Behind the Hospital Ward: In-Hospital Mortality of Type 2 Diabetes Mellitus Patients in Indonesia (Analysis of National Health Insurance Claim Sample Data).

The rising global prevalence of diabetes mellitus, a chronic metabolic disorder, poses significant challenges to healthcare systems worldwide. This study examined in-hospital mortality among patients diagnosed with non-insulin-dependent diabetes mellitus (NIDDM) of ICD-10, or Type 2 Diabetes Mellitus (T2DM), in Indonesia, utilizing hospital claims data spanning from 2017 to 2022 obtained from the Indonesia Health Social Security Agency or Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan. The analysis, which included 610,809 hospitalized T2DM patients, revealed an in-hospital mortality rate of 6.6%. Factors contributing to an elevated risk of mortality included advanced age, the presence of comorbidities, and severe complications. Additionally, patients receiving health subsidies and those treated in government hospitals were found to have higher mortality risks. Geographic disparities were observed, highlighting variations in healthcare outcomes across different regions. Notably, the complication of ketoacidosis emerged as the most significant risk factor for in-hospital mortality, with an odds ratio (OR) of 10.86, underscoring the critical need for prompt intervention and thorough management of complications to improve patient outcomes.

Projection of diabetes morbidity and mortality till 2045 in Indonesia based on risk factors and NCD prevention and control programs.

Diabetes Mellitus is one of the biggest health problems in Indonesia but the research on the disease's projection is still limited. This study aimed to make a projection model of prevalence and mortality of diabetes in Indonesia based on risk factors and NCD programs. The study was a quantitative non-experimental study through multiple linear regression models and system dynamics. The baseline projection was created by 2018 data and projections until 2045 involved the dynamization of risk factors and programs, population, and case fatality rate. The model was created from 205 districts data. This study used secondary data from Basic Health Research, BPJS Kesehatan, NCD programs, and Ministry of Health. The prevalence of diabetes in Indonesia is estimated to increase from 9.19% in 2020 (18.69 million cases) to 16.09% in 2045 (40.7 million cases). The prevalence will be lower to 15.68% (39.6 million) if interventions of programs were carried out, and to 9.22% (23.2 million) if the programs were added with prevention of risk factors. The projected number of deaths due to diabetes increases from 433,752 in 2020 to 944,468 in 2045. Deaths due to stroke among diabetes increases from 52,397 to 114,092 in the same period. Deaths from IHD among diabetes increase from 35,351 to 76,974, and deaths from chronic kidney disease among diabetes increase from 29,061 to 63,279. Diabetes prevalence and mortality in Indonesia rise significantly in Indonesia and can be reduced by intervention of several programs and risk factors. This study findings could be source of planning and evaluation of Diabetes prevention and control program at national and provincial level in the future related to risk factors control and program development.

Smokeless and combustible tobacco use among 148,944 South Asian adults: a cross-sectional study of South Asia Biobank.

INTRODUCTION: Tobacco use, in both smoking and smokeless forms, is highly prevalent among South Asian adults. The aims of the study were twofold: (1) describe patterns of SLT and combustible tobacco product use in four South Asian countries stratified by country and sex, and (2) assess the relationships between SLT and smoking intensity, smoking quit attempts, and smoking cessation among South Asian men. METHODS: Data were obtained from South Asia Biobank Study, collected between 2018 and 2022 from 148,944 men and women aged 18 years and above, living in Bangladesh, India, Pakistan, or Sri Lanka. Mixed effects multivariable logistic and linear regression were used to quantify the associations of SLT use with quit attempt, cessation, and intensity. RESULTS: Among the four South Asian countries, Bangladesh has the highest rates of current smoking (39.9% for male, 0.4% for female) and current SLT use (24.7% for male and 23.4% for female). Among male adults, ever SLT use was associated with a higher odds of smoking cessation in Bangladesh (OR, 2.88; 95% CI, 2.65, 3.13), India (OR, 2.02; 95% CI, 1.63, 2.50), and Sri Lanka (OR, 1.36; 95% CI, 1.14, 1.62). Ever SLT use and current SLT use was associated with lower smoking intensity in all countries. CONCLUSIONS: In this large population-based study of South Asian adults, rates of smoking and SLT use vary widely by country and gender. Men who use SLT products are more likely to abstain from smoking compared with those who do not.

Income Disparity and Healthcare Utilization: Lessons from Indonesia's National Health Insurance Claim Data.

BACKGROUND: Indonesia's National Health Insurance Program, known as Jaminan Kesehatan Nasional (JKN), has a variety of membership pathways for those wishing to gain access. Claim data from JKN offers a cost-effective way of observing who is accessing healthcare services and what types of services are being used. This study is a novel attempt to measure disparities amongst JKN users in their engagement with services, providing an opportunity to reflect on patterns of use. METHODS: Using claims data collected from JKN users between 2015-2016, we used the Ordinary Least Square estimation model to compare health services utilization among subsidized and non-subsidized users. We focused primarily on the individual use of the hospital for outpatient and inpatient treatment. RESULTS: Analysis reveals that subsidized users access primary healthcare services more frequently than non-subsidized users. Conversely, non-subsidized users access secondary and tertiary health care services more frequently than other users. Subsidized users who utilize secondary and tertiary health care tend to suffer more severe health illnesses than non-subsidized members. CONCLUSIONS: This study concludes that income disparity affects healthcare utilization. Non-subsidized members are more likely than subsidized members to access secondary and tertiary health care services. Our study offers evidence of the potential underutilization of secondary and tertiary healthcare (STHC) by subsidized members, which could lead to inefficiency since subsidized members seeking STHC treatment had severe health conditions, thus needing to be treated longer and requiring higher healthcare expenditures.

Mental Health, Environmental, and Socioeconomic Geographic Factors of Severe Drug Addiction: Analysis of Rehabilitation Center Data in Indonesia.

Background: A growing number of recent literatures have attempted to document the factors related to drug use in different contexts, but limited studies analyzed the factors related to patient's severity level. Objective: We aimed to examine the correlates of behavioral, environmental, socioeconomic, geographic factors, and severe drug addiction. Methods: We used a sample of 6790 people who use drugs (PWUD) from rehabilitation centers during 2019 to 2020 in Indonesia. Data were obtained from Drugs Rehabilitation Information System (SIRENA) by the Indonesian National Narcotics Agency (BNN) during 2019 to 2020. SIRENA used the adapted version of WHO's Addiction Severity Index (ASI), which assesses patient's addiction severity level and relevant factors. A composite of the ASI factors is classified as "poor" or "serious" if its score is 4 or higher. The data was analyzed using logistic regression model to estimate correlations of severe drug addiction. Results: We found a high prevalence (65.08%) of our sample reported having severe drug addiction, which needed intervention and support. Poor psychiatric condition (OR = 4.02, CI: 2.97-5.44), serious work-related issue (OR = 2.10, 1.75-2.51), poor medical condition (OR = 2.01, 1.32-3.06), and serious family and social problems (OR = 2.56, 2.15-3.05) were significantly associated with severe drug addiction. Male users had higher odds of severe drug addiction (OR = 1.81, 1.55-2.20), compared to female counterparts. Patients in urban areas had higher odds of severe drug addiction (OR = 1.19, 1.1-1.3) than those in rural. Those in less developed regions (eg, Sumatera, Kalimantan, and Sulawesi) had higher odds of severe drug addiction (OR = 2.33, 1.9-2.9), compared to those in the most developed region (eg, Java and Bali). Conclusion: This evidence can help policymakers in refining the harm reduction policies in Indonesia and other countries with similar settings.

Beyond the Plate: Uncovering Inequalities in Fruit and Vegetable Intake across Indonesian Districts.

BACKGROUND: Non-communicable diseases (NCDs) are responsible for the deaths of 41 million individuals every year, with 77% of them occurring in low- and middle-income countries. Among the main NCD risk factors, inadequate intake of fruits and vegetables (FV) was one of the leading causes of death in 2019. Our study aims to identify disparities in inadequate FV intake among adults in 514 districts. We utilized the latest Indonesian Basic Health Survey 2018 to conduct geospatial and quantitative analyses. We used the World Health Organization's definition of inadequate FV intake, which refers to consuming less than five servings of fruit and vegetables daily. We analyzed inadequate FV intake among adults over the age of 18 years, as well as by gender and age group (including young adults 18-24 years, adults 25-59 years, and older adults 60+ years). Our study showed an alarmingly high prevalence of inadequate FV intake among adults, with 96.3% in 2018. The prevalence of inadequate FV intake drastically varied across 514 districts, ranging from 70.1% to 100%. Notable geographic and socioeconomic disparities were observed across the districts studied. Rural districts exhibited a higher prevalence of inadequate FV intake, translating to poorer diets, particularly among females and older adults, when compared to their urban counterparts. Interestingly, districts within more developed regions had poorer FV diets than those in less developed regions. Although districts with lower incomes generally had poorer FV diets, the association was not significant in multivariate analysis. However, districts with lower levels of education demonstrated poorer FV diets, especially among females, adults, and older adults. Despite its limitations, our study provides crucial insights for health policies in Indonesia and other LMICs.

Growing Up Unequal: Disparities of Childhood Overweight and Obesity in Indonesia's 514 Districts.

BACKGROUND: Childhood obesity is a major public health concern as it increases the risk of premature death and adult disability. Globally, the latest estimates showed that more than 340 million children and adolescents between the ages of 5 and 19 were overweight or obese in 2016. This study aimed to investigate the disparities in childhood overweight and obesity across 514 districts in Indonesia, based on geographic and socioeconomic factors. METHODS: Geospatial and quantitative analyses were performed using the latest Indonesian Basic Health Survey data from 2018. Dependent variables were rates of overweight and obesity among children aged 5-17 years including by gender. RESULTS: This study found that the rates of overweight were 17.2%, 17.6%, and 16.8% among all children, boys, and girls, while the rates of obesity were 7.0%, 7.9%, and 6.1%, respectively. Boys were 1.30 times more likely to be obese than girls, while overweight was similar between both sexes. Urban cities had significantly higher prevalence of childhood overweight and obesity compared with rural districts by up to 1.26 and 1.32 times, respectively. In addition, the most developed region had significantly higher prevalence of childhood overweight and obesity than the least developed region by up to 1.37 and 1.38 times, respectively. With regard to socioeconomic factors, our analysis demonstrated a notable disparity in the prevalence of childhood overweight and obesity across income quintiles. Specifically, the wealthiest districts exhibited a 1.18 times higher prevalence of overweight and obesity among all children compared with the poorest districts. This association was particularly pronounced among boys; in the richest quintile, the prevalence of overweight and obesity was 1.24 and 1.26 times higher, respectively, in comparison to the poorest income quintile. In contrast, district-level education appears to exhibit an inverse relationship with the prevalence of childhood overweight and obesity, although the findings were not statistically significant.

The influence of anti-smoking messages to Indonesian youth smoking behavior: the Indonesian 2019 Global Youth Tobacco Survey (GYTS).

INTRODUCTION: Various anti-tobacco promotions have emerged in order to reduce the detrimental impacts of tobacco advertising on adolescents. The objective of this study is to explore the relationship between the exposure to anti-smoking messages and Indonesian youth smoking behavior. METHOD: We used secondary data from the Indonesian 2019 Global Youth Tobacco Survey (GYTS). The participants were students from grades seven to twelve. We used multiple logistic regression to assess the relationship of anti-smoking messages exposure on the smoking behavior variable. We used complex samples process logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) and controlling for relevant covariables. RESULTS: The percentage of the exposure to anti-smoking messages in all types were not more than 25% in each outcome variables. The results also showed that in the current smoker variables, adolescent who exposed to the two variables of anti-smoking messages increased the odds to become current smoker. The variables were anti smoking messages in media (AOR 1.41; 95% CI 1.15-1.73) and in school (AOR 1.26; 95% CI 1.06-1.50). On the other hand, in the smoking susceptibility variables, there were no variables of anti-smoking messages that had relation with it. CONCLUSIONS: The study concluded that there were only two variables of the anti-smoking messages that had relation with the Indonesian youth smoking behavior, which were current smokers. Unfortunately those variables increased the odds of the respondents to become current smokers. Indonesia government should develop media following international best practices to convey the anti-smoking messages.

Associations of the built environment with type 2 diabetes in Asia: a systematic review.

OBJECTIVES: Our study aimed to systematically review the literature and synthesise findings on potential associations of built environment characteristics with type 2 diabetes (T2D) in Asia. DESIGN: Systematic review of the literature. DATA SOURCES: Online databases Medline, Embase and Global Health were used to identify peer-reviewed journal articles published from inception to 23 January 2023. ELIGIBILITY CRITERIA: Eligible studies included cohort, cross-sectional and case-control studies that explored associations of built environment characteristics with T2D among adults 18 years and older in Asia. DATA EXTRACTION AND SYNTHESIS: Covidence online was used to remove duplicates and perform title, abstract and full-text screening. Data extraction was carried out by two independent reviewers using the OVID database and data were imported into MS Excel. Out of 5208 identified studies, 28 studies were included in this systematic review. Due to heterogeneity in study design, built environment and outcome definitions, a semiqualitative analysis was conducted, which synthesised results using weighted z-scores. RESULTS: Five broad categories of built environment characteristics were associated with T2D in Asia. These included urban green space, walkability, food environment, availability and accessibility of services such as recreational and healthcare facilities and air pollution. We found very strong evidence of a positive association of particulate matter (PM2.5, PM10), nitrogen dioxide and sulfur dioxide (p<0.001) with T2D risk. CONCLUSION: Several built environment attributes were significantly related to T2D in Asia. When compared with Western countries, very few studies have been conducted in Asia. Further research is, therefore, warranted to establish the importance of the built environment on T2D. Such evidence is essential for public health and planning policies to (re)design neighbourhoods and help improve public health across Asian countries. PROSPERO REGISTRATION NUMBER: CRD42020214852.

The Effectiveness of Enhanced Primary Healthcare (EnPHC) interventions on Type 2 diabetes management in Malaysia: Difference-in-differences (DID) analysis.

AIMS: To evaluate the effectiveness of the Enhanced Primary Healthcare (EnPHC) interventions on process of care and intermediate clinical outcomes among type 2 diabetes patients. METHODS: This was a quasi-experimental controlled study conducted in 20 intervention and 20 control public primary care clinics in Malaysia from November 2016 to June 2019. Type 2 diabetes patients aged 30 years and above were selected via systematic random sampling. Outcomes include process of care and intermediate clinical outcomes. Difference-in-differences analyses was conducted. RESULTS: We reviewed 12,017 medical records of patients with type 2 diabetes. Seven process of care measures improved: HbA1c tests (odds ratio (OR) 3.31, 95% CI 2.13, 5.13); lipid test (OR 4.59, 95% CI 2.64, 7.97), LDL (OR 4.33, 95% CI 2.16, 8.70), and urine albumin (OR 1.99, 95% CI 1.12, 3.55) tests; BMI measured (OR 15.80, 95% CI 4.78, 52.24); cardiovascular risk assessment (OR 174.65, 95% CI 16.84, 1810.80); and exercise counselling (OR 1.18, 95% CI 1.04, 1.33). We found no statistically significant changes in intermediate clinical outcomes (i.e. HbA1c, LDL, HDL and BP control). CONCLUSIONS: EnPHC interventions was successful in enhancing the quality of care, in terms of process of care, by changing healthcare providers behaviour.

Does the Disparity Patterning Differ between Diagnosed and Undiagnosed Hypertension among Adults? Evidence from Indonesia.

BACKGROUND: Healthcare systems in many low- and middle-income countries (LMICs) are not yet designed to tackle the high and increasing burden of non-communicable diseases (NCDs), including hypertension. As a result, a large proportion of people with disease or risk factors are undiagnosed. Policymakers need to understand the disparity better to act. However, previous analyses on the disparity in undiagnosed hypertension, especially from LMICs, are lacking. Our study assessed the geographic and socioeconomic disparity in undiagnosed hypertension and compared it with diagnosed hypertension. METHODS: We used the Basic Health Survey (Riskesdas) 2018 and performed geospatial and quantitative analyses across 514 districts in Indonesia. Dependent variables included diagnosed and undiagnosed hypertension among adults (18+ years) and by gender. RESULTS: A high prevalence of undiagnosed hypertension at 76.3% was found, with different patterns of disparity observed between diagnosed and undiagnosed hypertension. Diagnosed hypertension was 1.87 times higher in females compared with males, while undiagnosed hypertension rates were similar between genders. Urban areas had up to 22.6% higher rates of diagnosed hypertension, while undiagnosed hypertension was 11.4% more prevalent among females in rural areas. Districts with higher education rates had up to 25% higher diagnosed hypertension rates, while districts with lower education rates had 6% higher rates of undiagnosed hypertension among females. The most developed regions had up to 76% and 40% higher prevalence of both diagnosed and undiagnosed hypertension compared with the least developed regions. CONCLUSION: The disparity patterning differs between diagnosed and undiagnosed hypertension among adults in Indonesia. This highlights the need for effective measures, including healthcare system reforms to tackle NCDs in LMICs.

The effect of maternal hypertension and maternal mental illness on adverse neonatal outcomes: A mediation and moderation analysis in a U.S. cohort of 9 million pregnancies.

BACKGROUND: While hypertensive disorders of pregnancy (HDP) coexist with maternal anxiety and depression, it is unclear how these conditions affect neonatal outcomes. We evaluated the prevalence as well as associations and potential mechanisms between HDP, maternal anxiety and depression, preterm birth (PTB), and small for gestational age (SGA). METHODS: We conducted a retrospective population-based study using the Healthcare Cost and Utilization Project (HCUP) database from 2004 to 2014. Preterm birth (<37 weeks), SGA (<10th percentile for gestational age and sex), HDP, and mental disorders (anxiety and depression) were extracted using the International Classification of Diseases, Ninth Revision (ICD-9). Mediation and moderation models were constructed separately to evaluate potential mechanisms between maternal anxiety and depression, HDP, and adverse neonatal outcomes. Multivariate logistic regressions were used to determine their associations. RESULTS: Of 9,097,355 pregnant women, the prevalence of HDP was 6.9 %, anxiety 0.91 %, depression 0.36 %, preterm birth 7.2 %, and SGA 2.1 %. Anxiety increased the probability of having HDP (OR = 1.242, 95 % CI 1.235-1.250), and HDP mediated the association between anxiety and preterm birth (mediation effect = 0.048, p-value<0.001). Depression significantly moderated the effect of HDP on preterm birth (moderation effect = -0.126, p-value = 0.027). HDP also mediated the association between anxiety and SGA (mediation effect = 0.042, p-value<0.001), but depression did not moderate the association between HDP and SGA (p-value = 0.29). CONCLUSION: Our study suggests that women with anxiety are more likely to have HDP, and HDP mediates the associations between anxiety and adverse neonatal outcomes. Depression moderates associations between HDP and preterm birth but not between HDP and SGA.

Geographic and Socioeconomic Inequalities in Delays in COVID-19 Vaccinations: A Cross-Sectional Study in Indonesia.

BACKGROUND: Previous studies have provided evidence of inequalities in the coverage of COVID-19 vaccination. However, evidence of such inequalities in delays in vaccinations is lacking. Our study examined the socioeconomic and geographic disparities in terms of days to get the first and second dose of COVID-19 vaccinations in Indonesia. METHODS: We conducted a cross-sectional study using the WhatsApp messaging app and social media platforms during December 2021-February 2022. We distributed the questionnaire through our university network to reach all regions. We included 3592 adults aged 15+ years in our analysis. We used two main dependent variables: days to receive the first dose (after national vaccine rollout) and days to receive the second dose (after receiving the first dose). We examined a range of socioeconomic and geographic indicators, including education level, income level, formal employment, working in health facilities, being a health worker, and region. We controlled for sex, age, religion, and urbanicity. We performed multivariate logistic regressions in STATA 15. RESULTS: Our findings show considerable delays in getting the first dose among participants (160.7 days or about 5.4 months on average) from Indonesia's national COVID-19 vaccination rollout on 13 January 2021. However, we found a shorter period to receive the second dose after receiving the first dose (41.1 days on average). Moreover, we found significant socioeconomic (i.e., education, income, formal employment, working in health facilities, and being a health worker) and geographic (i.e., in and out of the Java region) inequalities in terms of delays in getting the first dose. However, we did not find significant inequalities in getting the second dose for most inequality indicators, except for working in health facilities. By region, we found that participants living in more deprived areas (out of the Java region) received the second dose 4.9 days earlier. One of the study's key limitations is that there may be an inherent bias with respect to socioeconomics factors since it was conducted online (web-based). CONCLUSIONS: While there were considerable delays in getting the first dose, especially among those of a lower socioeconomic status and those in more deprived areas, the waiting time for the second dose was relatively similar for everyone once they were in the system. Effective efforts to address inequalities are essential to ensuring the effectiveness of the national COVID-19 vaccination rollout.

District-Level Inequalities in Hypertension among Adults in Indonesia: A Cross-Sectional Analysis by Sex and Age Group.

BACKGROUND: An estimated 1.28 billion adults 30-79 years old had hypertension globally in 2021, of which two-thirds lived in low- and middle-income countries (LMICs). Previous studies on geographic and socioeconomic inequalities in hypertension among adults have limitations: (a) most studies used individual-level data, while evidence from locality-level data is also crucial for policymaking; (b) studies from LMICs are limited. Thus, our study examines geographic and socioeconomic inequalities in hypertension among adults across districts in Indonesia. METHODS: We combined geospatial and quantitative analyses to assess the inequalities in hypertension across 514 districts in Indonesia. Hypertension data were obtained from the Indonesian Basic Health Survey (Riskesdas) 2018. Socioeconomic data were obtained from the World Bank. Six dependent variables included hypertension prevalence among all adults (18+ years), male adults, female adults, young adults (18-24 years), adults (25-59 years), and older adults (60+ years). RESULTS: We also found significant geographic and socioeconomic inequalities in hypertension among adults across 514 districts. All hypertension indicators were higher in the most developed region than in the least developed region. Districts in the Java region had up to 50% higher prevalence of hypertension among all adults, males, females, young adults, adults, and older adults. Notably, districts in the Kalimantan region had the highest prevalence of hypertension, even compared to those in Java. Moreover, income level was positively associated with hypertension; the wealthiest districts had higher hypertension than the poorest districts by up to 30%, but only among males and older adults were statistically significant. CONCLUSIONS: There were significant inequalities in hypertension among adults across 514 districts in the country. Policies to reduce such inequalities may need to prioritize more affluent urban areas and rural areas with a higher burden.

A Scoping Review on Biopsychosocial Predictors of Mental Health among Older Adults.

This review aims to map the available evidence on biopsychosocial predictors of elderly mental health. The articles were independently screened in three selected databases, namely Pubmed, Proquest and Google Scholar. The stages consist of identifying the research questions, seeking and selecting relevant evidence, mapping data, and concluding and reporting results. The PRISMA flowchart was used to show the PEOS evidence search flow. A total of 23,722 articles were obtained from all databases during the initial search, where 458 titles fulfilled the eligibility criteria at the title screening stage. Furthermore, 383 articles passed through abstract screening, where 75 met the inclusion criteria and were included for full-text screening. Based on the full-text screening stage, 28 articles were excluded and the remaining 47 articles that matched the search process were included for data extraction. This review creates biopsychosocial variables related to the mental health of the elderly. The biological factors consist of age, biomarkers, female, health conditions, chronic diseases, and physical function. Variables related to psychological factors are affect, personality traits, and subjective well-being. Meanwhile, social factors include smoking, sleep quality, physical activity, daily living, social support, marital status, loneliness, religiosity, spirituality, and early life conditions.

Disparities in Obesity Rates among Adults: Analysis of 514 Districts in Indonesia.

BACKGROUND: Globally, it was estimated that over 650 million adults 18 years old and older were obese in 2016. It is an increasing global health challenge with a significant health and economic impact. Thus, understanding geographic and socioeconomic disparities in obesity among adults is crucial. METHODS: We combined geospatial and quantitative analyses to assess the disparity in obesity across 514 districts in Indonesia. We used the Basic Health Survey (Riskesdas) 2018 for obesity data and the World Bank database for socioeconomic data. Dependent variables included obesity prevalence among all adults (18+ years), males, females, young adults (18-24 years), adults (25-59 years), and older adults (60+ years). RESULTS: We found significant geographic and socioeconomic disparities in adult obesity in Indonesia. In terms of region, districts in Java and Bali had a significantly higher prevalence of obesity than those in Papua, Maluku, and Nusa Tenggara. Districts in Java had 29%, 32%, 60%, and 28% higher prevalence of obesity among all adults, female adults, young adults, and adults. By income, compared to the poorest ones, most affluent districts had a significantly higher prevalence of obesity; they had a 36%, 39%, 34%, 42%, 33%, and 73% higher prevalence of obesity among all adults, males, females, young adults, adults, and older adults. Similarly, by education, compared to the least educated ones, the most educated districts had a significantly higher prevalence of obesity; they had a 34%, 42%, 29%, 36%, and 80% higher prevalence of obesity among all adults, males, females, adults, and older adults. CONCLUSIONS: There are significant disparities in adult obesity among 514 districts in Indonesia. Efforts by policymakers and stakeholders are needed to reduce obesity among adults, especially within districts with high prevalence.

Exposure to Outdoor Tobacco Advertisements Near Home is Associated with Smoking among Youth in Indonesia.

BACKGROUND: The prevalence of cigarette smoking among adults is persistently high, and among youth is increasing in Indonesia. OBJECTIVE: This study aims to examine the association between youth smoking behavior and outdoor tobacco adverts near home in Indonesia. METHODS: We conducted a cross-sectional survey of 3,557 students in North Sumatera during September-November 2020. The main independent variables include seeing tobacco advertisements near home, near school, on social media. The outcome variables included ever smoked and smoked in the last ten days. RESULTS: We found significant associations between exposure to outdoor tobacco adverts near home and youth smoking. High school students who reported seeing tobacco adverts near home were 1.42 times more likely to smoke and 2.29 times more likely to smoke in the last ten days. Moreover, students at private schools (a proxy for higher income) exposed to tobacco adverts near home were 1.56 times more likely to smoke and 2.93 times more likely to smoke in the last ten days. CONCLUSION: Exposure to outdoor tobacco advertisements near home is associated with smoking among youth in Indonesia. Comprehensive tobacco control efforts are needed, including through a ban of outdoor tobacco adverts.

Compliance With Tobacco Control Policy and Visibility of Cigarette Retailers Around Educational Facilities in Riyadh, Saudi Arabia.

Background: In Saudi Arabia, cardiovascular diseases are among the top causes of death and disability, and smoking is one of the leading risk factors, particularly among males. Objective: Our study aims to evaluate the compliance with the anti-smoking law among cigarette retailers and examine the visibility of cigarette retailers around educational facilities in Riyadh city, Saudi Arabia. Methods: We conducted a mapping survey and geospatial analysis of cigarette retailers around educational facilities from February to March 2020 (before the COVID-19 restriction) in Al-Olaya municipality in Riyadh city as a pilot study. We found 249 retailers, of which 152 sold cigarettes. Data analyses in ArcMap 10.6 compared the visibility within 250 and 500 meters from educational facilities. Results: We found many retailers were not compliant with the tobacco control regulation: 57.1% of minimarkets sell cigarettes, 15.8% of cigarette retailers display the products openly, and 12.5% of cigarette retailers sold cigarettes by the stick. Moreover, 71% of the total cigarette retailers were within 500 m from schools, and 62% of all schools had at least one cigarette retailer within 500 m buffer (5-min walking or 2-3-min driving distance). Conclusion: There is non-compliance with the anti-smoking law among cigarette retailers and high visibility of cigarette retailers around educational facilities in Saudi Arabia. Monitoring is needed for the effective implementation of tobacco control policies.

Food environment and diabetes mellitus in South Asia: A geospatial analysis of health outcome data.

BACKGROUND: The global epidemic of type 2 diabetes mellitus (T2DM) renders its prevention a major public health priority. A key risk factor of diabetes is obesity and poor diets. Food environments have been found to influence people's diets and obesity, positing they may play a role in the prevalence of diabetes. Yet, there is scant evidence on the role they may play in the context of low- and middle-income countries (LMICs). We examined the associations of food environments on T2DM among adults and its heterogeneity by income and sex. METHODS AND FINDINGS: We linked individual health outcome data of 12,167 individuals from a network of health surveillance sites (the South Asia Biobank) to the density and proximity of food outlets geolocated around their homes from environment mapping survey data collected between 2018 and 2020 in Bangladesh and Sri Lanka. Density was defined as share of food outlets within 300 m from study participant's home, and proximity was defined as having at least 1 outlet within 100 m from home. The outcome variables include fasting blood glucose level, high blood glucose, and self-reported diagnosed diabetes. Control variables included demographics, socioeconomic status (SES), health status, healthcare utilization, and physical activities. Data were analyzed in ArcMap 10.3 and STATA 15.1. A higher share of fast-food restaurants (FFR) was associated with a 9.21 mg/dl blood glucose increase (95% CI: 0.17, 18.24; p < 0.05). Having at least 1 FFR in the proximity was associated with 2.14 mg/dl blood glucose increase (CI: 0.55, 3.72; p < 0.01). A 1% increase in the share of FFR near an individual's home was associated with 8% increase in the probability of being clinically diagnosed as a diabetic (average marginal effects (AMEs): 0.08; CI: 0.02, 0.14; p < 0.05). Having at least 1 FFR near home was associated with 16% (odds ratio [OR]: 1.16; CI: 1.01, 1.33; p < 0.05) and 19% (OR: 1.19; CI: 1.03, 1.38; p < 0.05) increases in the odds of higher blood glucose levels and diagnosed diabetes, respectively. The positive association between FFR density and blood glucose level was stronger among women than men, but the association between FFR proximity and blood glucose level was stronger among men as well as among those with higher incomes. One of the study's key limitations is that we measured exposure to food environments around residency geolocation; however, participants may source their meals elsewhere. CONCLUSIONS: Our results suggest that the exposure to fast-food outlets may have a detrimental impact on the risk of T2DM, especially among females and higher-income earners. Policies should target changes in the food environments to promote better diets and prevent T2DM.