Prevalence of previously diagnosed diabetes and glycemic control strategies in Mexican adults: ENSANUT-2016.

OBJECTIVES: To describe the prevalence of previously diagnosed diabetes among Mexican adults, to characterize the associated risk factors, and to describe which glycemic control strategies are the most used.
METHODS: We analyzed data from 8,631 adults aged ≥20 years who participated in the ENSANUT-2016 and from whom we gathered data about previously diagnosed diabetes, risk factors, glycemic control strategies, and measures to prevent complications.
RESULTS: The prevalence of previously diagnosed diabetes in Mexican adults was 9.4% (10.3% in women and 8.4% in men). The adjusted OR for having diabetes was higher in adults aged ≥60 years (OR = 11.0 in women and OR = 30.7 in men) than in adults aged 20-39 years (OR = 1.0). The adjusted OR for having diabetes was higher in overweight men (OR = 1.7) than in men with normal BMI (OR = 1.0). A total of 30.5% of adults with diabetes did not report any control strategies, 44.9% measured their venous blood glucose, and 15.2% used the HbA1C as an indicator of glycemic control. Only 46.4% of them reported preventive measures. DISCUSSION: Diabetes is a common disease among Mexican adults. Being older or overweight are risk factors for an adult to be diagnosed with diabetes. Most adults with diabetes evaluate their glycemic control but only half practice preventive measures.

Introduction

Diabetes is a chronic disease that during its first stages produces no symptoms and that when not adequately treated causes complications such as retinopathy, nephropathy, heart attack and premature death [1].

There are non-modifiable risk factors, such as genetics; but others are indeed modifiable such as obesity [2], diet [3], screen time [4], sleep quality [5], and tobacco smoking. [6] Prevention and management of modifiable risk factors for diabetes type 2 could delay or prevent the occurrence of complications and improve its control.

During 2014, the prevalence of diabetes type 2 among adults was 8.5% [7] worldwide, and in Mexico, according to the national health survey 2012, the prevalence was 9.2%. [8]

Due to the multicausality and chronicity of diabetes, people living with this disease need lifestyle interventions to prevent or minimize its progression, continuous medical attention to assess and control glycemia according to its clinical response, and preventive measures to avoid and delay the occurrence of complications. [9, 10].

Identifying the risk factors associated with the diagnosis and control of diabetes in a population contributes to showing the areas to which the strategies for screening, hyperglycemia treatment and prevention of potential complications should be directed [5]. In Mexico, there is no recent evidence that characterizes at a national level the risk factors associated with the diagnosis of diabetes and to its control. Therefore, the objective of our study is to describe the prevalence of previously diagnosed type 2 diabetes in adults that live in Mexico, to characterize the associated risk factors, and to describe the most used glycemic control strategies.

Methodology

The National Health and Nutrition Survey 2016 (ENSANUT-2016, Encuesta Nacional de Salud y Nutricion 2016) followed a cross-sectional, probabilistic, regional representative, and by area of residence (urban ≥2,500 inhabitants and rural <2,500 inhabitants) design. A total of 9,406 adults were selected achieved a 91.7% response rate. The detailed description of the sampling procedures, survey methodology, regionalization (North, Center, Mexico City, and South), and the socioeconomic status (SES) configuration (low, medium, and high) has already been published elsewhere. [11]

Participants

In the analysis 8,631 adults that had full information about the previously diagnosed diabetes, risk factors, treatment, screening of the disease, associated complications, and complications preventive measures were included.

Diabetes medical diagnosis

The prevalence of previously diagnosed diabetes was determined based on the question: “Has a doctor ever told that you have diabetes or high blood sugar?”. We considered that there was a prior diagnosis of diabetes when the participants answered “Yes”.

Associated chronic diseases

We considered that a participant had any of the following diseases: high blood pressure, kidney failure, cerebrovascular disease, acute myocardial infarction or angina, when the participant self-reported that a medical doctor had diagnosed that pathology throughout his life.

Measurements for weight, size, and waist circumference were collected by trained and standardized staff using internationally accepted protocols. [12,13]. Weigh was measured using an electronic scale with an accuracy of 100 g and height was measured using a stadiometer with an accuracy of 2 mm. The World Health Organization (WHO) criteria was used to classify body mass index (BMI) into three categories: normal BMI (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), obesity (≥30.0 kg/m2). [14]

Physical activity and screen time

To determine the level of physical activity (PA), the short version of the International Physical Activity Questionnaire (IPAQ) was used. [15] To categorize the level of moderate to vigorous PA performed during the last seven days, we used the WHO classification: inactive <150 minutes, moderately active 150–299, and active >300. [16] To categorize the screen time, the minutes per week of tv watching, videogaming, and computer use were counted and then divided into three groups: ≤840, 840–1680, and >1680. [17]

Dietary diversity (DD)

A questionnaire on frequency of food intake (FFQ) was administered seven days before the interview. The FFQ included 140 foods that were divided in 22 food groups. [18] In the DD index, the number of food groups (2–22 groups) was weighed against the number of days they were consumed during the week. The DD score was 2–154 points. Afterwards, the score was classified into quartiles.

Sleep quality was measured with the question "how would you rate the quality of your sleep regularly?" the possible answers were: good or very good and bad or very bad. The strategies to assess glycemic control during the last year and the measures to prevent complications associated were self-reported only by participants previously diagnosed with type 2 diabetes.

Statistical analysis

We estimated the prevalence and the confidence interval at 95% (95% CI) of previously diagnosed diabetes, strategies to assess glycemic control during the last year and measures to prevent complications associated with diabetes, categorizing by variable of interest. We also calculated the odds rate (OR) for having diabetes, adjusting for sociodemographic, anthropometric, and clinical variables. A p<0.05 value was considered statistically significant. All analyses were conducted using the SVY module for complex samples of the statistical software STATA, version 14 (College Station, TX, USA).

Ethical considerations

All participants signed an informed consent approved by the Institutional Review Board of the National Institute of Public Health in Mexico. This study is based on an analysis of databases, the original protocol has the approvals of the ethical and research commissions of the National Institute of Public Health, with Commission number 1401, registration with Conbioetics: 17 CEI00120130424, registration with COFEPRIS CEI 17 007 36

Results

The prevalence of previously diagnosed diabetes was 9.4% in Mexican adults (10.3% in women and 8.4% in men). When categorizing by age groups, we observed that among 20–39 year-old-adults, the prevalence of diabetes was 3.8 times higher in women than in men (Table 1). Women with primary or less education were also more likely to be diagnosed with diabetes (18.8%; CI95% 14.9–23.4) than their male counterparts (12.5%; CI95% 10.4–14.8).

Table 1

Prevalence of previously diagnosed diabetes in ≥ 20 year-old Mexican adults.

ENSANUT 2016-Mexico*.

	Previously Diagnosed Diabetes
	Total			Women			Men
	n	n thousands	Prevalence (95% CI)	n	n thousands	Prevalence (95% CI)	n	n thousands	Prevalence (95% CI)
National	972	6,464.8	9.4 (8.2–10.8)	664	3,771.6	10.3 (8.7–12.4)	308	2,693.2	8.4 (7.0–10.1)
Age (years)
20–39	69	521.9	1.5 (1.1–2.1)	54	428.8	2.3 (1.5–3.4)	15	93.2	0.60 (0.3–1.1)
40–59	415	2,742.2	12.3 (10.5–14.5)	290	1,454.7	11.9 (9.8–14.5)	125	1,287.5	12.8 (10.1–16.3)
60 and more	488	3,200.6	27.4 (23.2–31.9)	320	1,888.1	30.6 (24.4–37.6)	168	1,312.5	24.1 (19.1–28.2)
Socioeconomic tertile
Low	448	2,374.6	10.3 (8.1–12.9)	319	1,575.1	12.8 (9.2–17.7)	129	799.5	7.4 (5.7–9.4)
Medium	331	2,288.1	10.1 (8.3–12.2)	221	1,229.1	10.0 (8.0–12.1)	110	1,059.0	10.3 (7.3–14.1)
High	193	1,802.1	7.9 (6.3–10.1)	124	967.3	8.1 (5.9–10.9)	69	834.7	7.8 (5.2–11.5)
Education level
Primary or less	655	3,756.2	15.9 (13.5–18.6)	457	2,411.8	18.8 (14.9–23.4)	198	1,344.4	12.5 (10.4–14.8)
Secondary or high school	246	2,068.1	6.7 (5.4–8.3)	168	1,048.5	6.5 (5.1–8.3)	78	1,019.6	7.1 (4.7–10.1)
Bachelor's degree	71	640.5	4.5 (3.3–6.3)	39	311.3	4.1 (2.5–6.4)	32	329.2	5.2 (3.2–8.1)
Area of residence
Rural	422	1,479.7	9.3 (7.8–10.9)	292	783.2	9.4 (8.1–11.1)	130	696.5	9.1 (6.8–11.9)
Urban	550	4,985.1	9.5 (0.8–11.2)	372	2,988.4	10.5 (8.3–13.4)	178	1,996.8	8.2 (6.7–10.3)
Region
North	224	1,271.4	8.7 (6.8–11.0)	155	737.2	9.8 (7.3–13.4)	69	534.2	7.5 (5.3–10.3)
Center	308	2,184.4	9.8 (7.3–12.9)	211	1,399.0	11.7 (7.6–17.6)	97	785.3	7.6 (5.4–10.5)
Mexico City	129	961.1	8.3 (5.7–11.8)	89	638.9	9.7 (6.5–14.4)	40	322.2	6.4 (3.9–10.3)
South	311	2,047.9	10.2 (8.5–12.4)	209	996.4	9.4 (7.4–11.7)	102	1,051.5	11.2 (8.3–14.9)
Physical activity‡
Inactive	173	1,191.8	13.8 (10.5–17.9)	121	576.6	11.8 (8.7–15.9)	52	615.2	16.3 (10.6–24.2)
Moderately active	81	504.3	8.9 (6.6–11.9)	51	273.6	7.7 (5.1–11.6)	30	230.7	10.9 (6.9–16.7)
Active	489	3,499.0	7.5 (6.1–9.2)	337	2,122.5	8.7 (6.4–11.8)	152	1,376.5	6.1 (4.8–7.6)
Prior medical diagnosis§
High blood pressure
No	514	3,357.0	5.8(05–6.7)	338	1,841.4	6.1(5.2–7.3)	176	1,515.7	5.4.(4.3–6.9)
Yes	458	3,107.8	29.6 (24.2–35.8)	326	1,930.2	29.3 (22.3–37.4)	132	1,177.6	30.3 (22.6–39.2)
Overweight or obesity
No	156	1,154.9	6.5(4.9–8.6)	100	3,013.4	6.6(4.7–9.2)	56	597.3	6.4(4.1–9.7)
Yes	756	4,912.7	10.4 (8.9–12.1)	534	3,013.4	11.6 (9.3–14.5)	222	1,899.3	8.9 (7.4–10.7)
Kidney failure
No	931	6,183.7	9.1(7.9–10.5)	635	3,577.3	9.9 (8.1–12.1)	296	2,606.4	8.2(6.8–9.9)
Yes	41	281.1	38.4 (25.5–53.2)	29	194.2	40.6 (24.0–59.7)	12	86.8	34.3 (16.9–57.1)
Cerebrovascular disease
No	952	6,253.2	9.2(8.0–10.5)	652	3,642.4	10.0(8.2–12.2)	300	2,610.8	8.2(6.8–9.9)
Yes	20	211.6	46.4 (29.3–65.6)	12	129.1	51.2 (27.4–74.9)	8	82.4	40.2 (17.2–68.5)
Acute myocardial infarction or angina
No	902	5,948.7	8.9(7.7–10.3)	620	3,531.4	9.7(8.0–12.1)	282	2,417.3	7.8(6.4–9.5)
Yes	70	516.1	27.7 (19.8–37.3)	44	240.2	29.4 (21.2–39.4)	26	276.0	26.4 (16.3–39.7)

*Data adjusted for the survey design

§Self-report of prior medical diagnosis of the described diseases

‡ Physical activity level (PA): Inactive <150 minutes a week, moderately active 150–299 minutes a week; and active >300 minutes a week.

Table 2 shows that among women as well as among men, the adjusted OR for having diabetes was significantly higher (p<0.01) in the ≥60 year-old-group (OR = 11.0 in women and OR = 30.7 in men) than in the 20–39 year-old-group (OR = 1.0). In overweight men, the OR for having diabetes was higher (1.7 CI 95% 1.1–3.0) than in normal BMI men; and in hypertense men, (4.2 CI 95% 2.5–6.9), the OR was higher than in men with no hypertension. In women, having a cerebrovascular disease, high blood pressure, acute myocardial infarction, or kidney failure was associated with a higher OR for having diabetes (p<0.05). When we compare the diversity of consumption of food groups or DD, we observe that in the total population and women with the highest quintile of DD (fourth quintile) the OR of having diabetes was lower (total population 0.5 CI 95% 0.3–0.7; women 0.4 CI 95% 0.2–0.7) than in the first quintile (OR = 1.0). In an adjusted model we tested interactions between each of the included variables and sex, observing significant interaction (p <0.055) only with age, socioeconomic tertile and education level.

Table 2

Adjusted odds ratio for previously diagnosed diabetes for sociodemographic, anthropometric, and clinical variables.

ENSANUT 2016-México.

	Total			Women			Men
	Adjusted OR			Adjusted OR			Adjusted OR
	OR	(95% CI)	p	OR	(95% CI)	p	OR	(95% CI)	p
Sex
Man	1.0			---	---	---	---	---	---
Woman	1.0	(0.8, 1.4)	0.916	---	---	---	---	---	---
Age (years)
20–39	1.0			1.0			1.0
40–59	6.3	(4.1, 9.6)	<0.001	4.2	(2.5, 6.8)	<0.001	17.5	(7.5, 40.6)	<0.001
60 and more	13.9	(8.5, 22.9)	<0.001	11.0	(6.2, 19)	<0.001	30.7	(11.7, 80.5)	<0.001
Socioeconomic tertile
Low	1.0			1.0			1.0
Medium	1.0	(0.7, 1.4)	0.87	0.7	(0.5, 1)	0.076	1.6	(0.9, 2.9)	0.096
High	0.7	(0.5, 1.2)	0.205	0.5	(0.3, 0.9)	0.017	1.4	(0.7, 2.7)	0.377
Education level
Primary or less	1.0			1.0			1.0
Secondary or high school	1.2	(0.8, 1.7)	0.358	1.1	(0.7, 1.6)	0.801	1.3	(0.7, 2.3)	0.375
Bachelor's degree	0.8	(0.5, 1.2)	0.287	0.5	(0.3, 1)	0.036	1.5	(0.7, 3.1)	0.253
Area of residency
Rural	1.0			1.0			1.0
Urban	1.1	(0.8, 1.6)	0.476	1.4	(0.9, 2.1)	0.107	0.8	(0.5, 1.4)	0.488
Region
North	1.0			1.0			1.0
Center	1.1	(0.8, 1.7)	0.539	1.2	(0.7, 2)	0.56	1	(0.5, 1.9)	0.968
Mexico City	0.8	(0.5, 1.3)	0.356	0.8	(0.4, 1.3)	0.317	0.9	(0.4, 1.8)	0.707
South	1	(0.7, 1.4)	0.819	0.7	(0.5, 1.2)	0.176	1.4	(0.8, 2.7)	0.275
Body Mass Index
Normal	1.0			1.0			1.0
Overweight	1.4	(0.9, 2)	0.136	1.1	(0.6, 1.7)	0.824	1.7	(1.1, 3.0)	0.051
Obesity	1.2	(0.8, 1.7)	0.351	1.1	(0.7, 1.8)	0.715	1.2	(0.7, 2)	0.593
Prior medical diagnosis§
No	1.0			1.0			1.0
High blood pressure	3.3	(2.4, 4.4)	<0.001	2.9	(2.0, 4.1)	<0.001	4.2	(2.6, 7)	<0.001
Cerebrovascular disease	2.8	(1.1, 6.9)	0.027	3.8	(1.4, 10.6)	0.011	1.3	(0.2, 9.8)	0.816
Acute myocardial infarction	1.4	(0.8, 2.7)	0.276	1.7	(0.8, 3.8)	0.182	1.4	(0.6, 3.7)	0.45
Kidney failure	3.5	(1.8, 7.1)	<0.001	5.1	(2.5, 10.7)	<0.001	1.8	(0.4, 7.2)	0.436
Physical activity‡
Inactive	1.0			1.0			1.0
Moderately active	0.9	(0.6, 1.4)	0.616	0.7	(0.4, 1.3)	0.288	1.2	(0.6, 2.7)	0.587
Active	0.8	(0.5, 1.1)	0.198	0.8	(0.5, 1.2)	0.212	0.7	(0.4, 1.3)	0.258
Screen time (minutes)
≤840	1.0			1.0			1.0
840–1680	1.0	(0.7, 1.5)	0.883	1.3	(0.9, 1.9)	0.149	0.7	(0.4, 1.1)	0.124
1680 or more	1.0	(0.6, 1.6)	0.908	1.3	(0.8, 2.4)	0.324	0.5	(0.2, 1.2)	0.105
Dietary diversity
First quartile	1.0			1.0			1.0
Second quartile	0.7	(0.5, 1.1)	0.104	0.6	(0.4, 0.9)	0.026	1.2	(0.6, 2.3)	0.578
Third quartile	0.7	(0.4, 1.1)	0.068	0.6	(0.3, 0.9)	0.022	1.2	(0.6, 2.3)	0.687
Fourth quartile	0.5	(0.3, 0.7)	<0.001	0.4	(0.2, 0.7)	0.001	0.7	(0.4, 1.3)	0.228
Has smoked more than 100 cigarettes
Never smoked	1.0			1.0			1.0
Has never smoked more than 100 cigarettes	0.8	(0.6, 1.2)	0.36	0.8	(0.5, 1.3)	0.342	0.8	(0.5, 1.4)	0.432
Has smoked more than 100 but not smoking anymore	1.1	(0.7, 1.6)	0.74	0.9	(0.4, 2)	0.781	1.1	(0.6, 1.8)	0.87
Has smoked more than 100 and is still smoking	0.7	(0.4, 1.1)	0.107	0.7	(0.3, 1.3)	0.197	0.7	(0.4, 1.4)	0.336
Sleep quality
Good to fair	1.0			1.0			1.0
Bad or very bad	1.0	(0.7, 1.5)	0.913	1.1	(0.7, 1.8)	0.692	1.0	(0.5, 2)	0.964

*Data adjusted for the survey design

Adjusted OR for sociodemographic variable (sex, age, socioeconomic tertile, education level, area of residency and region); anthropometric (body mass index); prior medical diagnosis (high blood pressure, cerebrovascular disease, acute myocardial infarction or angina and kidney failure); and lifestyles (physical activity, screen time, dietary diversity, smoking and sleep quality).

§ Self-report of prior medical diagnosis of the described diseases

‡ Physical activity(PA) level: Inactive <150 minutes a week, moderately active 150–299 minutes a week; and active >300 minutes a week.

A total of 30.5% of adults with diabetes did not report any control strategies, 44.9% measured their venous blood glucose, and 15.2% used the HbA1C as an indicator of glycemic control (Table 3). Only 46.4% of them reported preventive measures. When comparing by sex groups, frequency of when the glycemic control assessment was performed during the last year, measures to prevent complications, and lifestyle interventions, there were no differences when categorizing by sex, except when comparing how frequently the dental evaluation was performed: women self-reported 2.6 times more this practice than men did (11.3% vs 4.3%).

Table 3

Strategies for assessing glycemic control during the last year and measures to prevent complications associated with diabetes, categorizing by sex.

ENSANUT MC 2016*.

	Total			Women			Men
	n	%	(95% CI)	n	%	(95% CI)	n	%	(95% CI)
Glycemic control assessment
Urine reactive strips	60	4.6	(3.1–7.0)	36	3.1	(1.9–5.2)	24	6.7	(3.7–12.1)
Blood reactive strips	242	22.3	(17.7–27.7)	156	18.1	(13.6–25.6)	86	28.2	(20.7–27.2)
Urinalysis	308	29.6	(24.9–34.7)	227	34.2	(27.7–41.2)	81	23.1	(17.3–30.2)
Venous blood sampling	462	44.9	(28.2–51.7)	333	48.4	(39.9–57.2)	129	39.8	(30.6–49.1)
HbA1c testing	153	15.2	(11.7–19.5)	122	17.5	(13.1–22.9)	31	12.1	(7.1–19.1)
Protein in urine	44	4.6	(3.2–6.8)	27	3.9	(2.2–6.8)	17	5.7	(3.3–9.7)
Self-monitoring/self-management	19	1.7	(0.9–3.1)	12	1.3	(0.7–2.7)	7	2.3	(0.9–5.5)
No testing	716	30.5	(24.7–29.3)	499	30.5	(21.8–22.1)	217	30.6	(22.1–40.7)
Preventive measures
Eye exam	130	13.1	(10.4–16.4)	97	15.3	(11.7–19.6)	33	10.1	(6.5–15.2)
Cholesterol and triglyceride measurement	155	15.2	(12.3–18.7)	112	15.4	(11.3–20.7)	43	14.9	(10.6–20.6)
Blood pressure measurement	43	6.1	(3.2–10.9)	26	4.3	(2.4–7.5)	17	8.5	(3.2–20.5)
Kidney exam/microalbuminuria	140	14.2	(11.5–17.5)	103	15.1	(11.6–19.4)	37	13.1	(8.9–18.5)
Electrocardiogram	42	4.4	(2.8–6.9)	26	3.5	(1.8–7.0)	16	5.6	(3.2–9.8)
Taking a daily aspirin	61	5.1	(3.53–7.41)	46	7.2	(4.6–11.1)	15	2.3	(1.1–4.7)
Influenza-pneumococcal yearly immunizations	165	15.3	(12.3–18.9)	115	16.3	(12.3–21.6)	50	13.9	(10.1–19.1)
Dental exam	93	8.4	(6.2–11.2)	75	11.3	(7.8–16.1)	18	4.3	(2.7–6.9)
No preventive measure	503	53.6	(46.6–60.4)	345	52.1	(43.2–60.7)	158	55.8	(46.5–64.8)
Lifestyle interventions
Educational diabetes program	111	9.3	(6.9–12.2)	86	10.6	(7.5–14.7)	25	7.3	(4.5–11.8)
Quit smoking	19	2.4	(1.4–4.2)	8	1.8	(0.8–3.9)	11	3.2	(1.5–6.8)
Avoid shoes that injure feet	80	8.4	(5.6–12.5)	50	7.7	(4.9–11.9)	30	9.4	(5.49–15.8)
Physical activity	570	77.1	(69.7–83.1)	388	80.6	(73.1–86.4)	182	72.3	(59.5–82.3)

*Data adjusted for the survey design

Discussion

In our analysis, we found that in Mexican adults the prevalence of previously diagnosed diabetes was 9.4% and only 44.9% used some glycemic control strategy. The prevalence of diabetes in Mexico is higher than in countries like Holland [19] (5.4%) and the average prevalence in the world (8.5%) [20]; probably because the prevalence of overweight in Mexico is at the top of the worldwide rankings and it is the main precipitant factor. [21] The prevalence of previous diagnosis of diabetes in Mexico increased from 7.0 to 9.2% between 2006 and 2012, [8] however, in the following four years (2016) the increase was only 0.2%. [11] This reflects that fewer people with diabetes are unaware of having this disease and the timely diagnosis has improved in recent years.

Diabetes occurs mainly in persons in their fourth decade, [22] and in our results, we found that the prevalence was higher in adults aged 40 years and older. This trend is similar to the one in the U.S., because diabetes can be the result of a culmination of health problems that accumulate throughout life. [23]

It has been described that the excess of body fat is a factor tightly related to the development of insulin resistance and later to diabetes. [20] We found that adults with obesity had a higher probability ratio for being diagnosed with diabetes (OR 1.8, 95% CI 1.3–2.8) than adults with normal BMI do.

Diabetes can be a reflection of the behavioral, hereditary, and social context risk factors. Those who belong to the lowest SES tertile have a higher risk of developing diabetes because they have less access to health services, to prompt diagnosis, and to a healthy lifestyle. [24] We found that adults from a low SES had a higher probability ratio for being diagnosed with diabetes (OR 1.0) than those from a higher SES (OR 0.6, 95% CI 0.4–0.9).

One of the aims of this study was to describe which glycemic control strategies were used more frequently in Mexico. Venous blood glucose measurement and glycosylated hemoglobin (HbA1c) quantification are the glycemic control strategies recommended by the American Diabetes Association (ADA). [25] Our findings showed that 30.5% of the Mexicans with diabetes did not have any control strategies, that 44.9% measured their venous blood glucose, and only 15.2% used the HbA1c as an indicator for glycemic control during the last 12 months. Although there are no statistics of these indicators in other countries, in the National Health and Nutrition Examination Survey III, only 39% of the participants reported using glycemic screening. [26]

The ADA has established strategies for comorbidities prevention. These include measuring blood pressure, cholesterol and triglycerides in blood, protein in urine; eye and teeth evaluations, as well as applying immunizations. [25] In the ENSANUT-2016 we observed that 53.6% of the population did not take any preventive measures. Even though 49.2% of Mexican adults had hypertension. [27] Of the adults analyzed in this study, only 6.1% verified their blood pressure; therefore, it is possible that there is a high percentage of adults with hypertension who are unaware of having this disease. This would increase the risk of developing associated complications if this situation is not reversed in the short term.

As for lifestyle interventions, the ADA recommends performing PA, not smoking, and improving diet, among other. [28] In the ENSANUT-2016, we found that PA was the most practiced intervention (77.1%) to control glycemia and to prevent the development of comorbidities. This figure is similar to the one reported in persons without diabetes but could be overestimated due to the questionnaire used. [29]

Dietary management is important to prevent diabetes [30] and dietary diversity is inversely associated with the risk of developing diabetes. [31] In our analysis we found that in women and total population having a greater DD was associated with a lower probability ratio of being diagnosed with diabetes. In men we do not find that DD is associated with a lower risk of diabetes possibly because in some subpopulations such as Hispanics [32] the results are still inconsistent and it is necessary to use a methodology that measures DD more accurately. These findings should motivate the generation of new studies that analyze this association longitudinally to confirm the direction and magnitude of causality. If this association is confirmed, it would be advisable to design communication programs to promote DD as another strategy to prevent diabetes.

According to ADA’s standards, all people with diabetes should participate in a self-management educational program. In this study we show that only 9% of the adults with diabetes received an education to facilitate the knowledge and to improve self-management skills. This explains in part why half of the adults do not take a preventive measure.

Some of the limitations of our analysis are that due to the study design we could not establish causality with risk factors and we could not know the percentage of adults who had diabetes but have not been diagnosed yet. We recognize that our results may be influenced by the possible measurement bias that represents the use of a self-report and by the social desirability bias in answering the questionnaires, however, this measurement tool has a high sensitivity and specificity as an indicator of prior medical diagnosis of diabetes. [33-34]

Not having glucose measurement as a complementary diagnostic method may underestimate the true prevalence of diabetes by up to 50%. [35] For example, in Mexican immigrants participating in the National Health and Nutrition Examination Survey when self-report is used as a diagnostic tool, only half of adults with diabetes (11.3%) are detected compared to using glucose measurement as a complementary method (22.6%). [36]

One of the strengths of the study is that the results are representative of the Mexican adult population and are the most recent data on the prevalence of diabetes. This information will help the decision makers in health policies to know the magnitude of this disease, main associated risk factors and diabetes control practices.

The high prevalence of diabetes found in our study should motivate in the short term estimate the total prevalence of diabetes including glucose measurement as a diagnostic method. We also believe it is necessary to evaluate the suitability of current programs for the diagnosis, prevention and control of diabetes such as PrevenIMSS and PrevenISSSTE to reduce its prevalence and improve glycemic control.

Conclusion

The conclusion of this study is that the prevalence of previously diagnosed diabetes among Mexican adults who participated in the ENSANUT-2016 was high. Being older or obese are risk factors that increase the probability ratio for an adult being diagnosed with diabetes. Finally, approximately half of Mexican adults with diabetes implement strategies to assess glycemic control and to prevent complications.

10 Dec 2019

PONE-D-19-29166

Prevalence of previously diagnosed diabetes and glycemic control strategies in Mexican adults: ENSANUT-2016

PLOS ONE

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This study provides estimates of diabetes among Mexican adults using data from the most recent national health survey in Mexico. The topic of the study is of high importance, given how prominent diabetes and associated risk factors, like overweight and obesity, are in Mexico and the significant health, societal and economic impacts these conditions have at present.

The paper can be improved by clarifying certain methodological aspects and assertions, better organizing of the results,by situating the findings in the context of any national diabetes prevention and control strategies, and adding an implications/recommendations for research and/or practice paragraph to the discussion.

Abstract

• There is a typo on line 26, pertaining to the year of the ENSANUT survey.

• Unclear whether odds ratios are crude or adjusted for other factors.

• On lines 34-36, it is unclear whether the percentages reported refer to all ENSANUT participants or only those diagnosed with diabetes. Also, if 44.9% measured their venous blood glucose, how is it possible that 69.5% were estimated as not engaging in any control strategies? The two percentages would exceed 100%.

• The discussion should be based on reported results, not report new results. The authors mention activity and education, but those results are not reported in the results section.

• The discussion also mentions that half of partipants used control strategies but that percentage is not reported in the results section either.

Introduction

• It should be made clear whether the paper focuses on Diabetes Type 2 or any type of diabetes.

• Why is the ENSANUT 2012 reported as the last national health survey? Shouldn’t it be ENSANUT 2016?

Methods

• Line 71: I don’t think the word “considering” is appropriate here. I think the authors probably mean that the survey “achieved” a 91.7% response rate. Please, double check.

• Line 86: Did these questions inquire about lifetime diagnosis or within a certain time window?

• Lines 106-109: The decription of the DD score categorizatio into recommended and non-recommended foods is confusing. These dietary measures need to be explained more clearly. Perhaps some examples would help.

• Lines 110-112: These measures of sleep and glycemic control strategies require more elaboration to increase the rigor of the study. The authors also need to specify if questions about glycemic control strategies were asked of all participants or only those who reported a diabetes diagnosis. If only those with diabetes were administered these questions, the n sizes should be added to the first row of Table 3. If this information was obtained from everyone, it would make sense to stratify the results about glycemic control by previous diagnosis of diabetes, as they can expect to vary significantly by disease status.

Statistical Analyses

• Please, unpack the variables used for adjustment, to increase replicability of the study. The list of variables adjusted for should also be reported as a footnote under Table 2.

Results/Tables

• It appears, per the 95% CI, that women with primary or less education were also more likely to be diagnosed with diabetes than their male counterparts, but this result is not reported.

• The result reported for gender differences among those with overweight or obesity (Lines 128-129) seems at odds with the overlapping 95% CIs shown on Table 1. Is that result after adjustment for other factors? If so, this should be stated.

• Table 1 should show the prevalence rates among those with and without the conditions listed under “Prior Medical Diagnosis”. That is, prevalence for those with and without a diagnosis of high blood pressure; with and without overweight or obesity; etc.

• The reporting of results shown on Table 2 (Lines 145-151) can be significantly improved. I recommend reporting the results separately for women and men and being more systematic listing all of the factors that were statistically associated with a diabetes diagnosis after adjustiment for other confounders, instead of picking/choosing just a few.

• I would like to see the results for all (women and men combined) on Table 2, just like Tables 1 and 3. If it’s difficult to fit all of the information on one table, the authors could consider presenting only adjusted results and provide the unadjusted ORs as supplemental material?

• On Table 3, it is unclear what “no testing” means. As stated in one of my comments for the abstract, if 69.5% did not testing, how is it possible that 44.9% did venous blood sampling? This should be mutually exclusive categories, yet they add up to more than 100%.

Discussion

• Please, comment on how the estimated prevalence compares to estimates based on earlier ENSANUT surveys, to give a sense of any potential trends.

• Lines 207-208: Please, double check and clarify why these percents exceed 100%.

• Lines 211-212: Specify this statistic is for the U.S.

• Lines 219-220: Clarify what “sub-diagnosis” means here and revise this sentence to make its meaning clearer. Is this about hypertension or about diabetes?

• Lines 224-225: This sentence is unclear. Is this still based on ENSANUT 2016? Also, the issue of social desirability bias should be addressed separately, as part of the limitations, as it can apply to all of the self-report based data used for this analysis.

• Line 231-233: The authors could cite other studies that have compared measured versus self-reported diabetes for Mexican adults, even if outside Mexico, as further evidence of likely undestimatio of true prevalence of diabetes. See Barcellos et al. Health Affairs 2012;31(12).

• A paragraph with implications and/or recommendations for future research and practice would strengthen the discussion, as would adding a little bit of context regarding any national strategies to improve diabetes prevention and control.

**********

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29 Jan 2020

PONE-D-19-29166

Prevalence of previously diagnosed diabetes and glycemic control strategies in Mexican adults: ENSANUT-2016

Comments to the author.

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

3. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

4. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer´s comment 1. Abstract: There is a typo on line 26, pertaining to the year of the ENSANUT survey.

Authors response: We appreciate the observation. We have corrected the name of the survey and now "ENSANUT-2016" appears.

Reviewer´s comment 2. Unclear whether odds ratios are crude or adjusted for other factors.

Authors’ response: We clarify that in Table 2, in the last row it is described that OR are “adjusted for sociodemographic, anthropometric and clinical variables from the table”.

In the abstract, we now specify that the OR are adjusted: “The adjusted OR for having diabetes was higher in adults aged ≥60 years (OR = 11.0 in women and OR = 30.7 in men) than in adults aged 20-39 years (OR=1.0). The adjusted OR for having diabetes was higher in overweight men (OR=1.7) than in men with normal BMI (OR=1.0).”

Reviewer´s comment 3. On lines 34-36, it is unclear whether the percentages reported refer to all ENSANUT participants or only those diagnosed with diabetes. Also, if 44.9% measured their venous blood glucose, how is it possible that 69.5% were estimated as not engaging in any control strategies? The two percentages would exceed 100%.

Authors’ response: We appreciate the observation. We have corrected the data and now the following appears: “A total of 30.5% of the participants did not report any control strategies, 44.9% measured their venous blood glucose...,”.

Reviewer´s comment 4. The discussion should be based on reported results, not report new results. The authors mention activity and education, but those results are not reported in the results section.

Authors’ response: The authors have attended this comment. Now the risk factors described in the results section are the same as those included in the conclusions section (age and overweight).

Reviewer´s comment 5. The discussion also mentions that half of participants used control strategies but that percentage is not reported in the results section either.

Authors’ response: In response to this observation in results section we add: “A total of 30.5% of adults with diabetes did not report any control strategies, 44.9% measured their venous blood glucose, and 15.2% used the HbA1C as an indicator of glycemic control”

Reviewer´s comment 6. Introduction. It should be made clear whether the paper focuses on Diabetes Type 2 or any type of diabetes.

Authors’ response: Now we specify that the manuscript is focused on type 2 diabetes

Reviewer´s comment 7. Introduction. Why is the ENSANUT 2012 reported as the last national health survey? Shouldn’t it be ENSANUT 2016?.

Authors’ response: We appreciate the observation and to avoid confusion we have now written it as follows: "according to the national health survey 2012 ..."

Reviewer´s comment 8. Methods. Line 71: I don’t think the word “considering” is appropriate here. I think the authors probably mean that the survey “achieved” a 91.7% response rate. Please, double check.

Authors’ response: We appreciate the suggestion and now we include in the text "achieved”

Reviewer´s comment 9. Methods. Line 86: Did these questions inquire about lifetime diagnosis or within a certain time window?

Authors’ response: Now we specify in methods that the diagnosis of these pathologies refers to “throughout life”.

Reviewer´s comment 10. Methods. Lines 106-109: The description of the DD score categorization into recommended and non-recommended foods is confusing. These dietary measures need to be explained more clearly. Perhaps some examples would help.

Authors’ response: Now we specify: “... recommended (for example; fruits, vegetables, legumes, tubers, cereals with fiber, dairy, sugar-free drinks) and non-recommended foods (cereals with sugar, sweets and desserts, sugary drinks, alcoholic beverages, dairy drinks with sugar and processed meats).”

Reviewer´s comment 11. Methods. Lines 110-112: The authors also need to specify if questions about glycemic control strategies were asked of all participants or only those who reported a diabetes diagnosis. If only those with diabetes were administered these questions, the n sizes should be added to the first row of Table 3. If this information was obtained from everyone, it would make sense to stratify the results about glycemic control by previous diagnosis of diabetes, as they can expect to vary significantly by disease status.

Authors’ response: We have added the description that the questions about glycemic control “were self-reported only by participants previously diagnosed with type 2 diabetes”. On the other hand, Table 3 includes the “n” of each category.

Reviewer´s comment 12. Statistical Analyses. Please, unpack the variables used for adjustment, to increase replicability of the study. The list of variables adjusted for should also be reported as a footnote under Table 2.

Authors’ response: Now in Table 2 the variables that were used to adjust are shown as footnotes: “Adjusted OR for sociodemographic variable (sex, age, socioeconomic tertile, education level, area of residency and region); anthropometric (body mass index); prior medical diagnosis (high blood pressure, cerebrovascular disease, acute myocardial infarction or angina and kidney failure); and lifestyles (physical activity, screen time, dietary diversity, smoking and sleep quality).

Reviewer´s comment 13. Results/Tables. It appears, per the 95% CI, that women with primary or less education were also more likely to be diagnosed with diabetes than their male counterparts, but this result is not reported.

Authors’ response: Now we describe in the manuscript the following: " Women with primary or less education were also more likely to be diagnosed with diabetes (18.8%; CI95% 14.9-23.4) than their male counterparts (12.5%; CI95% 10.4-14.8)”.

Reviewer´s comment 14. Results/Tables. The result reported for gender differences among those with overweight or obesity (Lines 128-129) seems at odds with the overlapping 95% CIs shown on Table 1. Is that result after adjustment for other factors? If so, this should be stated.

Authors’ response: We appreciate the observation. Because 95% CIs overlap, we decided to exclude that description: “When identifying adults with overweight or obesity, the prevalence of diabetes was 30% higher in women than in men”.

Reviewer´s comment 15. Results/Tables. Table 1 should show the prevalence rates among those with and without the conditions listed under “Prior Medical Diagnosis”. That is, prevalence for those with and without a diagnosis of high blood pressure; with and without overweight or obesity; etc.

Authors’ response: Now the Table 1 shows the prevalence with or without the disease.

Reviewer´s comment 16. Results/Tables. The reporting of results shown on Table 2 (Lines 145-151) can be significantly improved. I recommend reporting the results separately for women and men and being more systematic listing all of the factors that were statistically associated with a diabetes diagnosis after adjustment for other confounders, instead of picking/choosing just a few.

Authors’ response: The authors appreciate the suggestion, however, we believe that the description included shows the most relevant findings. To provide more detail we have added the result of interactions: “In an adjusted model we tested interactions between each of the included variables and sex, observing significant interaction (p <0.055) only with age, socioeconomic tertile and education level."

Reviewer´s comment 17. Results/Tables. I would like to see the results for all (women and men combined) on Table 2, just like Tables 1 and 3. If it’s difficult to fit all of the information on one table, the authors could consider presenting only adjusted results and provide the unadjusted ORs as supplemental material?

Authors’ response: We attended this comment and now we include the combined results in Tables 1, 2 and 3.

Reviewer´s comment 18. Results/Tables. On Table 3, it is unclear what “no testing” means. As stated in one of my comments for the abstract, if 69.5% did not testing, how is it possible that 44.9% did venous blood sampling? This should be mutually exclusive categories, yet they add up to more than 100%.

Authors’ response: We appreciate the valuable comment. We review each value in the table and now we include the correct data: “... A total of 30.5% of adults with diabetes did not report any control strategies, 44.9% measured their venous blood glucose...”

Reviewer´s comment 19. Discussion. Please, comment on how the estimated prevalence compares to estimates based on earlier ENSANUT surveys, to give a sense of any potential trends.

Authors’ response: We have added the following information: “The prevalence of previous diagnosis of diabetes in Mexico increased from 7.0 to 9.2% between 2006 and 2012,[8] however, in the following six years (2016) the increase was only 0.2%.[11] This reflects that fewer people with diabetes are unaware of having this disease and the timely diagnosis has improved in recent years”.

Reviewer´s comment 20. Discussion. Lines 207-208: Please, double check and clarify why these percents exceed 100%.

Authors’ response: We appreciate the valuable comment. We review each value in the table and now we include the correct data. The percentage described before was 69.5%, but the correct was the complement (30.5%).

Reviewer´s comment 21. Discussion. Lines 219-220: Clarify what “sub-diagnosis” means here and revise this sentence to make its meaning clearer. Is this about hypertension or diabetes?

Authors’ response: To avoid confusion we have changed the description as follows: “...Even though 49.2% of Mexican adults had hypertension. [27] Of the adults analyzed in this study, only 6.1% verified their blood pressure; therefore, it is possible that there is a high percentage of adults with hypertension and are unaware of having this disease. This would increase the risk of developing associated complications if this situation is not reversed in the short term.

Reviewer´s comment 22. Discussion. Lines 224-225: This sentence is unclear. Is this still based on ENSANUT 2016? Also, the issue of social desirability bias should be addressed separately, as part of the limitations, as it can apply to all of the self-report based data used for this analysis.

Authors’ response: To avoid confusion:

1) We now specify that the result is based on ENSANUT 2016.

2) The reference to social desirability bias was moved to the limitations section. Now we describe this as follows: “We recognize that our results may be influenced by the possible measurement bias that represents the use of a self-report and by the social desirability bias in answering the questionnaires”.

Reviewer´s comment 23. Discussion. Line 231-233: The authors could cite other studies that have compared measured versus self-reported diabetes for Mexican adults, even if outside Mexico, as further evidence of likely undestimatio of true prevalence of diabetes. See Barcellos et al. Health Affairs 2012;31(12).

Authors’ response: We appreciate the suggestion of the reference and the comment.

We have now added the following paragraph to the discussion: "... in Mexican immigrants participating in the National Health and Nutrition Examination Survey when self-report is used as a diagnostic tool, only half of adults with diabetes (11.3%) are detected compared to using glucose measurement as a complementary method (22.6%).[33]

Reviewer´s comment 24. Discussion. A paragraph with implications and/or recommendations for future research and practice would strengthen the discussion, as would adding a little bit of context regarding any national strategies to improve diabetes prevention and control.

Authors’ response: To respond we have added the following paragraph in the discussion: “The high prevalence of diabetes found in our study should motivate in the short term estimate the total prevalence of diabetes including glucose measurement as a diagnostic method. We also believe it is necessary to evaluate the suitability of current programs for the diagnosis, prevention and control of diabetes such as PrevenIMSS and PrevenISSSTE to reduce its prevalence and improve glycemic control”.

Submitted filename: Respuesta a revisores - 240120.docx

Click here for additional data file.

24 Feb 2020

PONE-D-19-29166R1

Prevalence of previously diagnosed diabetes and glycemic control strategies in Mexican adults: ENSANUT-2016

PLOS ONE

Dear M.Sc Ramirez-Villalobos,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Kindly address reviewer comment.

We would appreciate receiving your revised manuscript by Apr 09 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Naeti Suksomboon

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed most of my previous comments adequately and I think this revised version is a fine contribution to the literature. I only have a remaining concern regarding the dietary measure and a few, very minor additional comments that I would like to see addressed:

• The description of the dietary measure is still unclear. I understand how the initial DD score was computed (number of food groups x number of days they were consumed) and the use of quartiles to create four groups from lowest to highest dietary diversity, but I am confused about the classification of food groups into desirable and not desirable. How was the classification of the food groups into these categories factored in when computing the DD score and quartiles?

• I would like to see the findings regarding dietary diversity as a protective factor against a diabetes diagnoses reported in the results section and commented on the discussion. It seems to me this is an important result with implications for public health campaigns promoting dietary improvements. It is also interesting that the pattern of results for this factor is different for men and women, with a significant association for women, but not for men.

• On Table 1, the estimates for individuals without kidney failure are missing.

• On line 195, the “six” years appears incorrect. It should be 10 (if the reference point is 2006) or 4 (if the reference point is 2012).

• On line 227, there seems to be a typo. I think the authors mean “…with hypertension who are unaware”.

• The sentence on lines 259-261 needs to be revised to make sense.

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Reviewer #1: No

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4 Mar 2020

RESPONSE TO REVIEWER'S COMMENTS

PONE-D-19-29166R1

Prevalence of previously diagnosed diabetes and glycemic control strategies in Mexican adults: ENSANUT-2016

Comments to the author.

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

3. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

4. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Comments to the Author, 1.

The description of the dietary measure is still unclear. I understand how the initial DD score was computed (number of food groups x number of days they were consumed) and the use of quartiles to create four groups from lowest to highest dietary diversity, but I am confused about the classification of food groups into desirable and not desirable. How was the classification of the food groups into these categories factored in when computing the DD score and quartiles?

Authors response: We appreciate the observation and we apologize because we had not updated this information.

We inform you that the classification of food groups (desirable and undesirable) was not considered in the final analysis. We only consider the score (quartiles) described by the reviewer (number of food groups x number of days they were consumed). Therefore, we have deleted the text associated with desirable and undesirable foods.

Comments to the Author, 2. I would like to see the findings regarding dietary diversity as a protective factor against a diabetes diagnoses reported in the results section and commented on the discussion. It seems to me this is an important result with implications for public health campaigns promoting dietary improvements. It is also interesting that the pattern of results for this factor is different for men and women, with a significant association for women, but not for men.

Authors’ response: To answer this comment we now include the following paragraphs in results and discussion:

Results : “When we compare the diversity of consumption of food groups or DD, we observe that in the total population and women with the highest quintile of DD (fourth quintile) the OR of having diabetes was lower (total population 0.5 CI 95% 0.3-0.7; women 0.4 CI 95% 0.2-0.7) than in the first quintile (OR = 1.0)”.

Discussión: “Dietary management is important to prevent diabetes [30] and dietary diversity is inversely associated with the risk of developing diabetes. [31] In our analysis we found that in women and total population having a greater DD was associated with a lower probability ratio of being diagnosed with diabetes. In men we do not find that DD is associated with a lower risk of diabetes possibly because in some subpopulations such as Hispanics [32] the results are still inconsistent and it is necessary to use a methodology that measures DD more accurately.These findings should motivate the generation of new studies that analyze this association longitudinally to confirm the direction and magnitude of causality. If this association is confirmed, it would be advisable to design communication programs to promote DD as another strategy to prevent diabetes”.

Reviewer´s comment, 3. On Table 1, the estimates for individuals without kidney failure are missing.

Authors’ response: We appreciate the observation. We have added the missing values on Table 1.

Reviewer´s comment 4. On line 195, the “six” years appears incorrect. It should be 10 (if the reference point is 2006) or 4 (if the reference point is 2012).

Authors’ response: The authors have attended this comment. Now the text describes that it was four years.

Reviewer´s comment 5. On line 227, there seems to be a typo. I think the authors mean “…with hypertension who are unaware”.

Authors’ response: We have modified the text and now the following is included: "... with hypertension who are unaware... “

Reviewer´s comment 6. The sentence on lines 259-261 needs to be revised to make sense.

Authors’ response: The authors have attended this comment. Now we describe the following: “One of the strengths of the study is that the results are representative of the Mexican adult population and are the most recent data on the prevalence of diabetes. This information will help the decision makers in health policies to know the magnitude of this disease, main associated risk factors and diabetes control practices.”

Submitted filename: Response to Reviewers_ 260220.docx

Click here for additional data file.

9 Mar 2020

Prevalence of previously diagnosed diabetes and glycemic control strategies in Mexican adults: ENSANUT-2016

PONE-D-19-29166R2

Dear Dr. Ramirez-Villalobos,

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Naeti Suksomboon

Academic Editor

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Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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Reviewer #1: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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Reviewer #1: (No Response)

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Reviewer #1: Yes

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Reviewer #1: I have no further comments. All of my concerns have been adequately addressed in this revised version.

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Reviewer #1: No

24 Mar 2020

PONE-D-19-29166R2

Prevalence of previously diagnosed diabetes and glycemic control strategies in Mexican adults: ENSANUT-2016

Dear Dr. Ramirez-Villalobos:

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