Metabolic Profiles of Maori, Pacific, and European New Zealanders

Diabetes Care e1

Metabolic Profiles of Maori, Pacific, and Dahai Yu,1,2 Yamei Cai,1 Uchechukwu Levi Osuagwu,3 European New Zealanders With Type 2 Karen Pickering,4 John Baker,4,5 Diabetes Over 25 Years Richard Cutfield,4,6 Rawiri McKree Jansen,7 https://doi.org/10.2337/dc21-1255 Brandon J. Orr-Walker,4,5 Gerhard Sundborn,8 Zhanzheng Zhao,1 and David Simmons,1,3

The population of New Zealand includes was provided by an authorized signatory 55.1%, and 2.8% of patients took antihy- a high proportion of Maori (Indigenous for each general practice. pertensives, statins, and anticoagulants, Polynesian) and Pacific(Pasifika) people, Adjusted marginal mean SBP, BMI, respectively, with 10.0% using insulin who have been shown to experience HbA1c, TC, and TG over baseline and 1, 2, alone, 58.0% oral antidiabetes agents worsetype2diabetesmellitus(T2DM) 3, 4, and 5 years of follow-up among alone, and 17.6% both oral antidiabetes outcomes than New Zealand Europeans Maori, Pasifika, and NZE patients were agents and insulin. Compared with Maori (NZE), a phenomenon persisting for >20 estimated with mixed-effects models and Pasifika patients, the NZE patients years (1). It remains unclear which meta- with adjustment for baseline characteris- group was older, had the lowest depriva- bolic targets are not being achieved tics(age,sex,smoking,socioeconomic tion scores, and included fewer women concurrent with these long-standing dis- status); baseline outcomes (e.g., baseline and fewer current smokers. Antihyperten- parities in diabetes complications. In this BMI, HbA1c, TC, and TG for comparing sive and statin therapy use was lowest study we compared five key clinical SBP over time); baseline antihyperten- among Pasifika patients. Use of antidiabe- measurements routinely assessed in pri- sive, antidiabetes and lipid-lowering treat- tes agents and insulin was lowest among mary care (systolic blood pressure [SBP], ments and anticoagulant therapy; and NZE patients. fi BMI, HbA1c, total cholesterol [TC], and tri- the enrollment period as xed effects. Fig. 1 shows that the overall adjusted glyceride [TG]) over time among patients Multiple imputation with chained equa- marginal estimation (95% CI) of SBP at with T2DM from these three main ethnic tions was used to tackle the missing baselineand1,2,3,4,and5yearsof groups (Maori, NZE, and Pasifika). values. All statistical analyses were per- follow-up was significantly higher among For this study we used the Diabetes formed with Stata/MP 16.1. NZE than Maori and Pasifika patients, Care Support Service (DCSS), a primary Overall, 32,327 patients with T2DM while HbA1c was significantly higher care diabetes audit program linked with (49.4% of whom were female and 47.9% among Pasifika than among Maori national death registration, hospitaliza- NZE, 19.9% Maori, and 31.8% Pasifika; patients, who had a higher HbA1c than e-LETTERS tion, pharmaceutical claims, and socio- mean [SD] age 57.1 [13.8] years and dia- NZE patients. The overall adjusted mar- economic databases, to identify a cohort betes duration 4.8 [1.2] years) were ginal estimation of TC was similar across of patients with T2DM (1). Ethics review enrolled between 1 January 1994 and 31 the three ethnic groups at each time –

was waived by the New Zealand Health December 2013, had baseline measure- point, the overall adjusted marginal esti- OBSERVATIONS and Disability Ethics Committees on 25 ments, and were followed up over the mation of TG was higher among Maori March 2019. Signed consent to participate following 5 years. At baseline, 70.0%, and NZE than Pasiﬁka patients, and the

1Department of Nephrology, First Afﬁliated Hospital, Zhengzhou University, Zhengzhou, China 2Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, U.K. 3Macarthur Clinical School, Western Sydney University, Campbelltown, Sydney, Australia 4Diabetes Foundation Aotearoa, Otara, New Zealand 5Department of Diabetes and Endocrinology, Counties Manukau Health, South Auckland, New Zealand 6Department of Diabetes and Endocrinology, Waitemata District Health Board, Auckland, New Zealand 7National Hauora Coalition, Auckland, New Zealand 8Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand Corresponding author: David Simmons, [email protected], and Zhanzheng Zhao, [email protected] Received 15 June 2021 and accepted 14 July 2021 © 2021 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for proﬁt, and the work is not altered. More information is available at https://www.diabetesjournals.org/content/license. Diabetes Care Publish Ahead of Print, published online August 6, 2021 e2 Metabolic Profiles in T2DM Over 25 Years Diabetes Care

Figure 1––Adjusted marginal estimation of measurements over time. Green, blue, and red line indicates estimation for NZE, Maori, and Pasiﬁka patients, respectively. For adjusted marginal estimation of SBP at each time point, age, sex, index of multiple deprivation, smoking status, duration of diabetes, antihypertensive treatment, statin treatment, antidiabetes treatment, and antiplatelet and anticoagulant treatment were adjusted for as well as BMI, TC, TG, albumin-to-creatinine ratio, and HbA1c at baseline. For adjusted marginal estimation of BMI at each time point, age, sex, index of multiple deprivation, smoking status, duration of diabetes, antihypertensive treatment, statin treatment, antidiabetes treatment, and antiplatelet and anticoagulant treatment were adjusted for as well as SBP, TC, TG, albumin-to-creatinine ratio, and HbA1c at baseline. For adjusted marginal estimation of HbA1c at each time point, age, sex, index of multiple deprivation, smoking status, duration of diabetes, antihypertensive treatment, statin treatment, antidiabetes treatment, and antiplatelet and anticoagulant treatment were adjusted for as well as SBP, TC, TG, albumin-to-creatinine ratio, and BMI at baseline. For adjusted marginal estimation of TC at each time point, age, sex, index of multiple deprivation, smoking status, duration of diabetes, antihypertensive treatment, statin treatment, antidiabetes treatment, and antiplatelet and anticoagulant treatment were adjusted for as well as SBP, HbA1c, TG, albumin-to-creatinine ratio, and BMI at baseline. For adjusted marginal estimation of TG at each time point, age, sex, index of multiple deprivation, smoking status, duration of diabetes, antihypertensive treatment, statin treatment, antidiabetes treatment, and antiplatelet and anticoagulant treatment were adjusted for as well as SBP, HbA1c, TC, albumin-to-creatinine ratio, and BMI at baseline.

overall adjusted marginal estimation of cardiovascular and end-stage renal dis- years but as a series of cross-sectional,

BMI among Maori patients was signifi- ease hospitalization among Maori and not longitudinal, studies (3). The HbA1c cantly higher than among NZE and Pasi- Pasifika patients with T2DM than among findings were similar to those for NZE fika patients. The discordance between NZE patients (1) are largely due to greater and SBP findings similar to Maori and

the ethnic groups in SBP, TC, and HbA1c hyperglycemia. A previous cross-sectional Pasifika patients here. levels continued over the 25-year period study also found that Maori and Pasifika This study raises the question of how and after adjustment for confounders. patients with T2DM were receiving antihy- (predominantly) primary care can achieve Ethnic disparities in glycemia, but not pertensive and lipid-lowering therapy simi- comparable blood pressure control bet- SBP or lipids, among patients with T2DM lar to that of NZE patients (2). Answering ween the ethnic groups (especially when have presented a major and consistent the question of whether there are ethnic blood pressure may have commenced health challenge in New Zealand for 25 differences in harm at the same SBP and higher among Maori and Pasifika than years. These ethnic differences remain TC after adjustment for confounders among NZE patients [4]) but not address after adjustment for sociodemographic, requires further research. Comparable U.S. disparities in glycemia. Addressing these period effect, and other clinical factors. data have not been reported. The National disparities likely requires greater integra- The discordance in ethnic differences Health and Nutrition Examination Survey tion between primary and secondary care between glycemic and SBP/TC suggests (NHANES) has monitored T2DM complica- and culturally tailored interventions to that the substantially increased risks of tions and metabolic measures over 30 address the multiple barriers that exist in care.diabetesjournals.org Yu and Associates e3

the day-to-day lives of people with B.J.O.-W., G.S., Z.Z., and D.S. contributed to longitudinal cohort study. Lancet Glob Health T2DM. interpretation of data and revision of the man- 2021;9:e209–e217 uscript. D.Y., Y.C., U.L.O., K.P., J.B., R.C., R.M.J., 2. Agban H, Elley CR, Kenealy T, Robinson E. Trends Funding. The DCSS was funded by the New B.J.O.-W., G.S., Z.Z., and D.S. contributed to in the management of risk of diabetes complications Zealand Ministry of Health through Counties revision of the manuscript. Z.Z. and D.S. are the in different ethnic groups in New Zealand primary – Manukau District Health Board. guarantors of this work and, as such, had full care. Prim Care Diabetes 2008;2:181 186 The funders had no role in the study access to all the data in the study and take 3. Wong ND, Patao C, Wong K, Malik S, Franklin design, data collection, data analysis, data responsibility for the integrity of the data and SS, Iloeje U. Trends in control of cardiovascular interpretation, or writing of the manuscript. the accuracy of the data analysis. risk factors among US adults with type 2 diabetes Duality of Interest. No potential conﬂict of from 1999 to 2010: comparison by prevalent interest relevant to this article were reported. References cardiovascular disease status. Diab Vasc Dis Res Author Contributions. D.Y., Z.Z., and D.S. 1. Yu D, Zhao Z, Osuagwu UL, et al. Ethnic 2013;10:505–513 conceived of and designed the study. D.Y., differences in mortality and hospital admission 4. Elley CR, Kenealy T, Robinson E, et al. Car- Y.C., Z.Z., and D.S. contributed to data collec- rates between Maori, Paciﬁc, and European New diovascular risk management of different ethnic tion, data analysis, and writing the manu- Zealanders with type 2 diabetes between 1994 groups with type 2 diabetes in primary care in New script. D.Y., Y.C., U.L.O., K.P., J.B., R.C., R.M.J., and 2018: a retrospective, population-based, Zealand. Diabetes Res Clin Pract 2008;79:468–473