disabilities, locomotor disabilities, and sensory disabilities may also face limitations in physical activity, dietary modifications, and access to self-care practices. This may predispose them to type 2 diabetes. Persons with physical disabilities are more likely to adopt healthy lifestyles if they have high levels of motivation, self-efficacy, and lesser physical dependence on others. A review of qualitative studies showed that persons with disabilities who have balancing difficulties, fear of falls, muscle stiffness, pains, bladder and bowel problems, and depression are least likely to adopt physical activities and healthy lifestyles. Therefore, they require support and adequate social welfare measures to engage in healthy lifestyles, which in turn will prevent type 2 diabetes. However, such circumstances and situations are less likely among persons with disabilities in poor and marginalized settings.
This systematic review and meta-analysis showed that the prevalence of type 2 diabetes is about 12.8% in this region among persons with disabilities, while it is only about 9% in the general population. Despite the significant heterogeneity of the studies that were included in the analysis and the high risk of bias of the included studies, this study does indicate that there is a trend toward higher prevalence of type 2 diabetes among persons with disabilities compared to the general population. Therefore, special measures are required for this vulnerable group to prevent and provide care for type 2 diabetes.
Persons with disability have poor access to health care. Geographical barriers, distance, lack of transportation facilities, noninclusive transportation, and nonaffordability of transportation were common reasons for limited access to health care. Therefore, they have barriers to accessing preventive as well as treatment services for type 2 diabetes. With the high prevalence as shown in this review, there is a need to prepare the public health system in these South-East Asian regions to make diabetes care more accessible to persons with disabilities. It is not sufficient if the public health system in these countries just focuses on treatment and provision of diabetes medications to persons with disabilities. Preventive services, disability-friendly lifestyle modifications, information, education, and communication related to healthy living specific to persons with disabilities and access to laboratory and other monitoring services must also be made accessible to them.
Article 25 of the United Nations Convention on the Rights of Persons with Disabilities states that every person with disability has the right to attain the highest standard of health.  Diabetes care and preventive services are essential given the context of high prevalence of diabetes in this region as well as increased prevalence among persons with disabilities as seen in this study.
This systematic review and meta-analysis is the first of its kind looking at prevalence of diabetes in this especially vulnerable group of persons with disabilities in the South-East Asian region. There are a few limitations in this review. The search was done using only a single database, namely Medline through PubMed. Since the other databases were not accessible to the researchers of this study, either individually or through their respective institutions, this limited the choice of databases that could be searched. As the number of prevalence studies which specifically looked at prevalence of type 2 diabetes among persons with disabilities was very low, this study resorted to obtaining diabetes rates from even case–control, cohort studies and randomized controlled trials. These studies are not designed to estimate prevalence.
| Conclusion|| |
This systematic review and meta-analysis revealed that there is a pattern of higher prevalence of type 2 diabetes among persons with disabilities. Although the included studies had a high degree of heterogeneity, the finding of a greater prevalence of type 2 diabetes cannot be ignored. This systematic review was also limited by the lack of good quality studies to estimate the prevalence of type 2 diabetes among persons with disabilities, and therefore, there is a need to do large-scale systematic prevalence studies to estimate the prevalence across different regions in these countries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]