Bmi and gender as mediators in the association between ethnicity and glycemic control in primary healthcare settings: Malaysia national diabetes registry cohort / Eliana Ahmad
Background: The prevalence of type 2 diabetes continues to escalate across all ethnic groups in Malaysia. Evidence on ethnic differences among Asian population mostly focused on the incidence and prevalence of diabetes, rather than on glycaemic control. Poor glycemic control leads to development...
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| Format: | Thesis |
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2019
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| Online Access: | http://studentsrepo.um.edu.my/11435/4/eliana.pdf http://studentsrepo.um.edu.my/11435/ |
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| Summary: | Background: The prevalence of type 2 diabetes continues to escalate across all
ethnic groups in Malaysia. Evidence on ethnic differences among Asian population
mostly focused on the incidence and prevalence of diabetes, rather than on glycaemic
control. Poor glycemic control leads to development of diabetes-related complications.
The association between ethnicity and glycemic control was investigated. The roles of
sex and body mass index (BMI) as mediators were assessed. We also determined the
association between ethnicity and diabetes-related complications. Methods: A
retrospective cohort study involving 338,349 primary care patients registered in the
Malaysian National Diabetes Registry (NDR) between 2011 and 2015 was conducted.
All major ethnic groups were included (Malays, Chinese, Indian, Indigenous Sabah
[consisted of Kadazan, Dusun, Bajau and Other Sabah] and Indigenous Sarawak
[consisted of Iban, Bidayuh, Melanau and Other Sarawak]). Linear mixed effect model
with random intercept and logistic random intercept models were used to analyze crosssectional associations (defined as glycemic control at five years of diabetes) and
longitudinal associations (defined as glycemic control for every five years of diabetes).
Generalized structural equation modeling (GSEM) was used to conduct mediation
analysis, and discrete-time survival analysis was used to determine the hazard of
diabetes-related complications. Results: Ethnicity was significantly associated with
HbA1c level. Cross-sectionally, all ethnicities were significantly associated with lower
HbA1c level compared to the Malays. In the longitudinal associations, the HbA1c levels
changed by 0.1% among Chinese and Indian, 0.24% among Dusun and 0.12% among
Indigenous Sarawak, compared to the Malays [Chinese and Indian: β= -0.10 (95%CI -
0.13, -0.07), Dusun: β= 0.24 (95%CI 0.07, 0.41), Indigenous Sarawak: β= 0.12 (95%CI
0.01, 0.22)]. Compared to Malays, the odds of good glycemic control increased by 20%
among the Indians and 7% among the Chinese [Indian: OR 1.20 (95%CI 1.13, 1.28),
iv
Chinese: OR 1.07 (95%CI 1.01, 1.12)], while among the Indigenous Sabah and
Indigenous Sarawak, the odds decreased by 14% and 20% [Indigenous Sabah: OR 0.86
(95%CI 0.75, 0.99), Indigenous Sarawak OR 0.80 (95%CI 0.65, 0.98)]. Sex mediated
the association between Chinese, Indian and Iban ethnicities and HbA1c level [Indirect
associations: Chinese (0.7%), Indian (1.1%) and Iban (0.1%)]. BMI mediated the
association between Chinese, Indian, Bajau, Iban and Melanau and HbA1c level
(Indirect associations ranged from 0.1% to 7.0%). Compared to Malays, Indian ethnicity
was associated with significantly increased hazard of diabetic retinopathy and peripheral
vascular disease (PVD) [Retinopathy: HR 1.18 (95%CI 1.13, 1.23), PVD: HR 1.11
(95%CI 1.00, 1.22)]. Chinese, Bajau, and Other Sabah had an increased hazard of
diabetic retinopathy [Chinese: 23%, Bajau: 93%, Other Sabah: 115%] and a decreased
hazard of diabetic nephropathy [Chinese: 5%, Bajau: 51%, Other Sabah: 32%] and PVD
[Chinese: 33%, Bajau: 67%, Other Sabah: 63%]. The Ibans had significantly decreased
hazard for all three diabetes-related complications [Retinopathy: HR 0.62 (95%CI 0.52,
0.75), Nephropathy: HR 0.68 (95%CI 0.58, 0.79), PVD: HR 0.58 (95%CI 0.36, 0.92)].
Conclusion: Ethnicity appears to be a significant predictor of glycemic control, and
diabetes-related complications. These associations are mediated by sex, and BMI. In
multi-ethnic settings like Malaysia, health programs aiming for early detection of
diabetes, improvement of health literacy in diabetes for better glycemic control,
prevention of diabetes-related complications, and provision of supportive care should be
tailored according to ethnic groups. Future studies should examine the potential
mediating role of other lifestyle factors in the control of diabetes. |
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