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Gaps in health behaviours and use of preventive services between patients with diabetes and the general population: a population-based cross-sectional study

Objectives Although both the prevalence and treatment rate of diabetes have increased, the degree of adherence to healthy behaviours by patients with diabetes has not yet been comprehensively evaluated. This study examines the differences in health management and mental health status according to diabetes status and awareness of that diagnosis. Methods This was a cross-sectional study of 14 655 people using data from the Korean National Health and Nutrition Examination Study 2010–2012, which used sampling weights. Multiple logistic regression analyses were used to compare health-risk behaviours, preventive healthcare utilisation and mental health status according to diabetes diagnosis and awareness of the disease. Results Compared with people without diabetes, people with diabetes had comparably worse smoking status (adjusted OR (aOR) 1.09, 95% CI 0.92 to 1.30), insufficient physical activity (aOR 1.09, 95% CI 0.95 to 1.24) and were less likely to receive cancer screenings and regular health check-ups (aOR 0.75, 95% CI 0.66 to 0.85). Furthermore, compared with people unaware of their diabetes, people aware of their diabetes had lower odds of physical inactivity (aOR 0.66, 95% CI 0.45 to 0.99) and greater odds of receiving colon cancer screening (aOR 1.55, 95% CI 1.17 to 2.05) and influenza vaccination (aOR 1.56, 95% CI 1.15 to 2.11). Conclusions People with diabetes were no better in terms of health behaviours and preventive healthcare utilisation than those who were without diabetes. Further efforts and political attention to ensure the delivery of quality care for people with diabetes are needed.


Introduction
The section is weak and needs strengthening. The case for the current work needs to build up further with specific reference to how does health behavior impact the course and outcome among these patients.
Methods the subjects were assessed for various health related conditions. Many of these are not related directly or indirectly to diabetes. For example, screening for cancer. It seems the authors have tried to fit in the available information within the framework of the post hoc question.
Binge drinking is not the only harmful way of drinking. People can have problem's due to alcohol use in spite of not having binge drinking pattern. As a result a large proportion of those with harmful drinking might have got excluded from the study.
The details of the sampling have not been provided.

Analysis and Results
The comparisons have been made with no diabetes as the base group. This makes limited sense as the study aimed to compare the differences based on the diabetes awareness status. The authors should first campare the diabetes and no diabetes group as a whole. And then they should explore the impact of awareness by comparing the diabetes aware and diabetes not aware groups directly.

Discussion
This section can be pruned down.

REVIEWER
Sarah Alderson University of Leeds, UK REVIEW RETURNED 11-Jul-2017

GENERAL COMMENTS
Thank you for asking me to review this paper which is a crosssectional study on the diabetes population and health behaviours. This study adds to the evidence that those with diabetes are less likely to undertake healthy lifestyle changes despite being at higher risks of complications and future ill-health.
The study is presented well and the tables and abstract are clear to read.
I have a few concerns about the study that I believe need addressing before publication.
The authors describe depression which is assessed by asking whether the person has felt low for 2 weeks or more and interfered with daily activities. Whilst I commend the use of assessing depression in this study, this is a screening tool and not a diagnostic tool. The authors refer to this as depression throughout the results, however the low specificity of this tool means that this is inaccurate. The depression should be changed to depression symptoms or screened positive for depression which would be more accurate. A depression diagnosis should have a review by a health care professional and not be based just upon a screening tool.
More information is needed in the introduction regarding the set up of the Korean healthcare system, in particularly diabetes care would help readers understand how this fits into the context. For example, are all new diabetes patients routinely offered diabetes education and are they reviewed and monitored in primary or secondary care? This would help explain the context to those not familiar with Korean healthcare.
I would also be interested to know why the authors think there is such a high rate of patients (one third of patients?) being unaware of their diabetes diagnosis given the importance of managing this condition to reduce future health complications.
The authors mention that this study is limited as it may have excluded people (such as those in nursing homes) with more severe diabetes. I would like to see how the sample population represents the national population for diabetes rates, deprivation, age and gender etc. This would help with interpreting the results. This could be included in the tables as a comparison.
I hope these comments are useful and constructive. Thank you for the opportunity to review this paper.

Cristina Santos
Faculty of Medicine, University of Porto, Portugal

GENERAL COMMENTS
The percentages in table 1 should be reviewed, for example in first  line, first column the percentage is not correct, I got 23.9% instead of  28.9%. Authors should provide in the methods section more details on multiple logistic regression. It is not clear how the independent variables (age, gender, BMI, education level, employment status, marital status, monthly income, living area, self-rated health status, and medical insurance) were chosen.
The variable "group" (without diabetes, with unaware diabetes, with aware diabetes) should be the dependent variable. Actually, the authors used as dependent variables each of health-risk behavior, each of preventive Health Care Utilization and each of psychosocial problem, and by this way they cannot adjust these variables to each other. For example, the authors claim: "Compared to people without diabetes, people who were aware of their diabetes had worse smoking status " and "People who were aware of their diabetes also had higher odds of depression". However, we may be in the presence of a confounding variable, i.e. maybe there are no association between smoking and the group, however, depression may be associated with both smoking and the group, and in this case not observing depression will create a spurious association between smoking status and the group.
In conclusion, authors should use as dependent variable the "group" (without diabetes, with unaware diabetes, with aware diabetes) and construct a model (and explain how the variables were chosen) considering all the independent variables (not only characteristics of the persons, but also health-risk behaviors, preventive Health Care Utilizations and psychosocial problems)

VERSION 1 -AUTHOR RESPONSE
Reviewer(s)' Comments to Author: Reviewer: 1 Reviewer Name: Yatan Pal Singh Balhara Institution and Country: AIIMS, India Please state any competing interests: None Declared Please leave your comments for the authors below I thank the editor for the opportunity to review the manuscript. The manuscript explores an important area with research and clinical implications. There are certain limitations of the manuscript that are listed below-

Introduction
The section is weak and needs strengthening. The case for the current work needs to build up further with specific reference to how does health behavior impact the course and outcome among these patients. I agree with reviewer's comments. Detail description regarding health behavior's impact on the course of diabetes was added to the introduction.
Methods the subjects were assessed for various health related conditions. Many of these are not related directly or indirectly to diabetes. For example, screening for cancer. It seems the authors have tried to fit in the available information within the framework of the post hoc question.
Recently, studies on the relationship between diabetes and cancer incidence have been continuously reported, and the necessity of cancer screening for diabetes patients has been emphasized more in the general group according to the guidelines from the Korean Diabetes Association [12]. This study showed differences in the diabetes and non-diabetes groups in terms of compliance with cancer screening programs mostly provided free of charge by the government. Further epidemiologic studies are needed to determine whether there is a positive effect on disease progression in diabetes patients with high compliance with cancer screening in the future.
Binge drinking is not the only harmful way of drinking. People can have problem's due to alcohol use in spite of not having binge drinking pattern. As a result a large proportion of those with harmful drinking might have got excluded from the study. Thank you for your comment. We changed the definition of alcohol drinking so that two or fewer drinks for men and one drink or less for women indicated "no drinker," and others were classified as "drinkers" according to the guidelines from the Korean Diabetes Association. The details of the sampling have not been provided. We described the sampling process in more detail.

Analysis and Results
The comparisons have been made with no diabetes as the base group. This makes limited sense as the study aimed to compare the differences based on the diabetes awareness status. The authors should first campare the diabetes and no diabetes group as a whole. And then they should explore the impact of awareness by comparing the diabetes aware and diabetes not aware groups directly. We agree with the reviewer's comments. We first compared diabetes and non-diabetes groups and then applied the same analyses to the aware and unaware groups within the diabetes group, as shown in Tables 2, 3, and 4.

Discussion
This section can be pruned down. We restructured and deleted content to ensure clarity and conciseness.
Reviewer: 2 Reviewer Name: Sarah Alderson Institution and Country: University of Leeds, UK Please state any competing interests: None declared Please leave your comments for the authors below Thank you for asking me to review this paper which is a cross-sectional study on the diabetes population and health behaviours. This study adds to the evidence that those with diabetes are less likely to undertake healthy lifestyle changes despite being at higher risks of complications and future ill-health. The study is presented well and the tables and abstract are clear to read. I have a few concerns about the study that I believe need addressing before publication.
The authors describe depression which is assessed by asking whether the person has felt low for 2 weeks or more and interfered with daily activities. Whilst I commend the use of assessing depression in this study, this is a screening tool and not a diagnostic tool. The authors refer to this as depression throughout the results, however the low specificity of this tool means that this is inaccurate. The depression should be changed to depression symptoms or screened positive for depression which would be more accurate. A depression diagnosis should have a review by a health care professional and not be based just upon a screening tool.
Thank you for your comment. We have changed the expression of "depression" to "depressive symptoms." More information is needed in the introduction regarding the set up of the Korean healthcare system, in particularly diabetes care would help readers understand how this fits into the context. For example, are all new diabetes patients routinely offered diabetes education and are they reviewed and monitored in primary or secondary care? This would help explain the context to those not familiar with Korean healthcare. Thank you for the comments. We have added explanation about the diabetes education system in the Korean medical context to the introduction.
I would also be interested to know why the authors think there is such a high rate of patients (one third of patients?) being unaware of their diabetes diagnosis given the importance of managing this condition to reduce future health complications. Because the National Health and Nutrition Examination Survey data are collected through a basic questionnaire and blood test, individuals who do not perform the usual diabetes test sometimes accidentally participate in this study and discover that they have diabetes. These groups are included as the "unaware diabetes" group. However, because of the one-time fasting blood glucose test in these data, there might be over-diagnosis of the unaware diabetes group.
The authors mention that this study is limited as it may have excluded people (such as those in nursing homes) with more severe diabetes. I would like to see how the sample population represents the national population for diabetes rates, deprivation, age and gender etc. This would help with interpreting the results. This could be included in the tables as a comparison. Thank you for the comments. We compare the prevalence of diabetes mellitus, diabetes type, oral dosage form, and insulin prescription rate by gender and age with Korean official diabetes data in Korea as follows. Authors should provide in the methods section more details on multiple logistic regression. It is not clear how the independent variables (age, gender, BMI, education level, employment status, marital status, monthly income, living area, self-rated health status, and medical insurance) were chosen. We have shown a step-by-step process of calibrating the confusion variables unadjusted in the table and Models 1 and 2. The selection of confounding variables was based on age, gender, and body obesity index in Model 1, as in public health studies, and then additional variables related to SES were shown at the next level in Model 2.
The variable "group" (without diabetes, with unaware diabetes, with aware diabetes) should be the dependent variable. Actually, the authors used as dependent variables each of health-risk behavior, each of preventive Health Care Utilization and each of psychosocial problem, and by this way they cannot adjust these variables to each other. For example, the authors claim: "Compared to people without diabetes, people who were aware of their diabetes had worse smoking status " and "People who were aware of their diabetes also had higher odds of depression". However, we may be in the presence of a confounding variable, i.e. maybe there are no association between smoking and the group, however, depression may be associated with both smoking and the group, and in this case not observing depression will create a spurious association between smoking status and the group.
In conclusion, authors should use as dependent variable the "group" (without diabetes, with unaware diabetes, with aware diabetes) and construct a model (and explain how the variables were chosen) considering all the independent variables (not only characteristics of the persons, but also health-risk behaviors, preventive Health Care Utilizations and psychosocial problems) Thank you for your comments. According to the reviewer's comment, data were reanalyzed with the various variables related to the health behaviors as the independent variables and diabetes or nondiabetes/unaware or aware diabetes as dependent variables. Thank you for your good feedback.  The variable "group" (without diabetes, with unaware diabetes, with aware diabetes) should be the dependent variable. Actually, the authors used as dependent variables each of health-risk behavior, each of preventive Health Care Utilization and each of psychosocial problem, and by this way they cannot adjust these variables to each other.

VERSION 2 -AUTHOR RESPONSE
Reviewer's Comments to Author: Reviewer: 3 Thank you for the comment. We performed reanalysis and did stepwise regression analyses. As a result, age, gender, body mass index, education level, employment status, living area, self-rated health status, and medical insurance were set as confounding variables and a related explanation was added in the method section on page 11, lines 6-8. As the confounding variables were changed, the results of the OR and 95% CI were changed in Tables 2, 3, and 4. We confirmed that there were no interactions between the confounding variables.
The variable "group" (without diabetes, with unaware diabetes, with aware diabetes) should be the dependent variable. Actually, the authors used as dependent variables each of health-risk behavior, each of preventive Health Care Utilization and each of psychosocial problem, and by this way they cannot adjust these variables to each other.
This study was designed to investigate the disparity between the diabetes and no diabetes groups or aware diabetes group and unaware diabetes group in regard to three domains: health-risk behavior, preventive health care utilization, and mental health status. Therefore, independent variables were set as diabetes and no diabetes or aware of diabetes and unaware of diabetes, and dependent variables were set as three domains. We realized that the schematic of this study was not clear; therefore, we added Figure 1 to make this easy to understand at a glance and a study with similar design was cited as follows. 29-Jan-2018

GENERAL COMMENTS
As I said before, in my opinion, the variable "group" should be the dependent variable. Moreover, authors should provide more details in the statistical methods section. Actually, in the last version of manuscript, the authors re-analysed the data in order to use an automatic method from variable selection, and they claimed that the interactions were tested, however this is not yet enough. For example, they should provide the rationale for including each variable (prior studies/clinical knowledge ? exploratory analysis ? ). Is it stepwise method forward or backward? Which criteria of entry (or elimination) was used in the stepwise method? Use of stepwise only has limitations here, non-automated selection or prior knowledge should be considered. There is a strong recommendation for statistical support particularly with regard to Modeling and variable selection [1].
Thank you for the comment. Based on the comments, statistical corrections were made to the overall analysis with statisticians. 1. Dependent and independent variables. The hypothesis of this study is there is no difference in lifestyle, health prevention behavior and mental health according to whether diabetes or no diabetes / diabetes awareness or unawareness. As mentioned in the introduction, diabetes care in Korea is mainly focused on drug prescription. Therefore, education and counseling for life style modification/preventive behavior/mental health are necessary. In order to insist on this, this study shows the current status of healthy behavior among diabetes groups. We agree it is not possible to exclude the relationship between the cause and the effect of the dependent / independent variable due to the limitation of the cross sectional study. In this study, it is difficult to clarify the causal relationship between diabetes and health behaviors as it is not a cohort study. Therefore, the limitations of this study and the necessity of additional research should be added in the discussion section on page 16 and 17.

Logistic regression modeling
We supplemented the modeling of logistic regression analysis with an additional description of statistical methods in the text on page 11. And the final model was completed with the next step as follows. About dependent and independent variables.
As the title implies, the object of this study is to show the gaps in health behaviors and use of prevention services between diabetic and non-diabetic patients. The recommendation by the reviewer to exchange the dependent and independent variables was to analyze the factors related to diabetes, there is concern the purpose of this study may be distorted.
The hypothesis of this study is as follows; there is no difference in lifestyle, health prevention behavior and mental health according to whether diabetes or no diabetes / diabetes awareness or unawareness. As mentioned in the introduction, diabetes care in Korea is mainly focused on drug prescription. Therefore, education and counseling for life style modification/preventive behavior/mental health are necessary. In order to insist on this, this study shows the current status of healthy behavior between diabetes and non-diabetes groups. Therefore, we would like to express our opinion the groups (with and without diabetes / diabetes awareness or unawareness) as the independent variable are suitable in our study.