Spatial Distribution of Type 2 Diabetes and its Geographical Patterns

Spatial Distribution of Type 2 diabetes and its
geographical report
Introduction:
Diabetes is a common life-long health condition. According to Diabetes

UK, around 3.5 million people in the UK are diagnosed with Diabetes and
around 549,000 people who have the condition, but don’t know it.
(Diabetes UK). Moreover, Type 2 diabetes is a serious condition where
the insulin in our pancreas cannot work properly, or our pancreas
cannot make enough insulin. This means our blood glucose (sugar)
levels remain in fluctuation and most likely higher than the normal
range. According to Harvard Medical School, Type 2 diabetes is a
chronic disease and it is characterized by high levels of sugar in the
blood. Type 2 diabetes is also called type 2 diabetes mellitus and adult-
onset diabetes. That is because it used to start almost always in middle-
and late-adulthood. However, more and more children and teens are
developing this condition. Type 2 diabetes is much more common than
type 1 diabetes, and is really a different disease. But it shares with type 1
diabetes high blood sugar levels, and the complications of high blood
sugar.
Nonetheless, according to centre of diabetes control and prevention, there

is not a cure yet for diabetes, except losing weight, eating healthy food,
and being active can really help. Taking medicine as needed,
getting diabetes self-management education and support, and keeping
Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 1|Page

health care appointments can also reduce the impact of diabetes on our
life. Diabetes is one of the top 10 causes of death globally. Together with
cardiovascular disease, cancer and respiratory disease, these conditions
account for over 80% of all premature non-communicable diseases
(NCDs) deaths.
Additionally, World Health Organisation (WHO) on 14 November always

commemorate diabetic day to observe the graph of diabetes across the
globe. WHO also has spread awareness of diabetes as a chronic,
metabolic disease characterized by elevated levels of blood glucose (or
blood sugar), which leads over time to serious damage to the heart, blood
vessels, eyes, kidneys and nerves.
According to WHO, the most common is type 2 diabetes, usually in adults,

which occurs when the body becomes resistant to insulin or doesn't make
enough insulin. In the past three decades the prevalence of type 2
diabetes has raised dramatically in countries of all income levels. Type 1
diabetes, once known as juvenile diabetes or insulin-dependent diabetes,
is a chronic condition in which the pancreas produces little or no insulin by
itself. For people living with diabetes, access to affordable treatment,
including insulin, is critical to their survival. Anyhow, there is a globally
agreed target to halt the rise in diabetes and obesity by 2025.

About 422 million people worldwide have diabetes, the majority living in
low and middle-income countries, and 1.6 million deaths are directly
attributed to diabetes each year. Both the number of cases and the
prevalence of diabetes have been steadily increasing over the past few
decades..
Types of Diabetes
There are two common types of diabetes
 Type 1 Diabetes – where the body’s immune system attacks and

destroys the cells that produce insulin.
 Type 2 Diabetes – where the body doesn’t produce enough insulin, or the

body’s cells don’t react to insulin.

Causes of Type 2 Diabetes
Our pancreas makes a hormone called insulin. It helps your cells

turn glucose, a type of sugar, from the food you eat into energy.
People with type 2 diabetes make insulin, but their cells don't use
it as well as they should.
At first, your pancreas makes more insulin to try to get glucose into

your cells. But eventually, it can't keep up, and the glucose builds
up in your blood instead.
Usually, a combination of things causes type 2 diabetes. They

might include:
 Genes. Scientists have found different bits of DNA that affect

how your body makes insulin.
 Extra weight. Being overweight or obese can cause insulin
resistance, especially if you carry your extra pounds around
your middle.
 Metabolic syndrome. People with insulin resistance often
have a group of conditions including high blood sugar, extra
fat around the waist, high blood pressure, and high
cholesterol and triglycerides.
 Too much glucose from your liver. When your blood sugar
is low, your liver makes and sends out glucose. After you eat,
your blood sugar goes up, and your liver will usually slow

down and store its glucose for later. But some people's livers
don't. They keep cranking out sugar.
 Bad communication between cells. Sometimes, cells send
the wrong signals or don't pick up messages correctly. When
these problems affect how your cells make and use insulin or
glucose, a chain reaction can lead to diabetes.
 Broken beta cells. If the cells that make insulin send out the
wrong amount of insulin at the wrong time, your blood sugar
gets thrown off. High blood sugar can damage these cells,
too.

For some people with type 2 diabetes this can eventually tire the
pancreas out, meaning their body makes less and less insulin. This
can lead to even higher blood sugar levels and mean we are at risk
of hyperglycaemia.
Signs and symptoms of type 2 diabetes
When we have type 2 diabetes our body can’t get enough glucose into
our cells, so a common symptom is feeling very tired. There are also
other symptoms to look out for. These include feeling thirsty, going
to the toilet a lot and losing weight without trying to.
The symptoms of type 2 diabetes can develop more slowly than the
symptoms of type 1 diabetes, making the condition harder to spot.
That’s why a lot of people don’t get any symptoms, or don’t notice
them.
Treatment of the Type 2 diabetes

There are a number of different ways to treat type 2 diabetes, such as
making healthy lifestyle choices, using insulin or taking medication.
Type 2 and insulin
We may not need to use insulin straight away but many people with type
2 diabetes need to use insulin as treatment at some point.
Some people have very high blood sugar levels when they are first
diagnosed and insulin can be used as a short-term treatment to help
quickly bring down their blood sugar levels.
Some people may need to take insulin for a particular reason, like
during pregnancy, a severe illness, or after surgery. But there may
also a need to start insulin as a treatment if other medications have
not helped managed blood sugar levels or are not appropriate.
It’s still important to keep going to our appointments and manage our
condition with healthy lifestyle choices. Staying active and eating
a healthy diet will reduce the risk of complications from our diabetes.
Risk factors of type 2 diabetes
There are several factors that can affect our risk of developing type 2
diabetes. Because the symptoms of type 2 diabetes are not always
obvious, it’s really important to be aware of these risk factors. They
can include:
 our age
 if we have a parent, brother, sister or child with diabetes

 our ethnicity
 high blood pressure
 being overweight
Type 2 diabetes is far more common than type 1. In the UK, around 90%
of all adults with diabetes have Type 2. (NHS)
Literature reviews:
i. In 2016 National Library of Medicine published an article in which

various German doctors K. Boris et al in their collective article
namely “Spatial Distribution of Type 2 Diabetes Mellitus in Berlin”
conducted a research and clinical practice study in Peru (country in
west South America) that aimed to estimate the incidence and risk
factors for T2D in four settings with different degree of urbanization and
altitude in Peru.
This was a prospective cohort study conducted in urban, semi-urban,

and rural areas in Peru. An age- and sex-stratified random sample of
participants was taken from the most updated count of population.
People who had fasting blood glucose of ⩾7.0 mmol/L or taking anti-
diabetic medication were considered to have T2D. The study
concluded that T2D was more prevalent in high altitude sites.
New cases of diabetes were largely attributed to obesity, but with

substantial variation in the contribution of obesity depending on the

environment. These findings can inform appropriate context-specific
strategies to reduce the incidence of diabetes.
Moreover, an ordinary least squares regression model (OLS) was

applied to identify population-based risk factors of T2D. A
geographically weighted regression model (GWR) was then
constructed to analyse the spatially varying association between the
identified risk factors and T2D.
T2D is especially concentrated in the east and outskirts of Berlin. The

OLS model identified proportions of persons aged 80 and older,
persons without migration background, long-term unemployment, and
households with children and a negative association with single-
parenting households as socio-demographic risk groups.
The results of the GWR model point out important local variations of
the strength of association between the identified risk factors and T2D.
The risk factors for T2D depend largely on the socio-demographic
composition of the neighbourhoods in Berlin and highlight that a one-
size-fits-all approach is not appropriate for the prevention of T2D.
ii. Following the research conducted in Peru, another study was

conducted by International Journal of Health Geographic which
further investigated if location affects the risk factors for Type 2
Diabetes. Type 2 Diabetes (T2D) has high rates of potentially
preventable complications but it is a very cost-intensive disease,
therefore, provision of healthcare as well as access to preventive
measures is necessary to reduce the burden of T2D. This study
applied a bivariate, adaptive kernel density estimation (KDE) to display

the spatial heterogeneity of type 2 diabetes. The data was anonymized
and was geocoded based on exact street-level data using the ESRI
ArcGIS geocoder.
The data included only age in broad age categories (0–5, 6–11, 12–17,
18–24, 25–44, 45–64, 65–79 and 80 and older) and the address
coordinates. High-risk areas for type 2 diabetes were detected by
spatial scan statistic (SaTScan). Global and local spatial regression
models were then constructed to analyse socio-demographic risk
factors of T2D.
The results showed high prevalence of Diabetes in rural areas around

Berlin. There was relatively low concentration of T2 Diabetes in the
centre of larger villages or urban areas. The risk factors for T2
Diabetes consist of proportions of 65–79 year olds, 80 + year olds,
unemployment rate among the 55–65 year olds, proportion of
employees covered by mandatory social security insurance, mean
income tax, and proportion of non-married couples.
iii. Furthermore, The Royal Society Open Science published an article in

2015 based on the research carried out by B. Jannah et al. It was
investigated hat with the rising incidence of type II diabetes mellitus
(diabetic type II) worldwide, methods to identify high-risk geographical
areas have become increasingly important.
A total of 1894 potentially relevant citations were identified and

different studies were included if spatial methods were used to explore
outcomes of diabetic type II or type I and 2 diabetes combined.
Moreover, descriptive tables were used to summarize information from
Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 10 | P a g e

included studies out of which ten spatial studies conducted in the USA,
UK and Europe were considered to be most relevant ones.
They defined spatial studies as studies involving aggregate or point-

level spatial information. This broad definition includes ecological and
multi-level studies, and models with correlated and uncorrelated spatial
effects.
It was researched that about 11.3% of the USA and 4.45% of the UK
adult population are estimated to have diabetes and diabetic type II
accounts for 90–95% of these cases. Diabetes was considered to be
the leading cause of renal failure, non-traumatic lower-limb amputation,
and new cases of blindness, the major cause of heart disease and
stroke, and the seventh leading cause of death in the USA.
The direct and indirect costs of diabetes are estimated to exceed USD
612 billion in the USA in 2014 and onwards whereas £23.7 billion in the
UK in 2011 and AUD 14.6 billion in Australia in 2010 as per the figures
calculated. The authors used the chart below to figure out the
overgrowing impact of diabetes
Factors associated with increased risk of developing type II

diabetes mellitus.
demographic factors metabolic markers
male gender elevated fasting plasma

glucose

increasing age elevated 2-h post-prandial
glucose
increasing BMI elevated random glucose
indicators of low socio-economic status elevated triglyceride: high-

(education, income, occupation) density lipoprotein ratio
increasing waist: hip ratio white cell count
increasing waist: height ratio elevated HbA1c
black/Hispanic ethnicity elevated interleukin-2

receptor A
sedentary lifestyle/physical inactivity elevated adiponectin
smoking history elevated C-reactive protein
excessive alcohol use elevated ferritin
low levels of fruit and vegetable elevated Ga-glut amyl

consumption trans peptidase

— elevated insulin level
clinical factors environmental factors
hypertension reduced green

space/walkability
cardiovascular disease increased fast-food

availability
tachycardia less access to healthy food
family history of diabetes in first degree car-dominated transport

relative
history of gestational diabetes reduced opportunities for

exercise
corticosteroid use lower SES
— higher proportion of daily

clinical factors environmental factors
smokers
Nevertheless, the diagnosis of diabetic type II appears to be related

with diagnosis of several other disorders, including hypertension,
coronary arterial disease, congestive heart failure, chronic obstructive
pulmonary disease, colorectal cancer, pancreatic cancer, endometrial
cancer, acute pancreatitis, biliary disease, psoriasis, urinary tract
calculi and diagnosis with high-grade prostate cancer. Spatial analysis
allow examination of joint spatial correlations between multiple
diseases, and describing these methodologies would be useful for
future research into geographical associations between these
diseases.
Additionally, a systematic review was conducted to identify all articles

published between January 1950 and June 2013 involving spatial
methodology to examine outcomes of diabetic type II, or diabetic type I
and diabetic type II combined. The eight steps of the Cochrane
Collaboration guidelines for a systematic review below were followed:
 step 1: defining the review questions and developing criteria for

including studies;
 step 2: searching for studies;
 step 3: selecting studies and collecting data;
 step 4: assessing risk of bias in included studies;
 step 5: analysing data and undertaking meta-analyses;

 step 6: addressing reporting biases;
 step 7: presenting results and ‘summary of findings’ tables; and
 Step 8: interpreting results and drawing conclusions.
Overall, 1854 citations were excluded on the basis of abstract

information and full manuscripts were obtained and examined for 37
articles, and 10 studies met selection criteria, of which three used
Bayesian spatial methodology and seven used classical modelling
techniques. Risk of bias was assessed as mentioned in steps and
coverage bias was a possibility with all studies included but difficult to
assess. Other types of bias described in the Cochrane Handbook,
including selection, performance, detection, attrition and reporting bias,
relevant to studies comparing two arms, were less relevant to the
spatial studies included.
A descriptive analysis was performed accordingly. Owing to large

differences in outcomes measured and methodology used between
studies, meta-analysis was not possible, nor was publication bias able
to be assessed via funnel plots and sensitivity analyses.
Anyhow, the management of Diabetic type II is complex and time-

consuming and may involve regular health consultations, lifestyle
modification, frequent blood glucose and podiatry checks and complex
medication regimes.
Fortunately, there is evidence that around 60% of Diabetic type II

cases are preventable with lifestyle change and/or medications. Early
detection and management of glycaemic control and cardiovascular
risk factors should lead to more effective treatment while reducing the
risk of diabetic complications. Screening for undiagnosed cases using

a fasting plasma glucose test thus has the potential to significantly
reduce the healthcare burden of Diabetic type II. Effective placement of
screening services can be determined using spatial analysis of
Diabetic type II outcomes to identify areas of high risk .
iv. One of the most leading article “Investigating the Spatial

Distribution of Diabetes in Africa Using Both Classical and
Bayesian Approaches” written by Dr Siaka Lounge in 2017 has also
contributed a step towards a great success in spatial distribution of
type 2 diabetes. Dr Lounge in his research described Diabetes as
below:
“Diabetes is a chronic condition that occurs when the body

cannot produce enough insulin or cannot use insulin and is
diagnosed by the observation of a rise in the level of glucose in
the blood (International Diabetes Federation IDF, 2015; ADA,
2014). Insulin is a hormone produced in the pancreas which is
required to transport glucose from the bloodstream into the body
cells where it is used as energy. A person with diabetes is
characterized by the lack or ineffectiveness of insulin in the body
and the resulting circulation of glucose in the blood.”
Moreover, Dr Lounge has also suggested that on the African continent

where diabetes was once rare, there has been a tremendous increase
in its prevalence due to an increase in economic development.
According to IDF (2015), in Africa, the adult population (age 20-69)
with diabetes is 441 million, with a projection of 926 million in 2040 and
a regional prevalence of 3.2% with a projection of 3.7% in 2040.

In Africa, an increasing and alarming issue is the fact that people’s
lifestyles are becoming more sedentary, unhealthy eating habits are
becoming widely adopted, and urbanization is increasing. These are
environmental factors contributing to the rise of diabetes prevalence on
the continent. Type 2 Diabetes is the common type of diabetes which
affects 90% of the people who have diabetes (IDF, 2015).
However, according to Dr Lounge diabetes is now considered to be a

common disease in Africa, a situation that seemed to have remained
virtually static until recent years. Indeed, from 1959 to the mid-1980s,
medical statistics showed that the prevalence of diabetes in Africa was
equal to or less than 1.4%, apart from South Africa, where the rate was
estimated to be as high as 3.6% in 2001 (Motala, 2002; Motala et al.,
2003; Omar et al., 1993). As at 1994, the continent-wide prevalence of
diabetes mellitus stood at 3 million and was then predicted to double or
triple by the year 2010 (Peer et al., 2014, Sobngwi et al., 2012,
Sobngwi et al., 2001, Kengne et al., 2013).

Approximately 7.1 million Africans were said to be suffering from
diabetes at the end of 2000, a figure that was expected to rise to 18.6
million by 2030 (Wild et al., 2004). According to Organisation (2000),
an estimated 2.9 million people died globally from diabetes in 2000, i.e.
a case-fatality rate (CFR) of 0.0161. Also, in 2000, the prevalence of
diabetes in the WHO African Region was estimated at 7.02 million
people, out of which about 0.702 million (10%) people had type 1
diabetes and 6.318 million (90%) had type 2 diabetes (IDF, 2015). It
was also estimated that about 113,100 people died from diabetes-
related causes, 561,600 were permanently disabled, and 6,458,400
experienced temporary disablement (IDF, 2015, Whiting et al., 2011).
It is also of an important notion that Dr Lounge has indicated that by

2030, the prevalence of type 2 diabetes in the Middle East, Indian,
South Asia and Sub Sahara Africa is expected to increase by more
than 150% (Hossain et al., 2007). Diabetes has been associated with
poverty in low and high-income countries, compared to middle-income
countries where it is associated with overconsumption of high fats
foods with low or no physical activity due to urbanization (Aspray et al.,
000; Assah et. al., 2011).

Furthermore, the South East-Asia (SEA) region, consisting of India, Sri
Lanka, Bangladesh, Bhutan, and Mauritius and Maldives, was
home to more than 72 million adults with diabetes in 2013 and is
expected to exceed 123 million in 2035, with a substantial number
(24.3million) of people also having impaired glucose tolerance (IGT)
(IDF, 2015). A sharp increase in the prevalence has been observed in
the SEA Region, both in urban and rural areas, which is mostly
associated with the lifestyle transitions towards urbanization and
industrialization.
The highest prevalence in the South East-Asia region is found in

Mauritius 14.8% and followed by India 9.1%. Study have highlighted
that Asian Indians have a higher risk of diabetes compared to other
Asians, whether they are living in their land of birth or in an affluent
foreign country (Ramachandran et. al., 2010).
Thus far, a strong relationship has been found between population age
and diabetes according to Dr Lounge, as indicated. Diabetes has also
been found to increase the risk of dementia (Shaw et al., 2010, Booth
et al., 2006, Biessels et al., 2002, Wang et al., 2014). Studies show
that diabetes is rising globally, particularly in Africa due to population
ageing and rapid urbanisation (Hall et al., 2011, Assah et al., 2011,
Mbanya et al., 2010, Kanmogne et al., 2010, Lim et al., 2012, De
Ramirez et al., 2010, Wang et al., 2014). Since the risk of developing
diabetes increases with age, the global aging of the population,
especially Africa, is a major driver of the global rise in diabetes.
According to IDF (2015), by 2035, diabetes peak in Africa is expected
to be in the oldest individuals.

Conclusively, all the past studies reviewed, it has been found that risk
factors such as population age, obesity, alcohol consumption,
urbanization, physical inactivity, and access to care, all have a
significant association with diabetes prevalence and this justifies the
selection of these variables as risk factors for diabetes.
Not only this, Dr Lounge had succeeded in collecting data using

various methods and algorithms such as Shapiro–Wilk Normality
Test, Spearman Rho Correlation Test, Geographic Weighted
Regression (GWR), 𝑦𝑖 = 𝛽0 + ∑𝑘 𝛽𝑘 𝑥𝑖𝑘 + 𝜀 and most importantly
Spatial Analysis in which Dr Lounge discussed the spatial
configuration/distribution of diabetes prevalence through clustering with
the aim of showing the pattern of a disease cluster which is divided into
three sub-sections that explains the importance of investigating
disease clustering and its classification and describes the statistical
methods for computing spatial analysis of a geographical distribution
area.
Anyhow, this study is significant, as it aims to reveal the underlying

high-risk factors of diabetes and hotspots countries in Africa. Countries
and regions with a similar pattern of the prevalence will be revealed
and this could aid the approach in curbing the disease collectively.
v. In 2019, G. Weiwei et al also have successfully achieved a milestone

by introducing a thorough analysis on Spatial Distribution of Type 2
Diabetes in China as evident from their combined article “Type 2
diabetes mellitus and neighborhood deprivation index: A spatial
analysis in Zhejiang, China”. According to the authors the type 2
diabetes mellitus data analysed in the present study came from a

population-based diabetes registry system maintained by Zhejiang
Provincial Centre for Disease Control and Prevention (Zhejiang CDC).
Type 2 diabetes mellitus cases between 2012 and 2016 were routinely
reported to the Zhejiang CDC diabetes surveillance system and
verified by the provincial Non-Communicable Disease program.
As per the article, all the cases that had elevated blood glucose
according to at least one of the following World Health Organization
criteria are random plasma glucose ≥11.1 mmol/, Fasting plasma
glucose ≥7.0 mmol/L; or 2-h plasma glucose value after the oral
glucose tolerance test ≥11.1 mmol/L; and presented classic symptoms
and were diagnosed as diabetes . A different approach was used in this
case study in which satellite-derived night-time light was extensively
used as an efficient proxy measure for monitoring urbanization
dynamics and socioeconomic activity. For the purposes of better and
significant results, local indicators of spatial association (LISA) to detect
clusters and outliers and as expected, the result of LISA analysis for
NDI suggested the hot spots persisted in eight cities’ centres, except
Lishui city; the cold spots were detected in the west and south of
Zhejiang, which were considered as the relatively deprived areas.
Visual comparison of the spatial pattern of type 2 diabetes mellitus
incidence with NDI pattern and can clearly be seen that the risk of type
2 diabetes mellitus was roughly prevalent in the relatively affluent
areas, consistent with the results shown.

Conclusively, the present study showed spatial variation in type 2 diabetes
mellitus incidence and neighbourhood deprivation index at the finest scale
in Zhejiang. The spatial and place based methods aid future investigators
to improve understanding of the association between neighbourhood
deprivation and type 2 diabetes mellitus in developing countries.
It is very stimulating that type 2 diabetes mellitus incidence is higher in

well-heeled areas than the deprived areas across the study period. The

implication is that health prevention and programs can be focused to
specific neighbourhoods of high risk to better meet their health needs.
There is not a one-size-fits-all strategy for all neighbourhoods within a
large-scale area.
It is suggested that the policymakers should enhance the public

knowledge of the risk factors for type 2 diabetes mellitus and strongly
promote community based chronic disease organisation programs for
urban areas. Meanwhile, it should also be realized that a non-trivial
proportion of people living with diabetes in rural China has not been
diagnosed. Diabetes detection was not proportional to the primary
incidence. Therefore, improving the quality of the local public health
service and reinforcing access to routine health checks in the relatively
deprived rural areas could be a key priority for policymakers and
practitioners.
vi. In 2015, American Diabetes Association (USA) also published an

article “Spatial Patterns of Structural Brain Changes in Type 2
Diabetic Patients and Their Longitudinal Progression with Intensive
Control of Blood Glucose” by Dr Guray Erus and Christos
Davatzikos to find out structural changes in brain due to Type 2 Diabetes.

The purpose of this investigation was to examine whether diabetes
characteristics were associated with spatially specific patterns of brain
changes and whether those patterns were affected by intensive versus
standard glycaemic treatment.

ADA used the baseline MRIs of 488 participants with type 2 diabetes
from the Action to Control Cardiovascular Risk in Diabetes-Memory in
Diabetes (ACCORD-MIND) study and applied a new voxel-based
analysis methodology to identify spatially specific patterns of grey
matter and white matter volume loss related to diabetes duration and
HbA1c. The longitudinal analysis used 40-month follow-up data to
evaluate differences in progression of volume loss between intensive
and standard glycaemic treatment arms.
The studies showed that the regions in which cognitive change was
associated with longitudinal volume loss had only small overlap with
regions related to diabetes duration and to treatment effects. Also, this
is the first study to use pattern analysis methods to investigate the
spatial specificity of patterns of brain volume loss in relation to diabetes
duration and HbA1c.
Research applied methods to find the spatial patterns of treatment

effects on brain structure in a large diabetes clinical trial and using
state-of-the-art pattern analysis methodology as well. Anyhow, it was
expressed by the doctors that participants with longer diabetes

duration had significantly reduced GM volumes in a number of brain
regions and the frontal and temporal lobes were particularly more
vulnerable to diabetes effects. The purpose of this article is to show
that type 2 diabetes not only have an adverse impact on our bodies but
how chemical changes also take place both in our brain and body.
vii. In 2017, European Journal of Public Health published article

“Ethnicity and place: the geography of diabetes inequalities under
a strong welfare state” followed by research of K. Anne et al. The
purpose of this article is to target the structural inequalities, distinct
health in Norway. The examiners examine the social geography of
diabetes in Oslo to examined whether the link between ethnicity and
diabetes is confounded by place and hence using data from the 2002
Oslo Health Study to fit logistic regression models, assessing whether
contextual factors, such as the concentration of fast food outlets,
predict self-reported diabetes outcomes after controlling for relevant
individual level covariates. They also tested for spatial autocorrelation
in the geographical distribution of diabetes and in consequence their
findings suggested that the organisation of urban space and the spatial
distribution of health-related resources exert an independent effect on
diabetes prevalence, controlling for ethnicity and other covariates.
Living on the east side of Oslo had also increases the odds of suffering
from diabetes by almost 60%, whilst living in a neighbourhood
characterized by a relative concentration of fast food and relative
absence of healthy food shops and physical exercise facilities
upsurges the probabilities by 30%.

Also, using the Morans I Statistics Calculations it was revealed that out
of the 17,325 individuals who completed the Oslo Health Study
questionnaire, 741 reported diabetes (4.3%). However, the distribution
of cases seems to be highly unequal across spatial contexts and
diabetes seems to be cluster in the eastern regions of Oslo, with the
eastern districts counting 659 total cases with 5.4% ratio, and for the
western districts it was 1.6% with only 82 cases.he spatial
autocorrelation test, which simply assessed the degree of clustering of
diabetes prevalence across neighbourhoods, revealed that the test
statistic is highly significant: Moran’s I is equal to 0.58 (P value = 4.34
× 1 0−7), suggesting that the probability of suffering from diabetes is not
randomly distributed across Oslo’s capital. Therefore, it was suggested
that the subjective perception of neighbourhood characteristics is a
significant factor that impacts on health-related behaviours: viewing the
residential context and comparison of several tables and graphs such
as one below:

Spatially mediated variation in predicted probabilities of suffering from diabetes for
the six largest ethnic groups in Oslo. Each point represents a separate
neighbourhood. Circles designate eastern neighbourhoods, whilst triangles
designate western neighbourhoods.
Nonetheless, the research conducted was fruitful and it was founded

that the spatial context and toxic environments contribute to diabetes
inequalities in Oslo, Norway and future research and policy-making
should take the geography of health disparities into account.

viii.In 2019, The University of Canterbury published an article written by
Jesse Diamond, “The built environment and health: a spatial
analysis of type 2 diabetes and childhood weight status in urban
New Zealand”. The prime focus that the author had in this article was
the impacts on health outcomes of high weight status in children and
population level Type 2 Diabetes Mellitus (T2DM). According to the
author, the prevalence of these health issues has increased alongside
societal, demographic and cultural changes. The author had used an
ecological approach to analysis which utilises Geographic Information
Systems (GIS) and spatial epidemiological methods. However, it is
believed that this was the first study in New Zealand to spatially
quantify the effects of multiple environmental exposures on health
outcomes of both high weight status in children and population level
T2DM, for all urban areas, using a geospatial approach.
It established the novel measures of the built environment using data

on fast food outlets, takeaways, dairy/convenience stores,
supermarkets, fruit and vegetable stores, physical activity facilities, and
greenspace to assess potential associations between contextual
factors and health outcomes. In the context of this study, the former
three of these categories were considered to be unhealthy contacts
and detrimental to overall health. The latter four categories, in disparity,
were considered to be vigorous acquaintances and health-promoting.
Such analysis also provides the opportunity to assess how the built
environment may relate to not only outcomes of multiple chronic health
conditions, but also different population groups.
When considering relationships between measures of the built

environment and socioeconomic deprivation, results of this study

indicated that approachability to both and unhealthy and healthy
exposures is generally higher in the most deprived areas compared to
the least deprived areas. It was also found that some notable results
when looking at the spatial distribution of both high weight status in
children and population level T2DM, finding that T2DM are more
spatially clustered than high weight status in children. Both health
outcomes were also shown to be heavily influenced by demographic
factors and associated with accessibility to environmental exposures.
Captivatingly, results display that both of these health issues may be

more heavily influenced by health-promoting resources than those
considered detrimental to health. Health-promoting resources were
shown to have a consistently positive effect on both health outcomes,
while those considered detrimental to health showed varying, and
largely insignificant, associations. Caution must be exercised, however,
to ensure that a balanced approach is taken within prevention efforts
which addresses environmental factors as well as economic
accessibility, individual behaviours and societal norms.
ix. In 2012, Cambridge University Press published an article “Spatial

distribution of the risk for metabolic complications: an application
in south-east Brazil” based on finding of Nucci et al. The objective of
the study was to identify spatial variation in the risk for metabolic
complications (RMC) by means of a semi-parametric approach for
multinomial data. The authors used an association of abdominal
circumference and BMI as a combined form of risk assessment for type
2 diabetes, hypertension and CVD. This combined risk, called ‘risk for
metabolic complications’ (RMC) herein, was defined according to the
National Institutes of Health as in the table below:

The authors conducted a population-based cross-sectional study
between November 2006 and December 2007 in one of five health
districts of Campinas (São Paulo, Brazil) of area 128 km 2 and
estimated population 277 000 inhabitants. The sample was then
selected in two stages, households and individuals according to
records of Housing Department. The study samples were composed of
651 (89 %) local residents of 730 visited households. The samples
were then implemented on a routine based spatial risk functions for
epidemiological studies proposed by Bithell and the estimated spatial
risk through Generalized Additive Models (GAM).
The results were in line as to what was expected due to high rate of
type 2 diabetes as the sample was composed mostly of women (55·7
%), mean age was 41·6 (S D 12·5) years and more than half of the
sample (52·5 %) had studied for >8 years. Obesity (BMI ≥ 30·0 kg/m 2)
was present in more than 20 % of the total sample (17·0 % of men and
25·1 % of women). Overweight (BMI = 25·0–29·9 kg/m 2) was present
in about a third of the total sample (29·8 % of women and 36·5 % of
men). Abdominal circumference values above the upper limit (102 cm

for men and 88 cm for women) were found in 12·8 % of men and 39·7
% of women.
Besides, a third of men presented an increased RMC (33·0 %), while

almost a quarter of women (22·9 %) had very high RMC. Older people
presented very high RMC (21·4 % of those aged >55 years), although
increased RMC was seen for 25 % of individuals in all age categories.
RMC was more frequent among those with lower levels of education
(63·9 % for 0–4 years of study) than among the higher educated (51·2
% for >8 years of study).
Risk and protective areas for metabolic complications were identified

despite the distribution of the population according to gender, age and
schooling.
x. Hernandez et al., 2020, wrote an article “Geographic Variation and

Associated Covariates of Diabetes Prevalence in India” to
describe an association of diabetes with tuberculosis
endemicity at national scale.
This cross-sectional study included 803 164 men aged 15 to 54 years
and women aged 15 to 49 years who participated in the Demographic
Health Survey (2015-2016), carried out by the India Ministry of Health
and Family Welfare using a 2-stage clustered sampling, which included
a diabetes estimation component. The survey was conducted from
January 2015 to December 2016, and data analysis was conducted
from July 2018 to January 2019.

Moreover, a total of 7 covariates were included in the final model, as
sex, age, religion, marital status, alcohol consumption, smoking
tobacco, and body mass index (BMI; calculated as weight in kilograms
divided by height in meters squared); 4 control variables were added to
control for confounding, including educational level, rural or urban
residence, wealth index, and land travel friction.
When the results came it was found that among 803 164 sampled
individuals (691 982 [86.2%] women; mean [SD] age, 30.09 [9.97]
years), substantial geographic variation in diabetes prevalence in India
was found, with a concentrated burden at the southern coastline
(cluster 1, Andhra Pradesh and Telangana: prevalence, 3.01% [1864
of 61 948 individuals]; cluster 2, Tamil Nadup and Kerala: prevalence,
4.32% [3429 of 79 435 individuals]; cluster 3, east Orissa: prevalence,
2.81% [330 of 11 758 individuals]; cluster 4, Goa: prevalence, 4.43%
[83 of 1883 individuals]). Having obesity and overweight (odds ratio
[OR], 2.44; 95% CI, 2.18-2.73; P < .001; OR, 1.66; 95% CI, 1.52-
1.82; P < .001, respectively), smoking tobacco (OR, 3.04; 95% CI,
1.66-5.56; P < .001), and consuming alcohol (OR, 2.01; 95% CI, 1.37-
2.95; P < .001) were associated with increased odds of diabetes.
Regional TB endemicity and diabetes spatial distributions showed that
there is a lack of consistent geographical overlap between these 2
diseases (eg, TB cluster 4: 60 213 TB cases; 186.79 diabetes cases in
20 183.88 individuals; 0.93% diabetes prevalence; TB cluster 8: 47 381
TB cases; 180.53 diabetes cases in 22 449.18 individuals; 0.80%
diabetes prevalence; TB cluster 9: 37 620 TB cases, 601.45 diabetes
cases in 12 879.36 individuals; 4.67% diabetes prevalence).

Also, these areas comprised 40.44% of the total diabetes cases (8706
of 14 109), and prevalence was 3.68% (5706 of 155 023) in cluster
areas compared with 1.30% (8403 of 648 141) in non-cluster areas.
Prevalence of diabetes varied between clusters (cluster 3, east Orissa:
2.81% [330 of 11 758]; cluster 1, Andhra Pradesh and Telangana:
3.01% [1864 of 61 948]; cluster 2, Tamil Nadup and Kerala: 4.32%
[3429 of 79 435]; cluster 4, Goa: 4.43% [83 of 1883]) as seen in the
below tables:
Clusters and Interpolated Surface Prevalence Levels of Diabetes and Tuberculosis

The number of diabetes cases and prevalence in each category,
grouped by covariate and categorized between cluster and non-cluster
areas, was determined by additional aggregation analyses.
Additionally, Tuberculosis exposure levels from the surrounding areas

did not show a statistically significant association with diabetes at the
individual level, except for slightly higher odds in TB level 3 areas in
the adjusted model (odds ratio [OR], 1.16; 95% CI, 1.04-1.29; P = .03).
In contrast, age, BMI, smoking tobacco, and alcohol consumption
showed a positive association with reporting diabetes as evident
below:

Concluding the above, in this study, the observed spatial variation of
diabetes highlighted the existence of spatial clusters of diabetes at
different scales with heterogeneities at regional scales in India,
associated with behavioural and environmental covariates and partially
overlapping with TB endemicity in areas with a high prevalence of
diabetes. The results highlighted the need for more investment in early
detection of diabetes, identification of populations at risk, and

education about healthy life habits in the areas with high burdens.
Identifying diabetes in individuals with early TB symptoms should also
be encouraged, especially in southern states, where diabetes
prevalence is high, making the collision between both diseases highly
likely.
xi. Khan et al., 2014, published an article “The Geography of

Diabetes among the General Adults Aged 35 Years and Older in
Bangladesh: Recent Evidence from a Cross-Sectional Survey” .
Like other low and middle-income countries in South Asia, Bangladesh,
the eighth most populous country (with more than 153 million
population) in the world is also observing the rising prevalence of
diabetes. The assembled frequency of type 2 diabetes increased from
3.8% in 1995–2000 to 5.3% in 2001–2005 and to 9.0% in 2006–2010.
This country is predicted to be one of the top 10 countries worldwide
with 10.4 million cases with diabetes in 2030 in the age group of 20–
79, which were approximately 5.7 million in 2010. Such a rapid
increase in diabetes can be attributed to remarkable socioeconomic,
demographic and epidemiologic changes, which Bangladesh has
undergone over the last few decades.
However, geographical variations of sex-specific diabetes by place of

residence and region of residence among general adults (35+ years of
age) in Bangladesh has been used to see the variance in Diabetes and
for this purpose, the recent cross-sectional data, extracted from the
nationally representative Bangladesh Demographic and Health Survey
(BDHS) 2011 were used for this study. The BDHS 2011 was the sixth
round survey with previous surveys of 1993–94, 1996–97, 1999–2000,

2004, and 2007. It was conducted under the authority of the National
Institute of Population Research and Training (NIPORT) of the Ministry
of Health and Family Welfare. The ICF International, located in
Calverton, Maryland, provided all technical assistance to the survey
and following the questionnaires a total of 3,720 men and 3,823
women aged 35+ years participated in the fasting blood sugar testing,
were analysed.
Anyhow, the prevalence of diabetes was 10.6% in men and 11.3% in

women. Bi variable analyses indicated significant variations of diabetes
by both geographical variables. The prevalence was highest in city
corporations (men 18.0%, women 22.3%), followed by small towns
(men 13.6%, women 15.2%) and rural areas (men 9.3%, women
9.5%). Regional disparities in diabetes prevalence were also
remarkable, with the highest prevalence in Chittagong division and
lowest prevalence in Khulna division. Multivariable logistic regression
analyses provided mixed patterns of geographical disparities
(depending on the adjusted variables).
Consequently, it was revealed that more than 90% (both sexes) of the
adults aged 35 years or more had ever heard of diabetes with slightly
higher rate among men than women. Around 6% of the adults had ever
been told by a doctor or nurse that they had diabetes (men 5.2% and
women 6.6%). Only 4% of the informed adults (both sexes) having
diabetes were taking medicine (mostly orally) for diabetes.
The prevalence of diabetes (based on the fasting plasma glucose

testing) was around 9.6% for the total sample. Similarly, the prevalence
of pre-diabetes for the combined sample was 25% (men 25.6% and

women 24.8%). Combining both fasting plasma glucose outcomes and
being on diabetes treatment, the overall prevalence of diabetes was
11.0% with slightly higher prevalence among women (11.3%) as
compared to men (10.6%). Out of 390 men and 405 women aged 35
years and older with diabetes, 67.4% and 61.5% were not on
medication. Similarly, out of the total sample who were on medication,
only 32.6% men and 39.7% women had fasting plasma glucose.
Therefore, serious measure should be taken to avoid any further
increase in the occurrence of Type 2 Diabetes.
xii. In 2017, an article “Spatial analysis for prevalence of type 2

diabetes mellitus – A state investigation (Malaysia)” was written by
amin et al. As Malaysia is one of the many countries facing this
epidemic. Therefore, based on the increasing current trend of T2DM
patients’ cases from the National Diabetes Registry (NDR) Report from
2009 to 2012, there were approximately 2.6 million adults aged 18
years and above living with diabetes disease in Malaysia. Thereafter,
the above-named authors conducted few researches and
investigations to perform preliminary spatial analysis for the prevalence
of T2DM patients based on some factors.
Study population and Spatial Method were used in this research and
the secondary data of T2DM patients was collected from the Jabatan
Kesihatan Negeri Perlis (JKNP) and the NDR database for 2010 until
2016 which involved adults of age 17 years and the locations of the
subjects being analysed. Hence, for this study, spatial analysis was

also applied to investigate the prevalence of T2DM patients for the
studied state based on the nine health clinics (KKs).
In consequence, the total number of registered T2DM patients

fluctuates from different years. It seems that there were inconsistencies
with the total number of registered T2DM especially from 2012 to 2015
and that could affect the generalization made in the analysis later. In
specific, KK Kangar seems to be consistently recorded the highest
number of registered T2DM patients except for 2013. Considering the
previous data collected, it was estimated that in the coming years the
prevalence of the T2DM will rise vigorously.
xiii. BMJ Open also published an article in 2015, “Impact of geography

on the control of type 2 diabetes mellitus: a review of geocoded
clinical data from general practice” (Australia) by Mr Moyez Jiwa,
Ori Gudes, Richard Varhol and Narelle Mullan. Just like all
developed countries, Australia also conducted research to figure out
the number of populations suffering from T2DM.
This was one of the case studies which uses Geocoding which is a
process of enriching a description of a location, most typically a postal
address or place name, with geographic coordinates from spatial
reference data, such as street addresses or postal codes. Likewise,
Patient data were extracted from a general practice; Data for which
was extracted on 13 June 2014, and included all patients with
diabetes, as coded by the general practice. Only data related to
patients coded as having T2DM was considered for analysis. The
practice had computerised data for all their patients dating back 20

years in Western Australia. Iterative data-cleansing steps were taken.
Data were grouped into Statistical Area level 1 (SA1), designated as
the smallest geographical area associated with the Census of
Population and Housing. The data were analysed to identify if SA1s
with people aged 70 years and older, and with relatively high
glycosylated haemoglobin (HbA1c) were significantly clustered, and
whether this was associated with their medical consultation rate and
treatment. The analysis included Cluster and Outlier Analysis using
Moran’s I test.
Continuing with the analysis, the results were announced and all in all,
median age of the population was 70 years with more males than
females, 53% and 47%, respectively. Older people (>70 years) with
relatively high HbA1c comprised 9.3% of all people with diabetes in the
sample, and were clustered around two ‘hotspot’ locations. These 111
patients do not attend the practice more or less often than people with
diabetes living elsewhere in the practice. There was some evidence
that they were more likely to be recorded as having consulted with
regard to other chronic diseases.
Also, the average number of prescribed medicines over a 13-month

time period, per person in the hotspots, was 4.6 compared with 5.1.
Moreover, older patients with relatively high HbA1c were clustered in

two locations within the practice area. Their hyperglycaemia and
ongoing cardiovascular risk indicated causes other than therapeutic
inertia. The causes might be related to the social determinants of
health, which are influenced by geography.

Conclusion:
Following the above articles and the information obtained, It is strongly

suggested that to overcome the spread of Type 2 Diabetes in children,
adults and old people, a system of check and balance with consistently
monitors the lifestyle; including daily activities and diet is needed to be
maintained.
In order to achieve an effective lifestyle, modifications including

counselling on weight loss, adoption of a healthy dietary pattern like the
Mediterranean diet, together with physical activity are the cornerstone in
the prevention of type-2 diabetes. Therefore, emphasis must be given to
promoting a healthier lifestyle and finding solutions in order to increase
adherence and compliance to the lifestyle modifications, especially for
high-risk individuals.
Results from epidemiological studies and clinical trials evaluating the role
of the Mediterranean dietary pattern regarding the development and
treatment of type-2 diabetes indicate the protective role of this pattern. As
a result, promoting adherence to the Mediterranean diet is of considerable
public health importance as this dietary pattern, apart from its various
health benefits, is tasty and easy to follow in the long-term.
Diet is an important aspect in the management of a diabetic patient. The

diabetic healthcare provider and the patient should understand the basic
dietary needs of the patient. In this form, there may be plenty of insulin in
the bloodstream, but the cells are resistant to it. Glucose cannot easily get

into the cells, and it backs up in the bloodstream. Over the short run,
people with uncontrolled diabetes may experience fatigue, thirst, frequent
urination, and blurred vision.
In the long run, they are at risk for heart disease, kidney problems,
disorders of vision, nerve damage, and other difficulties.
The above charts are based on the ongoing figures since 2019 and it was
estimated that 463 million people (95% confidence interval: 369–601 million)

have diabetes in 2019 and the figures obtained were quite close to what was
expected. Given that half a billion people are living with diabetes, there is an
urgent need for developing and implementing multi-sectoral strategies to
tackle diabetes. Without urgent and sufficient actions, it is predicted that 578
million people will have diabetes in 2030 and the number will increase by
51% (700 million) in 2045. So, policymakers and practitioners should take an
extra step towards the better development of the same to overcome the
disease before half of the world’s populations is suffered from diabetes.

Spatial Distribution of Type 2 Diabetes and its Geographical Patterns

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Spatial Distribution of Type 2 diabetes and its

Diabetes is a common life-long health condition. According to Diabetes

Nonetheless, according to centre of diabetes control and prevention, there

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 1|Page

Additionally, World Health Organisation (WHO) on 14 November always

According to WHO, the most common is type 2 diabetes, usually in adults,

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 2|Page

There are two common types of diabetes

 Type 1 Diabetes – where the body’s immune system attacks and

 Type 2 Diabetes – where the body doesn’t produce enough insulin, or the

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 3|Page

Our pancreas makes a hormone called insulin. It helps your cells

At first, your pancreas makes more insulin to try to get glucose into

Usually, a combination of things causes type 2 diabetes. They

 Genes. Scientists have found different bits of DNA that affect

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 4|Page

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 5|Page

Signs and symptoms of type 2 diabetes

Treatment of the Type 2 diabetes

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 6|Page

Type 2 and insulin

Risk factors of type 2 diabetes

 if we have a parent, brother, sister or child with diabetes

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 7|Page

 high blood pressure

i. In 2016 National Library of Medicine published an article in which

This was a prospective cohort study conducted in urban, semi-urban,

New cases of diabetes were largely attributed to obesity, but with

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 8|Page

Moreover, an ordinary least squares regression model (OLS) was

T2D is especially concentrated in the east and outskirts of Berlin. The

ii. Following the research conducted in Peru, another study was

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 9|Page

The results showed high prevalence of Diabetes in rural areas around

iii. Furthermore, The Royal Society Open Science published an article in

A total of 1894 potentially relevant citations were identified and

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 10 | P a g e

They defined spatial studies as studies involving aggregate or point-

Factors associated with increased risk of developing type II

demographic factors metabolic markers

male gender elevated fasting plasma

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 11 | P a g e

increasing BMI elevated random glucose

indicators of low socio-economic status elevated triglyceride: high-

increasing waist: hip ratio white cell count

increasing waist: height ratio elevated HbA1c

black/Hispanic ethnicity elevated interleukin-2

sedentary lifestyle/physical inactivity elevated adiponectin

smoking history elevated C-reactive protein

excessive alcohol use elevated ferritin

low levels of fruit and vegetable elevated Ga-glut amyl

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 12 | P a g e

clinical factors environmental factors

hypertension reduced green

cardiovascular disease increased fast-food

tachycardia less access to healthy food

family history of diabetes in first degree car-dominated transport

history of gestational diabetes reduced opportunities for

corticosteroid use lower SES

— higher proportion of daily

Farkhanda Shahnaz Assignment-Geography Department (University of Punjab) (MPhil) 13 | P a g e

Nevertheless, the diagnosis of diabetic type II appears to be related

Additionally, a systematic review was conducted to identify all articles