Original article
Estimation of diabetes prevalence among immigrants from the Middle East in Sweden by using three different data sourcesÉvaluation de la prévalence du diabète sucré chez des immigrants du Moyen-Orient en Suède à partir de trois sources différentes de données

https://doi.org/10.1016/j.diabet.2008.01.012Get rights and content

Abstract

Aims

To estimate diabetes prevalence in immigrants from the Middle East in Sweden compared with Swedish-born subjects. This group accounts for around 15% of Sweden's non-European immigrants.

Methods

Three samples were used: self-reported diabetes in a random sample (SALLS sample) of subjects aged 35–64 years in Sweden (n = 22,032); known diabetes among patients aged 35–64 years in primary care (PC) at four primary healthcare centers in Stockholm County (n = 30,679); and known and newly diagnosed diabetes in a random population sample of subjects aged 60 years in Stockholm County (n = 4106).

Results

The odds ratio (OR) for subjects from the Middle East was: 1.69 (95% confidence interval [CI] 0.96–2.99) in the SALLS sample; 4.43 (95% CI 3.38–5.56) in the PC sample; and 3.96 (95% CI 1.98–7.92) in the age-60 sample, compared with native Swedes. Subjects from European and other Organization for Economic Cooperation and Development (OECD) countries showed an excess risk only in the SALLS sample (1.43, 95% CI 1.11–1.83).

Conclusions

Immigrants from the Middle East showed a four-fold higher risk of diabetes compared with Swedish-born subjects in two of the three data sources. More studies are needed to confirm these results, but the findings call for targeted preventative strategies in this population group.

Résumé

Cette étude transversale avait pour but d’évaluer la prévalence du diabète sucré chez des sujets originaires du Moyen-Orient vivant en Suède, menée dans trois échantillons, le premier pris au hasard parmi la population suédoise âgée de 35 à 64 ans au cours des années 1998–2005 (n = 22 032), le deuxième parmi la population âgée de 35 à 64 ans de quatre centres de santé primaires du département de Stockholm (n = 30 679) et le troisième pris au hasard dans la population générale âgée de 60 ans du département de Stockholm (n = 4106). Les sujets atteints de diabète sucré ont été identifiés dans le premier échantillon par autodéclaration, dans le deuxième à partir des registres et dans le troisième par autodéclaration et par dosages au laboratoire. La prévalence du diabète sucré était élevée chez les sujets originaires du Moyen-Orient, avec dans le premier échantillon un rapport de cote [odds ratio (OR)] de 1,69 (IC à 95 % 0,96–2,99), dans le deuxième de 4,43 (IC 95 % 3,38–5,56) et dans le troisième de 3,96 (IC 95 % 1,98–7,92). En conclusion, la prévalence du diabète sucré est plus élevée en Suède chez les immigrants venus des pays du Moyen-Orient par comparaison à la population née en Suède.

Introduction

Diabetes prevalence differs among ethnic groups, with a higher prevalence among some immigrant groups in European countries, such as South Asian immigrants in the UK [1], [2], immigrants from Surinam, Turkey and Morocco in the Netherlands [3], [4], and Lebanese and Turkish immigrants in Denmark [5]. In a review by Misra and Ganda, it was suggested that environmental factors played a critical role in conferring an increased risk of obesity and, thus, type-2 diabetes as well [6]. The important contributory factors to this phenomenon are urbanization, mechanization, and changes in nutrition and lifestyle behaviors, with an uncertain role for stress and other possible factors.

Foreign-born residents in Sweden now comprise 12% of the Swedish population [7]. A large proportion (41%) of immigrants in Sweden are of non-European origin, and those from the Middle East — in particular, Turkey, Lebanon, Syria, Iraq and Iran — constitute 15% of all foreign-born citizens and is the largest group of non-European immigrants in Sweden. A higher prevalence of diabetes among immigrants of non-European origin has recently been described [8], [9], [10]. In addition, an increased rate of self-reported diabetes has been seen in Turkish-born women [11].

Diabetes prevalence can be assessed in several ways. The diagnosis may be self-reported to estimate diabetes prevalence in countries [12] or ethnic groups [13]. This, however, will underestimate the true burden of diabetes [14]. Another way is through healthcare sources such as primary-care physicians [15], or by combining primary-care and secondary-care source data [16]. However, simply using record-linking will again underestimate the prevalence compared with the use of capture–recapture methods [16]. A third way is to carry out population-based screening, either in whole countries [17] or in specific regions of countries [18]. This allows subjects with an unknown diagnosis of diabetes to also be identified — which comprises around half of all cases [19]. Yet other ways include the use of data based on prescriptions of antidiabetic drugs [20], although this, too, will underestimate the true prevalence of diabetes by not including unknown or undiagnosed cases.

The aim of this study was to estimate the prevalence of diabetes among immigrants from the Middle East compared with Swedish-born subjects, using different study populations. A secondary aim was to compare the results derived from different data sources.

Section snippets

Study populations

The first study source population was a simple random sample of 22,032 men and women, aged 35–64 years, who had participated in the Swedish Annual Level of Living Survey (SALLS), 1998–2005. The age interval was used to match the second sample. The participants were interviewed face-to-face by trained interviewers about their living conditions, including detailed information on social, lifestyle and health indicators. The mean response rate was 79% for the Swedish-born subjects and 68% for the

Results

Demographic data from the three studies are shown in Table 1 by area of origin and gender. The age-standardized prevalence of diabetes is shown in Table 2. In total, the age-standardized prevalence was 2.8% in the SALLS sample, 2.3% in the PC sample and in the 60-year cohort, 4.5% for known diabetes and 7.3% for all diabetes. Altogether, 45 patients were classified as type-1 diabetes (6.8%) in the PC sample, with 38 in the Swedish-born group (8.9%), four in the Europe + OECD (4.8%), none in the

Discussion and conclusion

A higher prevalence of diabetes was found among immigrants from the Middle East in the PC sample and 60-year cohort. In the SALLS sample, a slightly higher, non-significant, prevalence was found.

These findings are supported by other studies, such as the Danish study reporting a five-fold greater prevalence of diabetes among immigrants from Lebanon and Turkey in Denmark [5], and an earlier Swedish study showing a three-fold higher prevalence of diabetes among female immigrants from Turkey [11].

Acknowledgements

The authors gratefully acknowledge Merja Heinonen and Gunnel Gråbergs for their skilful assistance. This study was supported by grants from the Stockholm County Council, Karolinska Institutet, the Swedish Diabetes Association, the Swedish Heart and Lung Foundation, the Swedish Council for Working Life and Social Research, the Swedish Research Council (Longitudinal Research and K2005-27X-14278-04A), AstraZeneca, Pfizer and Unilever.

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