Adrian Fianu

Le diabète de type 2 (DT2) est une pathologie plus fréquente dans les départements d'outre-mer qu'en France métropolitaine. Ce constat serait d'autant plus vrai dans les quartiers vulnérables ultra-marins présentant une population exposée de surcroît à des déterminants sociaux qui favorisent la survenue de cette maladie, notamment l'accès réduit au système de santé. Ainsi, dans ce cadre de travail, la modification des comportements pour la réduction des facteurs de risque selon une approche de prévention primaire dans un quartier vulnérable, serait une stratégie d'action appropriée pour améliorer la santé de la population locale. Afin de tester cette hypothèse, nous avons évalué l'effet à long terme d'une intervention sur le mode de vie réalisée en 2001-2003 pour réduire le risque de DT2 par la perte de poids, chez 445 sujets non diabétiques à risque, en surpoids ou obèses, âgés de 18-40 ans, vivant dans deux quartiers vulnérables de la Réunion. Neuf ans après l'inclusion dans l'essai d'intervention, le suivi des participants montrait une diminution du niveau d'adiposité dans le groupe intervention comparativement au groupe témoin. Ces résultats suggèrent que l'initiation de modifications comportementales sur l'alimentation et l'activité physique associée aux pratiques communautaires autour de la santé et à l'amélioration de l'accès à la prévention en proximité, dans un contexte et un environnement " obésogènes ", présenteraient un bénéfice en santé à long terme. Suite à cette étude épidémiologique portant sur la validation d'un modèle de prévention primaire destiné à la population réunionnaise défavorisée, nous nous sommes intéressés à la problématique de la transférabilité de ce type d'intervention. Les interventions de santé publique sont des " boîtes noires " difficiles à décrire, à évaluer et à transférer. Elles ne peuvent être reproduites en l'état dans un nouveau contexte d'implémentation au risque de ne plus être efficaces et de ne pas savoir pourquoi. Ainsi, dans ce cadre de travail, il serait utile de dégager les processus théoriques " standardisables par fonction " potentiellement transférables de l'intervention (les fonctions clés) des activités concrètes implémentées sur le terrain dépendantes du contexte, et d'identifier les éléments contextuels signifiants pouvant modifier l'intervention. La construction du modèle fonctions clés / implémentation / contexte (FIC) et l'explicitation du modèle de causalité du programme de prévention, selon une approche rétrospective, collaborative entre porteur de projet, acteur de terrain et chercheurs de différentes disciplines, a permis de mieux décrire l'intervention étudiée, d'analyser sa transférabilité et de discuter son évaluation. Cette intervention sur le mode de vie comprenait treize fonctions clés réparties selon trois stratégies d'action visant la réduction des inégalités sociales de santé (renforcement des individus, renforcement de la communauté, amélioration des conditions de vie) et six objectifs spécifiques sous-jacents. Le modèle de causalité impliquait des déterminants individuels, méso-sociaux et environnementaux de la santé. L'analyse des modalités du transfert du programme vers un autre quartier vulnérable de la Réunion en 2004, a montré que : des fonctions clés, des modalités d'implémentation et des éléments contextuels étaient possiblement engagés dans la transférabilité de cette intervention. Un élargissement des méthodes de recherche concernant la population, les indicateurs de résultats et les analyses de données, serait nécessaire pour mieux évaluer l'impact de ce type d'intervention dans le réseau social du quartier.

Populations undergoing extensive and rapid socio-economic transitions including historically disadvantaged communities face an increased risk of type-2 diabetes (T2D). In recent years, sedentary behavior and physical inactivity have been considered modifiable determinants when developing primary prevention programs to reduce T2D incidence. Reunion Island is a French overseas department with an increasing T2D population and a high level of socio-economic inequality. The objectives of our study were to identify the individual, social, and environmental factors associated with sedentary behavior and physical inactivity among the Reunion Island adult population, and to highlight these findings in order to propose T2D primary prevention strategies aiming at alleviating local social inequalities in health (SIH). In 2021, we conducted a population-based cross-sectional telephone survey using random sampling. Participants included adults over 15 years old living in ordinary accommodation on Reunion Island (n = 2,010). Using a sequential approach, multinomial logistic regression model (explaining 3 profiles of interest: sedentary/inactive, sedentary/active, non-sedentary/inactive), and sampling-design weighted estimates, we found that 53.9% [95% confidence interval: 51.1 to 56.7%] of participants had sedentary behavior and 20.1% [95% CI: 17.8 to 22.5%] were inactive. Abandoning physical activity due to the COVID-19 pandemic (p<0.001), final secondary school diploma or above (p = 0.005), student as professional status (p≤0.005) and living in fewer poor neighborhoods located far from city centers (p = 0.030) were four conditions independently associated with sedentary/inactive and/or sedentary/active profiles. Based on these findings, to help reduce SIH, we used a typology of actions based on the underlying theoretical interventions including four main action categories: strengthening individuals (using person-based strategies), strengthening communities, improving living and working conditions, and promoting health-based macro-policies. Our findings suggest several directions for reducing lifestyle risk factors and enhancing T2D primary prevention programs targeting psychosocial, behavioral, and structural exposures.

Background: Diabetes self-management education is exposed to attrition from services and structured ambulatory care. However, knowledge about factors related to attrition in educational programs remains limited. The context of social vulnerability due to low income may interfere. The aim of this study was to identify the sociodemographic, clinical, psychometric, and lifestyle factors associated with attrition from the ERMIES multicentre randomized parallel controlled trial (RCT) that was interrupted due to the combination of both slow inclusion and high attrition. Methods: The ERMIES trial was performed from 2011 to 2016 on Reunion Island, which is characterized by a multicultural population and high social vulnerability. The original objective of the RCT was to test the efficacy of a2-year structured group self-management education in improving blood glucose in adult patients with nonrecent, insufficiently controlled type 2 diabetes. One hundred participants were randomized to intensive educational intervention maintained over two years (n = 51) versus only initial education (n = 49). Randomization was stratified on two factors: centres (five strata) and antidiabetic treatment (two strata: insulin-treated or not). Sociodemographic, clinical, health-care access and pathway, psychometric and lifestyle characteristics data were collected at baseline and used to assess determinants of attrition in a particular social context and vulnerability. Attrition and retention rates were measured at each visit during the study. Multiple correspondence analysis and Cox regression were performed to identify variables associated with attrition. Results: The global attrition rate was 26% during the study, with no significant difference between the two arms of randomization (9 dropouts out of 51 patients in the intervention group and 17 out of 49 in the control group). Male gender, multiperson household, low household incomes (< 800 euros), probable depression and history of hospitalization or medical leave at inclusion were associated with a higher risk of attrition from the study in multivariate regression. Conclusions: Social context, vulnerability, and health care history were related to attrition in this 2-year longitudinal comparative study of structured care. Considering these potential determinants and biases is of importance in scaling up interventions aimed at the optimization of long-term care in type 2 diabetes mellitus. Trial registration: ID_RCB number: 2011-A00046-35, Clinicaltrials.gov number: NCT01425866 (Registration date: 30/08/2011). Source of funding: Ministry of Health, France.

In March 2020, the French government implemented nation-wide measures to reduce social contact and slow the progression of the emerging coronavirus responsible for COVID-19, the most significant being a complete home lockdown that lasted 8 weeks. Reunion Island is a French overseas department marked by large social inequalities. We draw the hypothesis that distancing and lockdown measures may have contributed to an increase in the social inequalities in health (SIH) on Reunion Island. The aim of our study was to describe the SIH during lockdown in the Reunionese population. We implemented a cross-sectional telephone survey conducted between 13 May and 22 July 2020, using a retrospective data collection on the lockdown period. A total of 892 adult participants (≥18 years) were recruited in the 114 large Reunionese neighborhoods using the quota method within the national “White Pages” telephone directory. Degraded psychological states, an increase in addictive behaviors, difficulties in accessing food, a decrease in physical activity, delayed medical appointments, violence against women, and health problems in children were driven by the socio-economic characteristics of the population, most often to the disadvantage of social groups exposed to poor living conditions. These results suggest that the COVID-19 lockdown contributed to an increase in SIH.

Background: Low socio-economic settings are characterized by high prevalence of diabetes and difficulty in accessing healthcare. In these contexts, proximity health services could improve healthcare access for diabetes prevention. Our primary objective was to evaluate the usefulness of home screening for promoting awareness of impaired glycemic status and utilization of primary care among adults aged 18-79 in a low socio-economic setting. Methods: This follow-up study was conducted in 2015-2016 in Reunion Island, a French overseas department in the Indian Ocean. Enrollment and screening occurred on the same day at the home of participants (N=907). Impaired glycemic status was defined as [glycated hemoglobin (HbA1c) ≥5.7%] OR [fasting capillary blood glucose (FCBG) ≥1.10 g/L] OR [HbA1c=5.5-5.6% and FCBG=1.00-1.09 g/L]. Medical, socio-cultural, and socio-economic characteristics were collected via a face-to-face questionnaire. A one-month telephone follow-up survey was conducted to determine whether participants had consulted a general practitioner (GP) for confirmation of screening results. A multinomial polytomous logistic regression model was used to identify factors independently associated with non-use of GP consultation for confirmation of screening results and nonresponse to the telephone follow-up survey. Results: Prevalence of glycemic abnormalities was 46.0% (95% CI = 42.7-49.2%). Among participants with impaired glycemic status (N=417), 77.7% (95% CI=73.7-81.7%) consulted a GP for confirmation of screening results, 12.5% (95% CI=9.3-15.6%) did not, and 9.8% failed to respond to the follow-up survey. Factors independently associated with non-use of GP consultation for confirmation of screening results were self-reported unwillingness to consult a GP (adjusted odds ratio [OR]: 4.86, 95% CI=1.70-13.84), usual GP consultation frequency of less than once a year (adjusted OR: 4.13, 95% CI=1.56-10.97), and age 18-39 years (adjusted OR: 3.09, 95% CI=1.46-6.57). Conclusion: Home screening for glycemic abnormalities is a useful proximity health service for diabetes prevention in low socio-economic settings. Further efforts, including health literacy interventions, are needed to increase utilization of primary care.

Evidence from literature is mixed regarding a possible association of maternal gestational diabetes mellitus (GDM) and overweight in the offspring. Sexual dimorphism, or sex disparities in the pathogenesis linking GDM exposure to overweight, could be at play. The objective of this study was to investigate the association between GDM and child overweight at 5–7 years. Six hundred pairs (1:1) of Reunionese liveborn singletons selected from a hospital-based birth registry, matched for sex, gestational age, and birth period, underwent a prospective in-home follow-up and were analyzed with respect to their exposure to GDM. The primary outcome was child overweight at 5–7 years, as defined by the International Obesity Task Force. The association between GDM exposure and child overweight was estimated by the odds ratio (OR) using conditional logistic regression models. For the subset of children exposed to GDM with available maternal glycemic data, we analyzed the relationship between maternal glycemic levels during pregnancy and child body mass index (BMI) at 5–7 years with a linear regression model. In light of the significant interaction between sex and GDM, all statistical analyses were then stratified by sex. After controlling for pre-pregnancy BMI and maternal sociodemographic characteristics, the risk of overweight increased with exposure to GDM for boys (adjusted OR: 2.34; 95% confidence interval = 1.26–4.34, P = 0.007) but not for girls (adjusted OR: 0.56; 95%CI = 0.28–1.10, P = 0.093). Consistent with this, the linear increase of boys’ BMI at 5–7 years with maternal blood glucose levels during pregnancy, in the exposed group, displayed a dose-response relationship. Our findings indicate that exposure to GDM is a risk factor for childhood overweight in boys but not in girls, which adds to the growing body of evidence suggesting greater sensitivity of male offspring to intrauterine hyperglycemia.

In type 2 diabetes (T2D) prevention research, evidence for maintenance of risk factor reduction after three years of follow-up is needed. The objective of this study was to evaluate the long-term effectiveness of a combined lifestyle intervention aiming at controlling body weight (BW) and waist circumference (WC) in non-diabetic, overweight/obese adults living in a low socio-economic community. On Reunion Island, 445 adults living in deprived areas, aged 18–40 and at high-risk for T2D, were included in an intervention versus control trial for primary prevention (2001–2002). The intervention promoted a healthy diet and moderate regular physical activity, through actions strengthening individuals or community and improving living conditions. The control group received a one-shot medical information and nutritional advices. After the end of the trial (2003), 259 of the subjects participated in a follow-up study (2010–2011). The outcomes were the nine-year changes from baseline in BW, body mass index (BMI) and WC measurements, separately. Statistical analyses were performed on an intention-to-treat basis, using available and imputed datasets. At inclusion, T2D risk factors were prevalent: family history of diabetes in first-degree relatives (42%), women with a personal history of gestational diabetes (11%), total obesity (43%, median BMI 29.1 kg/m²) and central obesity (71%). At follow-up, the adjusted effect on imputed dataset was significant for WC -2.4 cm (95% confidence interval: -4.7 to -0.0 cm, p = 0.046), non-significant for BW -2.2 kg (-4.6 to +0.2 kg, p = 0.073) and BMI -0.81 kg/m² (-1.69 to +0.08 kg/m², p = 0.074). A specific long-term effect was the increased likelihood of reduction in adiposity: BW loss, BMI reduction, and WC reduction were more frequent in the intervention group. In the context of low socio-economic communities, our data support the assumption of long-term effect of lifestyle interventions targeting total obesity and central obesity two major drivers of T2D.

Introduction: Long-lasting relapsing or lingering rheumatic musculoskeletal pain (RMSP) is the hallmark of Chikungunya virus (CHIKV) rheumatism (CHIK-R). Little is known on their prognostic factors. The aim of this prognostic study was to search the determinants of lingering or relapsing RMSP indicative of CHIK-R. Methods: Three hundred and forty-six infected adults (age ≥ 15 years) having declared RMSP at disease onset were extracted from the TELECHIK cohort study, Reunion island, and analyzed using a multinomial logistic regression model. We also searched for the predictors of CHIKV-specific IgG titres, assessed at the time of a serosurvey, using multiple linear regression analysis. Results: Of these, 111 (32.1%) reported relapsing RMSP, 150 (43.3%) lingering RMSP, and 85 (24.6%) had fully recovered (reference group) on average two years after acute infection. In the final model controlling for gender, the determinants of relapsing RMSP were the age 45-59 years (adjusted OR: 2.9, 95% CI: 1.0, 8.6) or greater or equal than 60 years (adjusted OR: 10.4, 95% CI: 3.5, 31.1), severe rheumatic involvement (fever, at least six joints plus four other symptoms) at presentation (adjusted OR: 3.6, 95% CI: 1.5, 8.2), and CHIKV-specific IgG titres (adjusted OR: 3.2, 95% CI: 1.8, 5.5, per one unit increase). Prognostic factors for lingering RMSP were age 45-59 years (adjusted OR: 6.4, 95% CI: 1.8, 22.1) or greater or equal than 60 years (adjusted OR: 22.3, 95% CI: 6.3, 78.1), severe initial rheumatic involvement (adjusted OR: 5.5, 95% CI: 2.2, 13.8) and CHIKV-specific IgG titres (adjusted OR: 6.2, 95% CI: 2.8, 13.2, per one unit increase). CHIKV specific IgG titres were positively correlated with age, female gender and the severity of initial rheumatic symptoms. Conclusions: Our data support the roles of age, severity at presentation and CHIKV specific IgG titres for predicting CHIK-R. By identifying the prognostic value of the humoral immune response of the host, this work also suggest a significant contribution of the adaptive immune response to the physiopathology of CHIK-R and should help to reconsider the paradigm of this chronic infection primarily shifted towards the involvement of the innate immune response.