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Diabetes-related social functioning worse in middle-, low-income countries

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January 12, 2018

Adrian Loerbroks
Adrian Loerbroks

Adults with diabetes living in middle- and low-income countries experience impaired social functioning to a greater degree than those living in high-income countries, in part due to delayed diabetes diagnoses and less access to adequate medical care, according to data from the World Health Survey.

“We found that diabetes is associated with impaired social functioning, which was defined by difficulties with participation in the community or with personal relationships,” Adrian Loerbroks, PhD, MSc, MHS, of the Institute of Occupational, Social and Environmental Medicine at the University of Dusseldorf, Germany, told Endocrine Today. “We also found that association both in high- and middle-income countries, but the link was particularly strong in low-income countries. Those associations were largely explained by physical and mental impairments, which may be due to diabetes, such as mood problems, poor vision or reduced mobility.”

Loerbroks and colleagues analyzed data from the cross-sectional World Health Survey, carried out in 2002-2003 in 70 countries across Africa, Asia, Australia, Europe and South America. In this study, researchers assessed national samples from 48 of the surveyed countries and stratified nations by income level: 10 low-income countries (n = 44,285), 15 lower middle-income countries (n = 81,573), 14 upper middle-income countries (n = 91,307) and nine high-income countries (n = 18,263). Diabetes was self-reported by participants completing questionnaires; social functioning was measured using a module that assessed limitations in eight different life domains, including mobility, self-care, pain/discomfort, subjective cognitive deficits and interpersonal activities. Potential diabetes-related impairments, including impairments in vision, mood, cognition and mobility, were also measured. Researchers used logistic regression analysis to estimate ORs for the association between reports of diagnosed diabetes and impaired social functioning.

The overall sample included mostly middle-aged adults. Across countries, 3.5% reported a diagnosis of diabetes and 14.6% had obesity, whereas 11.4% reported problems with mood, cognition and mobility. Poor social functioning and vision problems were less prevalent (6.8% and 8%, respectively), according to researchers, who also observed that the prevalence of diabetes, obesity and mobility increased with country income levels.

In unadjusted analyses, diagnosed diabetes was associated with more than double the risk for impaired social functioning (OR = 2.07; 95% CI, 1.74-2.46), with the risk falling slightly when adjusting for sociodemographic factors and health-related lifestyles (OR = 1.47; 95% CI, 1.18-1.83). However, this association between diabetes and poor social functioning was no longer significant after accounting for diabetes-related impairments, according to researchers.

In unadjusted analyses stratified by country income levels, researchers found that the association between self-reported diabetes and poor social functioning declined with increasing country income level, with the OR falling from 3 in low-income countries to 2.5 in lower middle-income countries and 2 in upper middle- and high-income countries. The ORs were attenuated after adjustment for age, sex, education, BMI and physical activity; however, the observed gradient persisted, according to researchers. No gradient was observed after accounting for potential diabetes-related impairments.

“Our study highlights the potential social impact of living with diabetes,” Loerbroks said. “However, one needs to bear in mind that our study had a cross-sectional design, and thus we cannot draw conclusions regarding potential causality.”

Loerbroks said the observations further highlight the importance of directing scarce health care resources to the adequate management of diabetes, especially within low-income settings.

“Such efforts will not only help to prevent complications, but may also reduce the impact of diabetes on the social functioning and participation of patients,” he said. – by Regina Schaffer

For more information:

Adrian Loerbroks, PhD, MSc, MHS, can be reached at the Institute of Occupational, Social and Environmental Medicine, Centre for Health and Society, Faculty of Medicine, University of Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany; email:

Disclosures: The authors report no relevant financial disclosures.