DIABETICMedicine DOI: 10.1111/dme.12510
Research: Epidemiology High diabetes risk among asylum seekers in the Netherlands S. Goosen1,2, B. Middelkoop3,4, K. Stronks1, C. Agyemang1 and A. E. Kunst1 1 Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, 2Netherlands Association for Community Health Services, Utrecht, 3Department of Epidemiology, Municipal Health Service The Hague, The Hague and 4Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
Accepted 21 May 2014
Abstract Aims To map the prevalence and incidence of recorded diabetes among asylum seekers according to demographic factors and length of stay in the host country. Methods We used a nationwide database from the Community Health Services for Asylum Seekers. The study population included all asylum seekers aged 20–79 years who arrived in the Netherlands between 2000 and 2008. Case allocation was based on International Classification of Primary Care codes. A general practice registry was used to obtain reference data. Standardized prevalence and incidence ratios were calculated and their association with length of stay was explored with Cox regression.
The study included 59 380 asylum seekers among whom there were 1227 recorded cases of diabetes. The prevalence of recorded diabetes was higher among asylum seekers compared with the reference population for both men (standardized prevalence ratio=1.85, 95% CI 1.71–1.91) and women (standardized prevalence ratio=2.26, 95% CI 2.08–2.45). The highest standardized prevalence ratios were found for asylum seekers from Somalia, Sudan and Sri Lanka. The standardized prevalence ratio was higher in asylum seekers aged ≥ 30 years. Incidence rates were higher compared with the reference population for all length-of-stay intervals. Results
Conclusions Asylum seekers from the majority of countries of origin were at higher risk of diabetes compared with the general population in the Netherlands. Asylum seekers from Somalia were particularly at risk. This emerging public health issue requires attention from policy-makers and care providers.
Diabet. Med. 31, 1532–1541 (2014)
Introduction Migrants from various non-Western countries of origin are reported to be at higher risk of diabetes in comparison with host populations of industrialized countries [1–7]; however, the available data are mainly on migrant groups with a relatively long migration history [1–7]. Epidemiological data on diabetes for migrant groups that have arrived more recently, including asylum seekers, are scarce. People who have fled their country of origin and are awaiting a decision on their asylum request are called asylum seekers. The United Nations High Commissioner for Refugees estimates that 479 300 asylum applications were registered in the 44 industrialized countries in 2012 [8]. The top 10 countries of origin were Afghanistan, Syria, Serbia, China, Pakistan, Russian Federation, Iraq, Iran, Correspondence to: Simone Goosen. E-mail: [email protected]
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Somalia and Eritrea [8]. The number of refugees, the persons who have been granted asylum, was estimated to be two million in the 44 industrialized countries in 2011 [9]. The asylum population may face an accumulation of diabetes risk factors such as: higher genetic susceptibility; early life exposures, for example, low birth weight; exposure to famine in childhood; sweeping socio-economic change; acculturation stress; and lifestyle factors in the host country [2,3,7,10,11]. In addition, some risk factors may be particularly prevalent among asylum seekers such as stress, depression, post-traumatic stress disorder and sleep disorders [12,13]. We have reported previously that asylum seekers with post-traumatic stress disorder had a nearly 1.5 times greater odds of diabetes diagnosis compared with other asylum seekers [14]. In several countries of origin of asylum seekers, the diabetes prevalence is higher than in the Netherlands (e.g. Iran, Iraq, Syria and Sudan). These high prevalence rates and the additional risks that asylum seekers may face imply that
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What’s new? • High diabetes risks have been reported for established migrant groups, but few publications address new migrant groups. • We studied the prevalence and incidence of recorded diabetes among asylum seekers during the first years after their arrival in the Netherlands. • Asylum seekers from the majority of countries of origin were at higher risk of diabetes compared with the general population in the Netherlands. Asylum seekers from Somalia were at particularly high risk. • The higher diabetes risk was observed as of arrival in the host country. • This emerging public health issue urgently requires attention from policy-makers and healthcare providers. asylum seekers may be a high-risk group for diabetes [15]. Further insight into the burden of diabetes among asylum seekers is needed to inform interventions aimed at prevention, early diagnosis and treatment of diabetes among asylum seekers, but data on the diabetes prevalence among asylum seekers are scarce. A study in the USA based on health screenings shortly after arrival in the USA, showed a low rate of diabetes among asylum seekers and refugees [16]. Other studies in the USA and Canada, however, found a 1.5 times higher diabetes risk for refugees compared with other migrants [6,17]. Several studies on migrants report on the regions of origin of asylum seekers, but do not distinguish by residence status and provide results for only a few of the countries of origin [1,5,6,12,13]. These studies found that onset of diabetes occurred at a younger age in asylum seekers than in the host population. Differences in diabetes risk were greater in women than in men, and they increased with increasing length of stay in the host country [1,5,6,12,13]. A database with health data on 59 380 asylum seekers in the Netherlands allowed us to analyse the prevalence rates of recorded diabetes for asylum seekers from 17 countries of origin. Reference data for comparison with the Dutch population were also available. The database allowed a unique analysis of the development of the incidence of recorded diabetes according to length of stay. The aim of the present study was to assess the prevalence and incidence of diabetes among asylum seekers by country of origin, gender, age and length of stay.
Subjects and methods Study population
The study population consisted of 59 380 asylum seekers. Inclusion criteria were arrival in asylum reception between 1
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January 2000 and 31 December 2008, at least 3 months’ stay in reception, and age on arrival between 20 and 79 years. Resettlement refugees were excluded as they were invited by the Dutch government to resettle in the Netherlands because of specific needs, which may include health problems. Asylum seekers in the Netherlands live in asylum-seeker centres managed by the Central Agency for the Reception of Asylum Seekers. Healthcare for asylum seekers in the Netherlands was not found to differ greatly from the healthcare provided to residents of the Netherlands [18]. Primary curative care is provided by nurse practitioners of the Community Health Services for Asylum Seekers and mainstream family physicians, who work in close collaboration. Nurses and public health physicians of the Community Health Services for Asylum Seekers offer all asylum seekers a (non-mandatory) preventive health assessment in the first months after arrival. There is no routine screening for diabetes or other chronic diseases.
Ethics
In line with Dutch legislation, the privacy statement of the Community Health Services for Asylum Seekers included a statement on the anonymous use of data for epidemiological purposes. Because only data collected for healthcare purposes were used, the medical ethics review committee of the Academic Medical Centre at the University of Amsterdam stated that no approval of the medical ethics review committee was required (letter W12-276#12.17.0315).
Data
We used the data included in an electronic database of the Community Health Services for Asylum Seekers. Staff of the Community Health Services for Asylum Seekers and family physicians recorded health and psychosocial data, based on their findings during preventive and curative consultations, in paper medical records. They used the ‘problem-oriented records’ method [19]. Main and chronic health problems were recorded on the problem list along with the International Classification of Primary Care code, date of diagnosis, and a short open field description. Problem list information was entered in the electronic medical record system of the Community Health Services for Asylum Seekers. This system also contained demographic and reception data from the Central Agency for the Reception of Asylum Seekers. The diagnosis of diabetes followed the protocol in use in family practices in the Netherlands. The diagnosis required an elevated glucose level (fasting plasma glucose levels of ≥ 7.0 mmol/l, fasting capillary glucose level of ≥ 6.0 mmol/l, or non-fasting plasma or capillary glucose level of ≥ 11.0 mmol/l), which was confirmed using a fasting glucose test a few days later. Data with respect to the type of diabetes were insufficiently complete to make a distinction between Type 1 and Type 2 diabetes.
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For case status allocation, a computerized search was performed to select all asylum seekers with the International Classification of Primary Care code for diabetes (T90) or an open field description containing ‘diabe’, ‘DM’, ‘D.M’, or ‘suikerziekte’ (Dutch for diabetes). One of the authors (S.G.) manually checked all records. Fifty-nine asylum seekers with International Classification of Primary Care code T90 were not allocated case status because the open field descriptions did not contain any information indicating diagnosis of diabetes or only contained a description of gestational diabetes. A total of 74 asylum seekers were allocated case status on the basis of open field descriptions. Country of origin was the country that was documented by the Immigration Department; in general this was the nationality of the asylum seeker. We grouped the asylum seekers into regions using the World Bank classification (http://data. worldbank.org/about/country-classifications/country-and-lending-groups). The Netherlands Information Network of General Practice was used to obtain the reference data on diabetes in the general population [20]. The database of the Netherlands Information Network of General Practice includes continuous family practice data on morbidity among > 350 000 listed patients. Participating general practices are considered representative of all general practices in the Netherlands [20]. Patients registered at general practices in this network are comparable with the general population of the Netherlands with respect to age, gender and health insurance type [20]. The Netherlands Information Network of General Practice does not contain data on patients’ socio-economic status or ethnicity, but there are indications that this network database is representative in these terms (I. Stirbu, personal communication). Non-Western migrants constituted ~10% of the population in the Netherlands in 2005 and the main countries of origin were Turkey, Morocco and Surinam [21].
Analysis of the prevalence of recorded diabetes
We calculated the prevalence of recorded diabetes as the number of recorded cases of diabetes per 100 asylum seekers. As diabetes is a chronic condition, this can be considered as an estimate of the point prevalence of diagnosed cases of diabetes at the end of the reception period. Comparison of the prevalence of recorded diabetes between asylum seekers and the population of the Netherlands Information Network of General Practice was carried out with standardized prevalence ratios using the indirect method of standardization [22]. Standardized prevalence ratios are ratios of the observed and the expected number of cases. The former represents the number of cases observed for the asylum seeker group. The latter represents the number of cases expected in the hypothetical case that this group would have the age-sex-specific diabetes prevalence rates of the patients whose data are included in the Netherlands
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Information Network of General Practice. In these calculations, asylum seekers were classified according to age at arrival in the Netherlands. Country-specific analysis of the prevalence was performed for countries with > 1000 asylum seekers in the study population. We calculated 95% CIs for the standardized prevalence ratios using the exact method proposed by Ulm [23].
Analysis of the association with length of stay
The incidence of recorded diabetes was calculated as the number of newly recorded cases divided by the cumulative number of years spent in reception, multiplied by 1000 to obtain the rate per 1000 person-years. As cases of diabetes recorded in the first months after arrival in the host country include both new diabetes diagnoses and cases that had already been diagnosed before arrival, it was not useful to estimate incidence rates for the first months after arrival; therefore, we only calculated incidence rates for the intervals beginning after 6 months’ length of stay. In addition, we calculated point prevalence rates at 6 months’ length of stay. For each individual, the number of person-years was calculated as from 6 months until the date of diagnosis of diabetes, departure, death or the end of the study period, whichever came first. Standardized incidence ratios and 95% CIs were calculated using the same methodology as for the standardized prevalence ratio. For studying the association with length of stay, we divided the data for each asylum seeker into records per length-of-stay interval (0–5, 6–11, 12–23, 24–35, 36– 47, 48–59 and 60–108 months). We applied Cox regression to calculate relative risks, controlling for country of origin, sex, age and calendar year. Details of the methodology are given in previous study that used the same database [24]. For reasons of statistical power, analyses of incidence or 6-month prevalence rates could only be performed for countries with > 5000 asylum seekers. Standardized prevalence and incidence ratios with 95% CIs were calculated using Microsoft Excel. Multivariate analyses were performed with SPSS statistical software (SPSS Inc., Version 20.0, Chicago, IL, USA).
Results The socio-demographic characteristics of the 59 380 asylum seekers in the study are shown in Tables 1 and 2. Nearly two-thirds of the asylum seekers were men. The countries with the largest number of asylum seekers were Iraq (15.9%), Somalia (10.5%) and Afghanistan (9.1%). The study population was young, with a mean age at arrival of 28.4 years for men and 30.5 years for women. The mean length of stay in reception during the study period was 2.5 years for men and 4.4 years for women. The mean age at arrival and the mean length of stay differed between countries of origin (Tables 1 and 2).
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The total number of diabetes cases recorded during the study period was 1227 and the crude prevalence of recorded diabetes was 2.1%. The prevalence was higher for women (2.7%) than for men (1.7%) for almost all countries of origin. Crude country-specific prevalence rates ranged from 0.7% for men from Angola, Turkey and Sierra Leone to 4.9% for men from Sri Lanka and from 0.3% for women from Guinea to 11.7% for women from Sri Lanka (Table 2). The standardized prevalence ratio indicated a two times higher prevalence for asylum seekers than for the reference population (standardized prevalence ratio 2.10, 95% CI 1.91–2.13). The standardized prevalence ratio in comparison with the reference population was higher for women (standardized prevalence ratio 2.26, 95% CI 2.08–2.45) than for men (standardized prevalence ratio 1.85, 95% CI 1.71– 1.99). For most countries of origin the age-standardized prevalence ratios of recorded diabetes were >1 for men and women (Tables 1 and 2). For men and women from China and men from Turkey the diabetes prevalence was approximately the same as that in the reference population (Tables 1 and 2). The countries with the highest standardized prevalence ratios for men and women were Sudan, Sri Lanka and Somalia (Tables 1 and 2). For Somali men and women, the prevalence of recorded diabetes was higher than in the reference population starting from the age group 20–29 years (Table 3). For all other
countries the standardized prevalence ratio was >1 starting from the age group 30–39 years, although the difference from the reference population was not statistically significant for any of the subgroups men and women from Afrghanistan and Iraq. Among asylum seekers aged 60–79 years the diabetes prevalence was 21% and the standardized prevalence ratio was nearly twice as high as in the reference population (standardized prevalence ratio for men 1.81, 95% CI 1.53–2.14 and standardized prevalence ratio for women 1.83, 95% CI 1.58–2.11; data not in tables). Figure 1 shows that the prevalence of recorded diabetes among asylum seekers 4 years). In multivariate analyses we were able to assess risk differences while controlling for length of stay; however, for reasons of power, this analysis could only be carried out for the larger countries of origin. The high diabetes prevalence and incidence ratios found for asylum seekers compared with the reference population may have been caused by the accumulation of risk factors such as genetic susceptibility, sweeping economic change, lifestyle factors and stress related to migration and the asylum context. Differences in risk from that in the reference population were larger for women than for men. This finding is consistent with studies on migrants in Canada and Sweden [1,5]. The higher risk as from the 30–39 year age group in comparison with the reference population adds to evidence from other studies that migrants are younger at diabetes onset [2,3,6].
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The present study is the first to provide data for migrants in Western host countries for various countries of origin. The higher risks found for most countries of origin compared with the reference population correspond to higher diabetes prevalence rates in most countries of origin. The most recent estimates of the International Diabetes Federation for African countries are lower than the estimate for the Netherlands (5.9%). Sudan is an exception with an estimated rate of 9.1% [15]. Non-African countries have estimated prevalence rates > 1.5 times higher than for the Netherlands, e.g. Iran (10.6%), Iraq (9.7%), Syria (9.6%) and China (8.8%). The high risks that we found for asylum seekers from Somalia are in striking contrast to the International Diabetes Federation estimates for Somalia of only 3.9% [15]. It should be noted, however, that the International Diabetes Federation estimates have a considerable level of uncertainty because of the limited availability of primary data, particularly in countries at war [15,30]. The particularly high diabetes risk for asylum seekers from Somalia is noteworthy. Several qualitative studies among Somali immigrants in Western host countries document that high diabetes risks in this population have already been noticed in practice [31,32]. The relatively low prevalence for asylum seekers from Iran may be an example of selection mechanisms. Iranian asylum seekers have a relatively high educational level, which in general is associated with lower diabetes risk [33]. The high diabetes prevalence for Sri Lankan men and women is in line with findings for Sri Lankan migrants in other Western host countries [34–36].
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Table 4 Number of cases and incidence of recorded diabetes as from 6 months after arrival, standardized incidence ratios compared with the reference population and relative risk compared with the 6–11-month interval by gender and length of stay*
Length of stay at start interval Men
Women
6–11 months (ref.) 12–23 months 24–35 months 36–47 months 48–59 months 60–108 months 6–11 months (ref.) 12–23 months 24–35 months 36–47 months 48–59 months 60–108 months
Recorded cases of diabetes
No. personyears
Incidence per 1000 person-years
44 34 29 25 20 26 30 45 22 18 19 31
13,222 18,752 12,720 8,812 5,754 8,132 7062 10 274 7403 5505 3695 5773
3.33 1.81 2.28 1.50 3.48 3.20 4.25 4.38 2.97 3.27 5.14 5.37
Comparison with reference population
Comparison with 6-11 months interval*
Standardized incidence ratio
95% CI
Relative risk
2.11 1.12 1.29 1.50 1.73 1.39 2.34 2.35 1.52 1.61 2.39 2.39
1.53–2.80 0.77–1.54 0.87–1.83 0.97–2.18 1.05–2.61 0.91–2.01 1.58–3.29 1.72–3.12 0.96–2.27 0.96–2.50 1.44-3.66 1.63-3.35
1 0.58 0.59 0.66 0.66 0.46 1 1.13 0.64 0.64 0.84 1.00
95% CI
0.36–0.93 0.34–1.02 0.38–1.16 0.35–1.25 0.22–0.96 0.70–1.85 0.35–1.19 0.34–1.23 0.43-1.66 0.51-1.99
*Cox regression model included country of origin, age (as continuous variable) and calendar year at start interval.
Across all the length-of-stay intervals, the incidence rates were persistently higher than in the reference population. This implies that, with increasing length of stay, the difference in prevalence between asylum seekers and the reference population may increase. The pattern observed in female asylum seekers of a decrease in the incidence ratio compared with the reference population after 2 years, followed by an increase as from 4 years after arrival, is striking. This pattern may be related to a combination of factors such as catching-up of diabetes diagnosis in the first years after arrival, the possibility of varying stress levels over time, and effects of changes in lifestyle and overweight. A longitudinal study from the Netherlands showed that the diabetes risk may continue to increase after the granting of asylum status (M Lamkaddem, ML Essink-Bot, WD Deville´, AA Gerritsen and K Stronks; unpubl. data). The difference in prevalence with the host population may, in line with studies in general migrant groups, continue to increase long after arrival in the host country [6,17]. Asylum populations in other Western host countries are also likely to be at high risk of diabetes as they largely originate from the same countries of origin as asylum seekers in the Netherlands and are likely to share diabetes risk factors. Nevertheless, it should be taken into account that the diabetes risk may be influenced by the demographic composition of the asylum population, conditions in the host country and distribution of length of stay [3]. Furthermore, the ratio between diagnosed and undiagnosed diabetes cases may vary between host countries as this may be influenced by differences in the accessibility and quality of healthcare for asylum seekers [18]. The high diabetes prevalence among asylum seekers shortly after arrival and the likelihood of further increase
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in risk over time suggest that diabetes among asylum seekers and refugees is a problem of considerable public health importance in Western host countries. The public health actions needed can build upon the actions formulated for migrants in general [36]. Raising diabetes awareness and supporting asylum seekers to develop a physically active lifestyle and healthy dietary habits in their new environment and reducing stress as from shortly after arrival are important [36,37]. Interventions aimed at increasing physical activity may have large effects as this would contribute to stress reduction, a risk factor for diabetes that is highly prevalent among asylum seekers. Policy-makers may play an important role in the prevention of diabetes by creating the conditions that stimulate asylum seekers and refugees to be physically active. Research is needed to provide insight into which interventions work and into the diabetes risk in refugee populations with longer lengths of stay. To ensure early identification of diabetes, health professionals should be aware of the high diabetes risks among asylum seekers and refugees. Evidence suggests that diabetes screening for recently arrived asylum seekers and refugees aged ≥ 35 years may be indicated [4]. Funding sources
The Netherlands Association for Community Health Services funded the creation of the database used in this study. The organization had no involvement in study design, data analysis or manuscript writing.
Competing interests
None declared.
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Acknowledgements
We would like to thank Hennie Nijsingh for reading and commenting on draft versions of the manuscript and The Netherlands Association for Community Health Services which funded the creation of the database of the Community Health Services for Asylum Seekers.
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Supporting Information
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Appendix S1 Standardized prevalence ratios of recorded diabetes in the first 6 months after arrival and standardized incidence ratios of recorded diabetes as from 6 months after arrival in comparison with the reference population and relative risks by gender and country of origin.
Additional Supporting Information may be found in the online version of this article:
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Research: Epidemiology High diabetes risk among asylum seekers in the Netherlands S. Goosen1,2, B. Middelkoop3,4, K. Stronks1, C. Agyemang1 and A. E. Kunst1 1 Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, 2Netherlands Association for Community Health Services, Utrecht, 3Department of Epidemiology, Municipal Health Service The Hague, The Hague and 4Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
Accepted 21 May 2014
Abstract Aims To map the prevalence and incidence of recorded diabetes among asylum seekers according to demographic factors and length of stay in the host country. Methods We used a nationwide database from the Community Health Services for Asylum Seekers. The study population included all asylum seekers aged 20–79 years who arrived in the Netherlands between 2000 and 2008. Case allocation was based on International Classification of Primary Care codes. A general practice registry was used to obtain reference data. Standardized prevalence and incidence ratios were calculated and their association with length of stay was explored with Cox regression.
The study included 59 380 asylum seekers among whom there were 1227 recorded cases of diabetes. The prevalence of recorded diabetes was higher among asylum seekers compared with the reference population for both men (standardized prevalence ratio=1.85, 95% CI 1.71–1.91) and women (standardized prevalence ratio=2.26, 95% CI 2.08–2.45). The highest standardized prevalence ratios were found for asylum seekers from Somalia, Sudan and Sri Lanka. The standardized prevalence ratio was higher in asylum seekers aged ≥ 30 years. Incidence rates were higher compared with the reference population for all length-of-stay intervals. Results
Conclusions Asylum seekers from the majority of countries of origin were at higher risk of diabetes compared with the general population in the Netherlands. Asylum seekers from Somalia were particularly at risk. This emerging public health issue requires attention from policy-makers and care providers.
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Introduction Migrants from various non-Western countries of origin are reported to be at higher risk of diabetes in comparison with host populations of industrialized countries [1–7]; however, the available data are mainly on migrant groups with a relatively long migration history [1–7]. Epidemiological data on diabetes for migrant groups that have arrived more recently, including asylum seekers, are scarce. People who have fled their country of origin and are awaiting a decision on their asylum request are called asylum seekers. The United Nations High Commissioner for Refugees estimates that 479 300 asylum applications were registered in the 44 industrialized countries in 2012 [8]. The top 10 countries of origin were Afghanistan, Syria, Serbia, China, Pakistan, Russian Federation, Iraq, Iran, Correspondence to: Simone Goosen. E-mail: [email protected]
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Somalia and Eritrea [8]. The number of refugees, the persons who have been granted asylum, was estimated to be two million in the 44 industrialized countries in 2011 [9]. The asylum population may face an accumulation of diabetes risk factors such as: higher genetic susceptibility; early life exposures, for example, low birth weight; exposure to famine in childhood; sweeping socio-economic change; acculturation stress; and lifestyle factors in the host country [2,3,7,10,11]. In addition, some risk factors may be particularly prevalent among asylum seekers such as stress, depression, post-traumatic stress disorder and sleep disorders [12,13]. We have reported previously that asylum seekers with post-traumatic stress disorder had a nearly 1.5 times greater odds of diabetes diagnosis compared with other asylum seekers [14]. In several countries of origin of asylum seekers, the diabetes prevalence is higher than in the Netherlands (e.g. Iran, Iraq, Syria and Sudan). These high prevalence rates and the additional risks that asylum seekers may face imply that
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Research article
What’s new? • High diabetes risks have been reported for established migrant groups, but few publications address new migrant groups. • We studied the prevalence and incidence of recorded diabetes among asylum seekers during the first years after their arrival in the Netherlands. • Asylum seekers from the majority of countries of origin were at higher risk of diabetes compared with the general population in the Netherlands. Asylum seekers from Somalia were at particularly high risk. • The higher diabetes risk was observed as of arrival in the host country. • This emerging public health issue urgently requires attention from policy-makers and healthcare providers. asylum seekers may be a high-risk group for diabetes [15]. Further insight into the burden of diabetes among asylum seekers is needed to inform interventions aimed at prevention, early diagnosis and treatment of diabetes among asylum seekers, but data on the diabetes prevalence among asylum seekers are scarce. A study in the USA based on health screenings shortly after arrival in the USA, showed a low rate of diabetes among asylum seekers and refugees [16]. Other studies in the USA and Canada, however, found a 1.5 times higher diabetes risk for refugees compared with other migrants [6,17]. Several studies on migrants report on the regions of origin of asylum seekers, but do not distinguish by residence status and provide results for only a few of the countries of origin [1,5,6,12,13]. These studies found that onset of diabetes occurred at a younger age in asylum seekers than in the host population. Differences in diabetes risk were greater in women than in men, and they increased with increasing length of stay in the host country [1,5,6,12,13]. A database with health data on 59 380 asylum seekers in the Netherlands allowed us to analyse the prevalence rates of recorded diabetes for asylum seekers from 17 countries of origin. Reference data for comparison with the Dutch population were also available. The database allowed a unique analysis of the development of the incidence of recorded diabetes according to length of stay. The aim of the present study was to assess the prevalence and incidence of diabetes among asylum seekers by country of origin, gender, age and length of stay.
Subjects and methods Study population
The study population consisted of 59 380 asylum seekers. Inclusion criteria were arrival in asylum reception between 1
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January 2000 and 31 December 2008, at least 3 months’ stay in reception, and age on arrival between 20 and 79 years. Resettlement refugees were excluded as they were invited by the Dutch government to resettle in the Netherlands because of specific needs, which may include health problems. Asylum seekers in the Netherlands live in asylum-seeker centres managed by the Central Agency for the Reception of Asylum Seekers. Healthcare for asylum seekers in the Netherlands was not found to differ greatly from the healthcare provided to residents of the Netherlands [18]. Primary curative care is provided by nurse practitioners of the Community Health Services for Asylum Seekers and mainstream family physicians, who work in close collaboration. Nurses and public health physicians of the Community Health Services for Asylum Seekers offer all asylum seekers a (non-mandatory) preventive health assessment in the first months after arrival. There is no routine screening for diabetes or other chronic diseases.
Ethics
In line with Dutch legislation, the privacy statement of the Community Health Services for Asylum Seekers included a statement on the anonymous use of data for epidemiological purposes. Because only data collected for healthcare purposes were used, the medical ethics review committee of the Academic Medical Centre at the University of Amsterdam stated that no approval of the medical ethics review committee was required (letter W12-276#12.17.0315).
Data
We used the data included in an electronic database of the Community Health Services for Asylum Seekers. Staff of the Community Health Services for Asylum Seekers and family physicians recorded health and psychosocial data, based on their findings during preventive and curative consultations, in paper medical records. They used the ‘problem-oriented records’ method [19]. Main and chronic health problems were recorded on the problem list along with the International Classification of Primary Care code, date of diagnosis, and a short open field description. Problem list information was entered in the electronic medical record system of the Community Health Services for Asylum Seekers. This system also contained demographic and reception data from the Central Agency for the Reception of Asylum Seekers. The diagnosis of diabetes followed the protocol in use in family practices in the Netherlands. The diagnosis required an elevated glucose level (fasting plasma glucose levels of ≥ 7.0 mmol/l, fasting capillary glucose level of ≥ 6.0 mmol/l, or non-fasting plasma or capillary glucose level of ≥ 11.0 mmol/l), which was confirmed using a fasting glucose test a few days later. Data with respect to the type of diabetes were insufficiently complete to make a distinction between Type 1 and Type 2 diabetes.
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For case status allocation, a computerized search was performed to select all asylum seekers with the International Classification of Primary Care code for diabetes (T90) or an open field description containing ‘diabe’, ‘DM’, ‘D.M’, or ‘suikerziekte’ (Dutch for diabetes). One of the authors (S.G.) manually checked all records. Fifty-nine asylum seekers with International Classification of Primary Care code T90 were not allocated case status because the open field descriptions did not contain any information indicating diagnosis of diabetes or only contained a description of gestational diabetes. A total of 74 asylum seekers were allocated case status on the basis of open field descriptions. Country of origin was the country that was documented by the Immigration Department; in general this was the nationality of the asylum seeker. We grouped the asylum seekers into regions using the World Bank classification (http://data. worldbank.org/about/country-classifications/country-and-lending-groups). The Netherlands Information Network of General Practice was used to obtain the reference data on diabetes in the general population [20]. The database of the Netherlands Information Network of General Practice includes continuous family practice data on morbidity among > 350 000 listed patients. Participating general practices are considered representative of all general practices in the Netherlands [20]. Patients registered at general practices in this network are comparable with the general population of the Netherlands with respect to age, gender and health insurance type [20]. The Netherlands Information Network of General Practice does not contain data on patients’ socio-economic status or ethnicity, but there are indications that this network database is representative in these terms (I. Stirbu, personal communication). Non-Western migrants constituted ~10% of the population in the Netherlands in 2005 and the main countries of origin were Turkey, Morocco and Surinam [21].
Analysis of the prevalence of recorded diabetes
We calculated the prevalence of recorded diabetes as the number of recorded cases of diabetes per 100 asylum seekers. As diabetes is a chronic condition, this can be considered as an estimate of the point prevalence of diagnosed cases of diabetes at the end of the reception period. Comparison of the prevalence of recorded diabetes between asylum seekers and the population of the Netherlands Information Network of General Practice was carried out with standardized prevalence ratios using the indirect method of standardization [22]. Standardized prevalence ratios are ratios of the observed and the expected number of cases. The former represents the number of cases observed for the asylum seeker group. The latter represents the number of cases expected in the hypothetical case that this group would have the age-sex-specific diabetes prevalence rates of the patients whose data are included in the Netherlands
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Information Network of General Practice. In these calculations, asylum seekers were classified according to age at arrival in the Netherlands. Country-specific analysis of the prevalence was performed for countries with > 1000 asylum seekers in the study population. We calculated 95% CIs for the standardized prevalence ratios using the exact method proposed by Ulm [23].
Analysis of the association with length of stay
The incidence of recorded diabetes was calculated as the number of newly recorded cases divided by the cumulative number of years spent in reception, multiplied by 1000 to obtain the rate per 1000 person-years. As cases of diabetes recorded in the first months after arrival in the host country include both new diabetes diagnoses and cases that had already been diagnosed before arrival, it was not useful to estimate incidence rates for the first months after arrival; therefore, we only calculated incidence rates for the intervals beginning after 6 months’ length of stay. In addition, we calculated point prevalence rates at 6 months’ length of stay. For each individual, the number of person-years was calculated as from 6 months until the date of diagnosis of diabetes, departure, death or the end of the study period, whichever came first. Standardized incidence ratios and 95% CIs were calculated using the same methodology as for the standardized prevalence ratio. For studying the association with length of stay, we divided the data for each asylum seeker into records per length-of-stay interval (0–5, 6–11, 12–23, 24–35, 36– 47, 48–59 and 60–108 months). We applied Cox regression to calculate relative risks, controlling for country of origin, sex, age and calendar year. Details of the methodology are given in previous study that used the same database [24]. For reasons of statistical power, analyses of incidence or 6-month prevalence rates could only be performed for countries with > 5000 asylum seekers. Standardized prevalence and incidence ratios with 95% CIs were calculated using Microsoft Excel. Multivariate analyses were performed with SPSS statistical software (SPSS Inc., Version 20.0, Chicago, IL, USA).
Results The socio-demographic characteristics of the 59 380 asylum seekers in the study are shown in Tables 1 and 2. Nearly two-thirds of the asylum seekers were men. The countries with the largest number of asylum seekers were Iraq (15.9%), Somalia (10.5%) and Afghanistan (9.1%). The study population was young, with a mean age at arrival of 28.4 years for men and 30.5 years for women. The mean length of stay in reception during the study period was 2.5 years for men and 4.4 years for women. The mean age at arrival and the mean length of stay differed between countries of origin (Tables 1 and 2).
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The total number of diabetes cases recorded during the study period was 1227 and the crude prevalence of recorded diabetes was 2.1%. The prevalence was higher for women (2.7%) than for men (1.7%) for almost all countries of origin. Crude country-specific prevalence rates ranged from 0.7% for men from Angola, Turkey and Sierra Leone to 4.9% for men from Sri Lanka and from 0.3% for women from Guinea to 11.7% for women from Sri Lanka (Table 2). The standardized prevalence ratio indicated a two times higher prevalence for asylum seekers than for the reference population (standardized prevalence ratio 2.10, 95% CI 1.91–2.13). The standardized prevalence ratio in comparison with the reference population was higher for women (standardized prevalence ratio 2.26, 95% CI 2.08–2.45) than for men (standardized prevalence ratio 1.85, 95% CI 1.71– 1.99). For most countries of origin the age-standardized prevalence ratios of recorded diabetes were >1 for men and women (Tables 1 and 2). For men and women from China and men from Turkey the diabetes prevalence was approximately the same as that in the reference population (Tables 1 and 2). The countries with the highest standardized prevalence ratios for men and women were Sudan, Sri Lanka and Somalia (Tables 1 and 2). For Somali men and women, the prevalence of recorded diabetes was higher than in the reference population starting from the age group 20–29 years (Table 3). For all other
countries the standardized prevalence ratio was >1 starting from the age group 30–39 years, although the difference from the reference population was not statistically significant for any of the subgroups men and women from Afrghanistan and Iraq. Among asylum seekers aged 60–79 years the diabetes prevalence was 21% and the standardized prevalence ratio was nearly twice as high as in the reference population (standardized prevalence ratio for men 1.81, 95% CI 1.53–2.14 and standardized prevalence ratio for women 1.83, 95% CI 1.58–2.11; data not in tables). Figure 1 shows that the prevalence of recorded diabetes among asylum seekers 4 years). In multivariate analyses we were able to assess risk differences while controlling for length of stay; however, for reasons of power, this analysis could only be carried out for the larger countries of origin. The high diabetes prevalence and incidence ratios found for asylum seekers compared with the reference population may have been caused by the accumulation of risk factors such as genetic susceptibility, sweeping economic change, lifestyle factors and stress related to migration and the asylum context. Differences in risk from that in the reference population were larger for women than for men. This finding is consistent with studies on migrants in Canada and Sweden [1,5]. The higher risk as from the 30–39 year age group in comparison with the reference population adds to evidence from other studies that migrants are younger at diabetes onset [2,3,6].
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The present study is the first to provide data for migrants in Western host countries for various countries of origin. The higher risks found for most countries of origin compared with the reference population correspond to higher diabetes prevalence rates in most countries of origin. The most recent estimates of the International Diabetes Federation for African countries are lower than the estimate for the Netherlands (5.9%). Sudan is an exception with an estimated rate of 9.1% [15]. Non-African countries have estimated prevalence rates > 1.5 times higher than for the Netherlands, e.g. Iran (10.6%), Iraq (9.7%), Syria (9.6%) and China (8.8%). The high risks that we found for asylum seekers from Somalia are in striking contrast to the International Diabetes Federation estimates for Somalia of only 3.9% [15]. It should be noted, however, that the International Diabetes Federation estimates have a considerable level of uncertainty because of the limited availability of primary data, particularly in countries at war [15,30]. The particularly high diabetes risk for asylum seekers from Somalia is noteworthy. Several qualitative studies among Somali immigrants in Western host countries document that high diabetes risks in this population have already been noticed in practice [31,32]. The relatively low prevalence for asylum seekers from Iran may be an example of selection mechanisms. Iranian asylum seekers have a relatively high educational level, which in general is associated with lower diabetes risk [33]. The high diabetes prevalence for Sri Lankan men and women is in line with findings for Sri Lankan migrants in other Western host countries [34–36].
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Table 4 Number of cases and incidence of recorded diabetes as from 6 months after arrival, standardized incidence ratios compared with the reference population and relative risk compared with the 6–11-month interval by gender and length of stay*
Length of stay at start interval Men
Women
6–11 months (ref.) 12–23 months 24–35 months 36–47 months 48–59 months 60–108 months 6–11 months (ref.) 12–23 months 24–35 months 36–47 months 48–59 months 60–108 months
Recorded cases of diabetes
No. personyears
Incidence per 1000 person-years
44 34 29 25 20 26 30 45 22 18 19 31
13,222 18,752 12,720 8,812 5,754 8,132 7062 10 274 7403 5505 3695 5773
3.33 1.81 2.28 1.50 3.48 3.20 4.25 4.38 2.97 3.27 5.14 5.37
Comparison with reference population
Comparison with 6-11 months interval*
Standardized incidence ratio
95% CI
Relative risk
2.11 1.12 1.29 1.50 1.73 1.39 2.34 2.35 1.52 1.61 2.39 2.39
1.53–2.80 0.77–1.54 0.87–1.83 0.97–2.18 1.05–2.61 0.91–2.01 1.58–3.29 1.72–3.12 0.96–2.27 0.96–2.50 1.44-3.66 1.63-3.35
1 0.58 0.59 0.66 0.66 0.46 1 1.13 0.64 0.64 0.84 1.00
95% CI
0.36–0.93 0.34–1.02 0.38–1.16 0.35–1.25 0.22–0.96 0.70–1.85 0.35–1.19 0.34–1.23 0.43-1.66 0.51-1.99
*Cox regression model included country of origin, age (as continuous variable) and calendar year at start interval.
Across all the length-of-stay intervals, the incidence rates were persistently higher than in the reference population. This implies that, with increasing length of stay, the difference in prevalence between asylum seekers and the reference population may increase. The pattern observed in female asylum seekers of a decrease in the incidence ratio compared with the reference population after 2 years, followed by an increase as from 4 years after arrival, is striking. This pattern may be related to a combination of factors such as catching-up of diabetes diagnosis in the first years after arrival, the possibility of varying stress levels over time, and effects of changes in lifestyle and overweight. A longitudinal study from the Netherlands showed that the diabetes risk may continue to increase after the granting of asylum status (M Lamkaddem, ML Essink-Bot, WD Deville´, AA Gerritsen and K Stronks; unpubl. data). The difference in prevalence with the host population may, in line with studies in general migrant groups, continue to increase long after arrival in the host country [6,17]. Asylum populations in other Western host countries are also likely to be at high risk of diabetes as they largely originate from the same countries of origin as asylum seekers in the Netherlands and are likely to share diabetes risk factors. Nevertheless, it should be taken into account that the diabetes risk may be influenced by the demographic composition of the asylum population, conditions in the host country and distribution of length of stay [3]. Furthermore, the ratio between diagnosed and undiagnosed diabetes cases may vary between host countries as this may be influenced by differences in the accessibility and quality of healthcare for asylum seekers [18]. The high diabetes prevalence among asylum seekers shortly after arrival and the likelihood of further increase
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in risk over time suggest that diabetes among asylum seekers and refugees is a problem of considerable public health importance in Western host countries. The public health actions needed can build upon the actions formulated for migrants in general [36]. Raising diabetes awareness and supporting asylum seekers to develop a physically active lifestyle and healthy dietary habits in their new environment and reducing stress as from shortly after arrival are important [36,37]. Interventions aimed at increasing physical activity may have large effects as this would contribute to stress reduction, a risk factor for diabetes that is highly prevalent among asylum seekers. Policy-makers may play an important role in the prevention of diabetes by creating the conditions that stimulate asylum seekers and refugees to be physically active. Research is needed to provide insight into which interventions work and into the diabetes risk in refugee populations with longer lengths of stay. To ensure early identification of diabetes, health professionals should be aware of the high diabetes risks among asylum seekers and refugees. Evidence suggests that diabetes screening for recently arrived asylum seekers and refugees aged ≥ 35 years may be indicated [4]. Funding sources
The Netherlands Association for Community Health Services funded the creation of the database used in this study. The organization had no involvement in study design, data analysis or manuscript writing.
Competing interests
None declared.
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Acknowledgements
We would like to thank Hennie Nijsingh for reading and commenting on draft versions of the manuscript and The Netherlands Association for Community Health Services which funded the creation of the database of the Community Health Services for Asylum Seekers.
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Supporting Information
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Appendix S1 Standardized prevalence ratios of recorded diabetes in the first 6 months after arrival and standardized incidence ratios of recorded diabetes as from 6 months after arrival in comparison with the reference population and relative risks by gender and country of origin.
Additional Supporting Information may be found in the online version of this article:
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