Author: Lorenzo De Min
Last update: 25/09/2019
Type 1 diabetes mellitus (T1DM) is a chronic noncommunicable disease, with a usual onset in childhood and adolescence (Boman et al., 2017). The condition is characterised by the destruction of pancreatic β-cells, which are responsible for the production of insulin – a hormone with a crucial role in the regulation of blood glucose levels. Insulin allows glucose to enter a cell, where it can be used as a source of energy for the body. If there is too little insulin in the body, glucose cannot enter the cells and accumulates in the blood vessels, causing potentially life-threatening complications (Gillespie, 2006). Acute complications include diabetic ketoacidosis (DKA) and severe hypoglycemia (Rewers et al., 2002). Chronic complications result from long-term damages caused by hyperglycemia at vascular level and include coronary disease, stroke, damage to the eye (retinopathy), to the nerves (neuropathy), and the kidneys (nephropathy). The disease is incurable, but complications can be prevented: affected individuals need insulin injections and have to regularly monitor their blood sugar levels (Gillespie, 2006), adjusting the insulin doses accordingly. The disease is incurable, but the blood sugar levels can be kept steady. The management of the condition is therefore complex and requires daily efforts and commitment from patients and caregivers (Boman et al., 2017). Furthermore, evidence shows that certain autoimmune diseases (such as thyroiditis and celiac diseases) and mental health conditions (such as depression and eating disorders) tend to occur more frequently among individuals affected by T1DM, adding a layer of complexity to the treatment of these patients (Kollipara, 2010).
Migrants and individuals from ethnic minorities affected by T1DM might be exposed to extra hardship resulting in higher risk of complications. This article will provide an overview of the factors contributing to the vulnerability of these populations.
Prevalence and regional variability
The incidence of T1DM varies widely between countries, ranging from 0.1 cases (China and Venezuela) to >40 cases (Sweden and Finland) per 100,000 persons per year (Hussen, Persson, & Moradi, 2013). The regional variability of the disease is believed to be only partially explained by the different distribution of genetic risk factors (Dzidzonu, Skrivarhaug, Joner, & Moger, 2016; Hussen, Moradi, & Persson, 2015). The risk of developing T1DM tends to increase in individuals who migrate from low to high-risk areas, indicating that environmental components can act as triggers in genetically predisposed individuals. Factors such as change in diet and exposure to viral infections may play a role in enhancing a migrant’s risk of developing the disease (Bodansky, Staines, Stephenson, Haigh, & Cartwright, 1992; Craig, Nair, Stein, & Rawlinson, 2013; Fredheim et al., 2014; Hussen et al., 2015), but the interplay between genetic and environmental factors is still poorly understood (Hussen, Yang, Cnattingius, & Moradi, 2013; Rasmussen et al., 2014; Söderström, Åman, & Hjern, 2012).
T1DM in migration contexts
Several social and psychological stressors associated with migration can add a burden to the already complex management of the disease. These stressors include socioeconomic status, access to care, language barriers, acculturation, literacy and mental health (Gandhi, Baranowski, Anderson, Bansal, & Redondo, 2016; Sunni et al., 2018). In particular, low socioeconomic status is associated with 2-3 times higher risk of developing cardiovascular diseases and death (resulting from complications of diabetes or cardiovascular conditions, such as heart attack and stroke) among patients with T1DM (Rawshani, Svensson, Rosengren, Eliasson, & Gudbjörnsdottir, 2015). Evidence shows that self-care – including following diet norms, measuring blood sugar levels and adjusting the dose of insulin when necessary – among young T1DM patients with a migration background is less successful than among young patients without a migration background. Developing culturally-sensitive programmes and empowering individuals with a migrant background to manage the disease is therefore important to improve patient outcomes (Boman et al., 2017; Gandhi et al., 2016).
Rigorous management of the disease is critical to prevent T1DM complications and maintain quality of life (Jaacks et al., 2012). In an increasingly multicultural world, cultural differences are essential features of disease management (Fredheim et al., 2014). As an example, food and eating habits are part of cultural identity, which may vary across national origins. The management of T1DM requires a change in dietary habits, which may contradict traditional practices, norms, and values related to food and eating patterns (Sunni et al., 2018), a fact that should be taken into account by health professionals when devising management plans. For example, carbohydrate counters may help the patients and their caregivers to be more aware of the food they are consuming, and the need for culturally-adapted materials to facilitate carbohydrate-counting is reported in the literature (e.g. picture-based tools including traditional foods) (Nasir & Narasimhan, 2016; Sunni et al., 2018).
Several studies describe worse control of the blood sugar level in T1DM patients with a migration background (Cadario et al., 2014; Jaacks et al., 2012; Söderström, Samuelsson, & Åman, 2016), suggesting a treatment gap. A higher incidence of DKA has also been reported among children with migration background (Fritsch et al., 2011). Particularly at risk for complications are those individuals who simultaneously use antipsychotic medications (Galler et al., 2015).
The role of health professionals in supporting T1DM management goes beyond merely informing patients and their families about correct diets and insulin intake and includes empowering the patients and guiding them towards the acceptance of the disease, in order to reach satisfactory adherence to therapy and prevent complications. When the patient is too young, involving family members in the care and educating them about the disease is crucial. Indeed, parents have a particularly important role in the management of the disease for younger children, with parental literacy associated with better health outcomes (DeWalt & Hink, 2009). On the other hand, adolescents tend to become gradually more independent and responsible for the self-management of their condition (Söderström et al., 2016) As discussed by Boman et al. (2017), type 1 diabetes is a disease that should be incorporated into the daily routines and self-image of the affected person. The authors describe four different attitudes shown by adolescents towards the disease: engulfment, rejection, acceptance, and enrichment. While the first two imply ignoring or refusing the illness and can lead to neglecting self-care, acceptance and enrichment are two positive attitudes associated with better adherence to the self-treatment norms described above. Education and counselling are therefore crucial to support and empower patients and their families, particularly among vulnerable populations such as ethnic minorities and migrant populations (Boman et al., 2017).
Bodansky, H. J., Staines, A., Stephenson, C., Haigh, D., & Cartwright, R. (1992). Evidence for an environmental effect in the aetiology of insulin dependent diabetes in a transmigratory population. BMJ (Clinical Research Ed.), 304(6833), 1020–1022.
Boman, Å., Bohlin, M., Eklöf, M., Forsander, G., Munthe, C., & Törner, M. (2017). Health care to empower self-care in adolescents with type 1 diabetes mellitus and an immigrant minority background. SAGE Open Medicine, 5, 2050312117700056. https://doi.org/10.1177/2050312117700056
Cadario, F., Cerutti, F., Savastio, S., Rabbone, I., Tumini, S., & Bruno, G. (2014). Increasing burden, younger age at onset and worst metabolic control in migrant than in Italian children with type 1 diabetes: an emerging problem in pediatric clinics. Acta Diabetologica, 51(2), 263–267. https://doi.org/10.1007/s00592-013-0514-6
Craig, M. E., Nair, S., Stein, H., & Rawlinson, W. D. (2013). Viruses and type 1 diabetes: a new look at an old story. Pediatric Diabetes, 14(3), n/a-n/a. https://doi.org/10.1111/pedi.12033
DeWalt, D. A., & Hink, A. (2009). Health Literacy and Child Health Outcomes: A Systematic Review of the Literature. Pediatrics, 124(Supplement 3), S265–S274. https://doi.org/10.1542/peds.2009-1162B
Dzidzonu, D. K., Skrivarhaug, T., Joner, G., & Moger, T. A. (2016). Ethnic differences in the incidence of type 1 diabetes in Norway: a register-based study using data from the period 2002-2009. Pediatric Diabetes, 17(5), 337–341. https://doi.org/10.1111/pedi.12294
Fredheim, S., Delli, A., Rida, H., Drivvoll, A.-K., Skrivarhaug, T., Bjarnason, R., … Svensson, J. (2014). Equal access to health care may diminish the differences in outcome between native and immigrant patients with type 1 diabetes. Pediatric Diabetes, 15(7), 519–527. https://doi.org/10.1111/pedi.12157
Fritsch, M., Rosenbauer, J., Schober, E., Neu, A., Placzek, K., & Holl, R. W. (2011). Predictors of diabetic ketoacidosis in children and adolescents with type 1 diabetes. Experience from a large multicentre database. Pediatric Diabetes, 12(4pt1), 307–312. https://doi.org/10.1111/j.1399-5448.2010.00728.x
Galler, A., Bollow, E., Meusers, M., Bartus, B., Näke, A., Haberland, H., … German Federal Ministry of Education and Research (BMBF) Competence Network Diabetes Mellitus. (2015). Comparison of Glycemic and Metabolic Control in Youth With Type 1 Diabetes With and Without Antipsychotic Medication: Analysis From the Nationwide German/Austrian Diabetes Survey (DPV). Diabetes Care, 38(6), 1051–1057. https://doi.org/10.2337/dc14-2538
Gandhi, K. K., Baranowski, T., Anderson, B. J., Bansal, N., & Redondo, M. J. (2016). Psychosocial aspects of type 1 diabetes in Latino- and Asian-American youth. Pediatric Research, 80(3), 347–355. https://doi.org/10.1038/pr.2016.87
Gillespie, K. M. (2006). Type 1 diabetes: pathogenesis and prevention. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 175(2), 165–170. https://doi.org/10.1503/cmaj.060244
Hussen, H. I., Moradi, T., & Persson, M. (2015). The Risk of Type 1 Diabetes Among Offspring of Immigrant Mothers in Relation to the Duration of Residency in Sweden: Table 1. Diabetes Care, 38(5), 934–936. https://doi.org/10.2337/dc14-2348
Hussen, H. I., Persson, M., & Moradi, T. (2013). The trends and the risk of type 1 diabetes over the past 40 years: an analysis by birth cohorts and by parental migration background in Sweden. BMJ Open, 3(10), e003418. https://doi.org/10.1136/bmjopen-2013-003418
Hussen, H. I., Yang, D., Cnattingius, S., & Moradi, T. (2013). Type I diabetes among children and young adults: the role of country of birth, socioeconomic position and sex. Pediatric Diabetes, 14(2), 138–148. https://doi.org/10.1111/j.1399-5448.2012.00904.x
Jaacks, L. M., Oza-Frank, R., D’Agostino, R., Dolan, L. M., Dabelea, D., Lawrence, J. M., … Mayer-Davis, E. J. (2012). Migration Status in Relation to Clinical Characteristics and Barriers to Care Among Youth with Diabetes in the US. Journal of Immigrant and Minority Health, 14(6), 949–958. https://doi.org/10.1007/s10903-012-9617-3
Kollipara, S. (2010). Comorbidities Associated With Type 1 Diabetes. NASN School Nurse, 25(1), 19–21. https://doi.org/10.1177/1942602X09354117
Nasir, H., & Narasimhan, S. (2016). Type 1 diabetes: the need for culture-appropriate nutritional information for carbohydrate counting. The Lancet Diabetes & Endocrinology, 4(10), 812. https://doi.org/10.1016/S2213-8587(16)30101-2
Rasmussen, T., Yap, S. E., Stray-Pedersen, B., Akselsen, H. E., McKinney, P. A., & Rønningen, K. S. (2014). HLA associated type 1 diabetes risk in children of Pakistani migrants to Norway. Medical Hypotheses, 83(6), 664–667. https://doi.org/10.1016/j.mehy.2014.09.013
Rawshani, A., Svensson, A.-M., Rosengren, A., Eliasson, B., & Gudbjörnsdottir, S. (2015). Impact of Socioeconomic Status on Cardiovascular Disease and Mortality in 24,947 Individuals With Type 1 Diabetes. Diabetes Care, 38(8), 1518–1527. https://doi.org/10.2337/dc15-0145
Rewers, A., Chase, H. P., Mackenzie, T., Walravens, P., Roback, M., Rewers, M., … Klingensmith, G. (2002). Predictors of Acute Complications in Children With Type 1 Diabetes. JAMA, 287(19), 2511. https://doi.org/10.1001/jama.287.19.2511
Söderström, U., Åman, J., & Hjern, A. (2012). Being born in Sweden increases the risk for type 1 diabetes – a study of migration of children to Sweden as a natural experiment. Acta Paediatrica, 101(1), 73–77. https://doi.org/10.1111/j.1651-2227.2011.02410.x
Söderström, U., Samuelsson, U., & Åman, J. (2016). National Swedish study of immigrant children with type 1 diabetes showed impaired metabolic control after three years of treatment. Acta Paediatrica, 105(8), 935–939. https://doi.org/10.1111/apa.13456
Sunni, M., Brunzell, C., Kyllo, J., Purcell, L., Plager, P., & Moran, A. (2018). A picture-based carbohydrate-counting resource for Somalis. The Journal of International Medical Research, 46(1), 219–224. https://doi.org/10.1177/0300060517718732
 DKA is a condition characterized by an excess of acid in the blood. When cells, due to lack of insulin, cannot use sugar as a source of energy, fat is used as an alternative fuel. However, burning fat results is the production of acids called ketones. Ketones accumulate in the blood and can lead to coma and death.