Diabetes Care in Romania: A Lesson on the Central Role of Lifestyle Medicine

Abstract

In this narrative review, diabetes care in Romania is discussed in terms of epidemiological data, lifestyle medicine, and research/knowledge/practice gaps. The principal drivers of cardiometabolic-based chronic disease—adiposity and dysglycemia—are manifest in Romania at concerning levels. Diabetes prevalence in Romania is 8.4%–11.6% of which 21.3% are unaware. Obesity prevalence in Romania is 31.9% and correlated with adverse lifestyle trends and cardiovascular risk. The large epidemiological studies conducted in Romania are highlighted to fully portray the magnitude of how lifestyle, diabetes, and cardiometabolic risk are related. Knowledge gaps among patients regarding this health risk are in large part due to low health literacy in the Romanian population. Educational programs and delivery of lifestyle medicine in structured centers are outlined as potential solutions to close knowledge and practice gaps. Understanding how lifestyle medicine issues affect diabetes and cardiometabolic care in Romania can prompt transformative management strategies in other ethnocultural settings across the globe.

“Building and operating diabetes and lifestyle medicine centers and their structured programs are key implementation tactics.”

Introduction

Lifestyle medicine (LM) is an evidence-based practice centered on non-pharmacological and non-surgical management of chronic disease. ¹ Notably, LM is not mutually exclusive with the use of medicines and procedures, but rather provides structured guidance for specific interventions such as healthy dietary patterns and nutrition, all types of physical activity, sleep hygiene, behavior and stress reduction, mitigation of tobacco and substance abuse, community engagement, and effective use of wearable technologies. Among the litany of chronic diseases amenable to LM interventions, diabetes is an exemplar of both success and imprecision. There are a host of variables that confound the impact of primary drivers (genetics, environment, and behavior) on diabetes care, as well as responses to therapy. For instance, in many global settings, structural (e.g., policies and politics) and their impact on social (e.g., culture, education level, housing, poverty, discrimination, and crime) determinants of health (SDOH) adversely impact population well-being. Another important dimension to consider is a strategy of early and sustainable prevention oriented to decrease the clinical and economic burdens of chronic disease. In this narrative review, the state of diabetes care in Romania is discussed with a focus on epidemiological data, emergent knowledge, and consequent gaps that must be narrowed in the near-term.

General Context: Dysglycemia-Based Chronic Disease

The driver-based chronic disease model was initially developed in the cardiometabolic space. This model is predicated on networking effects of many pathophysiological pathways, seminal effects of primary drivers, a dominant secondary/metabolic driver, and an individualized phenotype corresponding to a particular chronic disease. In the case of certain cardiovascular diseases (e.g., atherosclerosis, heart failure, and atrial fibrillation), there are a core set of secondary/metabolic drivers (adiposity-based chronic disease [ABCD]; dysglycemia-based chronic disease [DBCD]; hypertension [HTN]-based chronic disease [HBCD]; and lipid-based chronic disease [LBCD]) that interact and progress through 4 stages (1-risk; 2-predisease; 3-disease; 4-complications). Taken together, these processes and the resulting CVD phenotype encompass cardiometabolic-based chronic disease (CMBCD). The 2-dimensional stage x driver matrix is further modulated by a third dimension, SDOH, producing a robust model that can be used to interpret and guide diabetes care in various settings. ²

Romanian Context: Epidemiology of Dysglycemia and Associated Risk Factors

In 2021, worldwide, the number of people known to have diabetes (of which 90%–95% are T2D) was 537 million, with a prevalence rate of 10.5%. ³ Added to these numbers are approximately 240 million people with undiagnosed diabetes and 541 million people with prediabetes. ³ Since 2000, the estimated prevalence of diabetes in adults aged 20-79 years has more than tripled. ³ Without a structured and effective intervention to effectively prevent diabetes, the estimates for 2030 are 643 million adults with diabetes, representing 11.3%, and 783 million in 2045, representing 12.2% of the population. In parallel with these increases in T2D, the worldwide prevalence of obesity was 11.4% in 2010, with an estimated increase to 16.1% in 2025 and 17.5% in 2030. ⁴ The dominant non-modifiable risk factors for T2D development are advanced age and family history, but it is the modifiable risk factors that warrant the greatest attention—obesity and unhealthy lifestyle.^3,5

The prevalence of dysglycemia has been increasing in Romania, posing a considerable threat to population health. ³ There are 1.199 million people living with diabetes in Romania corresponding to a diabetes prevalence of 8.4%, but more importantly, unawareness is considerably high amounting to 255 400 individuals or 21.3%. ³ The Prevalence of Diabetes Mellitus and Prediabetes in the Adult Romanian Population (PREDATORR) study was conducted nationwide in Romania in 2014. ⁶ This was an epidemiological study with a stratified, cross-sectional, cluster random sampling design. PREDATORR analyzed the prevalence of diabetes and prediabetes, as well as their associations with cardiometabolic, sociodemographic, and lifestyle risk factors in adults aged 20-79 years. ⁶ There were 2728 subjects enrolled, both with and without a previous diagnosis of diabetes. Data were collected through self- and interviewer-administered questionnaires, biochemical assays, and oral glucose tolerance tests. ⁶ The overall age- and sex-adjusted prevalence of diabetes was 11.6% (95%CI 9.6%–13.6%), representing more than 1.7 million adult people, of whom 2.4% (95%CI 1.7%–3.1%) had not been previously diagnosed with diabetes. ⁶ The prevalence of diabetes increased with age and was higher in men than in women. ⁶ The age- and sex-adjusted prevalence of prediabetes was 16.5% (95%CI 14.8%–18.2%), with the highest percentage in the 60-79-year age group and in women. ⁶ In aggregate, 28.1% of enrolled subjects had diabetes or prediabetes. Based on these data, the prevalence of prediabetes (16.5%) in the Romanian population was higher than that of Spain (14.8%), while lower than that of Portugal (27%) and the U.S. (37%).^7,8 Undiagnosed diabetes in Romania is 21.4%, in Spain 14.8% and in Portugal 43.6%. ⁷ These findings are consistent with the United Kingdom ⁹ (8.2% diabetes prevalence and 23,3 undiagnosed diabetes cases), ⁷ Bulgaria (9.9% diabetes and 25.8% undiagnosed diabetes),^7,10 and Poland (9.4% diagnosed diabetes and 65.2% undiagnosed reported, very high). ⁷

Regarding obesity and overweight, the prevalence rates in Romania in PREDATORR were 31.9% and 34.7%, respectively, a slightly higher prevalence than that found in the Prevalence of Obesity and Risk Factors in Romania (ORO) study: 21.3% and 31.3%, respectively, (a difference that may be explained by population demographics and methods for participant selection). ¹¹ Of the total number of obesity cases, 73.9% had abdominal obesity in Predatorr. ORO study was done from 2014 to 2018 and data published in 2018.

Metabolic syndrome was present in 38.5% of cases in PREDATORR, ¹² compared with 38.5% in the US adn 25% in Europe.^13,14 In PREDATORR, 67.1% had at least one lipid abnormality: elevated low-density lipoprotein cholesterol (LDL-C) in 47.8% (95%CI 46.3%–49.2%, with 26.2% of the latter with LDL-C levels ≥2.58 mmol/l [100 mg/dl], which was associated with a higher risk for coronary heart disease (CHD), low high-density lipoprotein cholesterol (HDL-C) in 29.4% (95%CI 27.9%–30.8%), elevated triglycerides in 27.5% (95%CI 26.0%–28.9%). ¹⁵ These findings highlighted the need for better disease management and patient outcomes in Romania, which could address the related financial burdens for both the population and the individual.

Clinical and therapeutic characteristics of patients with T2D in Romania were evaluated by Metabolic Nutritional and Therapy Outcomes in Romanian Type 2 Diabetic Patients MENTOR, a cross-sectional study evaluating diabetes prevalence and complications in the context of rising social, economic, and clinical burdens. MENTOR (N = 1300) was the first study to evaluate the evolution, complications, and available treatment options for patients with T2D in Romania. ¹⁶ Mean blood pressure values were in the target range for all participants. Among patients with T2D and satisfactory blood pressures, neither LDL-C nor non-HDL-C were adequately treated, while HDL-C values were low, ultimately leading to increased CVD risk. It is important to note that similar to many other countries, lack of adherence to treatment remains the main cause for dyslipidemia in Romania. ¹⁷ Mean hemoglobin A1c (A1C) values were in the 7%-8% range, with targets <7% achieved in 60% of cases; this is comparable to only 43% globally. ¹⁸ Microvascular complication rates were also studied. The prevalence of chronic kidney disease was 25.89%, consistent with other European countries, ¹⁸ but lower than the U.S. ¹⁹ Diabetic retinopathy was present in 27.64% of participants, similar to International Diabetes Federation (IDF) estimates. ¹⁹ Neuropathy was present in patients with longer diabetes duration (90% after 20 years of diabetes compared to 35% in the first year after diagnosis). In Romania, 35.39% received insulin as either monotherapy or in association with other antidiabetic agents in comparison to patients in the U.S. (28%) ¹⁴ and UK (34%). ⁸

Finally, the Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk in Romania (SEPHAR) program ²⁰ encompassed 3 epidemiological surveys assessing the prevalence of HTN and other CMBCD risk factors in Romanian adults. The prevalence of HTN in the SEPHAR III survey was 45.1%. Overall, diabetes was found in 12.2% of the study sample, with 9.5% of participants having previously diagnosed and 2.7% having newly diagnosed diabetes. Overweight and obesity prevalence was roughly the same, present in 33.5% and 34.7% of the study sample, respectively. The prevalence of dyslipidemia in SEPHAR III was 77.3%. The general conclusion of the SEPHAR program was that HTN prevalence in Romania has been on the rise for the past 11 years, likely due to unhealthy lifestyle, adverse dietary patterns including increased salt intake, and more obesity and diabetes as consistently demonstrated in this and other studies.

Gaps in Diabetes Care in Romania

Research

Research gaps result from scientific questions without answers. In the last 30 years in Romania, interest has increased in conducting epidemiological studies on chronic diseases, especially diabetes, obesity, and CVDs diseases. Therefore by extension, research gaps in Romania primarily take the form of basic and translational science, prospective cohort interventional study, and randomized clinical trials, which would all build on hypothesis generation from the growing epidemiological evidence that places diabetes care within a CMBCD context. Besides the epidemiological studies detailed in the previous section, additional studies have expanded focus from just T2D to a broader array of CMBCD metabolic drivers.

The cross-sectional, multicenter, non-interventional ORO study (N = 2128) was carried out in 2014 until 2017 to assess overweight and obesity prevalence in the Romanian adult population. ¹¹ Study subjects were distributed among the Banat, Crisana, Transylvania, Moldova, Muntenia, and Oltenia regions. ORO sought to identify modifiable lifestyle risk factors such as eating behaviors and patterns, physical activity, stress, and knowledge about healthy lifestyles. Demographic, anthropometric data, educational status, family, personal medical history, and information about lifestyle and eating habits were collected using food frequency questionnaires and structured interviewing. The degree of physical activity was investigated in detail, considering physical activity within the workplace, during free time, and/or while practicing a sport. The overall prevalence of overweight was 31.1% and obesity 21.3%, with higher prevalence rates at ages between 40-59 years and 60-79 years. Men had a higher prevalence in both weight status categories, as did subjects from rural areas. Physical activity was generally of moderate intensity (both workplace or leisure) and carried out inconstantly on average 3 times a week. The study also showed an increased frequency of unhealthy lifestyles, especially among young people. ¹¹ Three frequent food patterns were identified: [1] a “high meat/high fat pattern” (increased red meat, processed meat, poultry, potatoes, pasta and rice, eggs, fried food, and fried potato intakes) associated with male gender, lower educational level, rural setting, and current tobacco use, [2] a “Western pattern” (increased processed meat, fast-food, snack, sauce, sweet, nut, and fruit intakes) associated with a high physical activity lifestyle, current tobacco use, and younger age, and [3] a “prudent pattern” (increased fish, vegetable, legume, fruit, and soy milk intakes) associated with a high physical activity lifestyle, no tobacco use, older age, and female gender.

Gender

Not surprisingly, when testing the association of lifestyle patterns with obesity risk, the Western pattern was associated with a higher risk for obesity (OR 1.2 [95%CI: 1.1-1.4]) and Prudent pattern was associated with a lower risk for obesity (OR .8 [95%CI: .7-.9]). ²¹

The European Observatory on Health Systems and Policies and the Organization for Economic Co-operation and Development developed Country Health Profiles for all 27 European Union (EU) Member States. According to this report, almost half of all deaths in Romania in 2019 were attributed to an unhealthy lifestyle (i.e., smoking, unhealthy diet, alcohol consumption, and low physical activity). Specifically, the study revealed low fruit and vegetable intakes, high sugar and salt intakes, and low numbers of people engaging in at least moderate physical activity every week. ²²

The European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE; EA) study ²³ consisted of cross-sectional, multicenter international surveys. This study evaluated the level of implementation of European guidelines on the primary and secondary prevention of CVD in people already at high risk for CMBCD progression. The 3 surveys have shown adverse lifestyle trends in patients with coronary heart disease, a substantial increase in obesity prevalence, and a concerning high prevalence of persistent tobacco use in younger patients. As a contributor to this study, Romania provided survey data from patients living in Timisoara County, 485 people participating in the EA III study (2006-2007), and 397 people participating in the EA IV study (2012-2013). Overall, obesity was present in 43% of the participants, with 37% in EA III, and up to 47% in EA IV. Among Romanians included in the EA studies, smoking was present in 18% in EA III, but decreased to 9% in EA IV conducted 6 years later. Those engaging in vigorous physical activity outside work for >20 min at least 3 times per week were 26% in EA III and up to 43% in EA IV. Blood pressure control in those under treatment was 28% in both EA III and IV surveys. Unfortunately, the only mentions about glycemic status refer to the 36% of the participants who had impaired fasting glycemia in EA IV (2006-2007).

National Health Insurance data showed an increase in the number of people registered with diabetes, from 899 339 in 2019, to 1,100,622 in 2021. However, these data under-represent the Romanian population since they only reflect patients included in the National Diabetes Program, registered within the National Health Insurance, and receiving medication.

The increase in diabetes prevalence is corroborated by the Epidemics of Diabetes (EPIDIAB) program, launched in 2000, which also examined other CMBCD risks. ²⁴ EPIDIAB was a prospective study with the following objectives: epidemiological analysis of newly diagnosed diabetes, study of quality of care, and strategic prediction. EPIDIAB was designed to last 5 years, included 14 counties, and represented one third of the total Romanian population. For financial and logistic reasons, the program was conducted over only 3 years. The number of newly diagnosed people with diabetes for 2000, 2001, and 2002 was: 15 057 (7.4% type 1 diabetes [T1D] and 92.1% T2D), 16 394 (6% T1D and 93.2% T2D), and 15 858 (5.4% T1D and 89% T2D), respectively. For the same years, among those with T2D, overweight was present in 48%, 19.5%, and 40%, obesity was present in 39.2%, 57.9%, and 43%, hypertension was present in 45.3%, 49.9%, and 48.3%, and CVD was present in 32%, 31.6%, and 27.7%, respectively, for each condition.

Knowledge

Knowledge gaps result from scientific answers without awareness. In general, these are manifested by the non-uniform distribution and awareness of information, which can be due to inadequate education, inability to access new information quickly, or a culture of learning that fails to keep abreast of new scientific findings and their interpretations. In Romania, there are multiple factors that converge and create the aforementioned gaps, involving both the medical staff and patient. While there are numerous guidelines and scientific reports focusing on the global management of a patient living with diabetes, lifestyle intervention remains a topic that rarely occupies a central position.

The Romanian Health care System is based on a Social Health Insurance model, and problems arising from the relatively low percentage of the population contributing to this resource results in a constant state of underfunding. While the average health expenditure in the EU is 9.8% of the gross domestic product, Romania’s health expenditure is only 5%, with 42% of these costs corresponding to inpatient care and 27% to medical goods and pharmaceuticals. This allows very little revenue for outpatient care and lifestyle education. ²²

Personnel shortages must also be considered in terms of education with merely 6.7 nurses and 2.9 practicing doctors for every 1000 individuals. ²⁵ The main targets of lifestyle education in the Romanian population at risk are dietary patterns, physical activity, smoking cessation, and alcohol consumption. Unfortunately, according to the Country Health Profile presented in 2019 by the EU, Romania fared poorly in terms of smoking, binge drinking, lack of physical activity, and fruit/vegetable. ²⁵ These pervasive habits render lifestyle education difficult. Another important factor to consider is health literacy among Romanians. In one study, 33.2% of the sample had a problematic level, while 7.5% had an inadequate level of health literacy. ²⁶

Healthy lifestyle is the subject of some courses in medical universities in Cluj-Napoca, Timisoara, Bucharest, and Iasi. A nutrition master is available in Targu Mures, Cluj-Napoca, Bucharest, Timisoara, and Iasi, representing about 25% of the total medical universities in Romania. At present, there are no dedicated lifestyle medicine Master degrees or training programs in Romania.

In 2020, the Medical Association for Prevention through Lifestyle Medicine, together with the Medicine Students Association and Carol Davila University, performed an online study about lifestyle behaviors of Romanian students at medical universities, but the study is not published. In total there were 824 respondents, mainly from the Carol Davila University of Medicine and Pharmacy in Bucharest. All students responded online to questionnaire about lifestyle. The most important message from the study is that 95% from Romanian students are interested in receiving more information about lifestyle medicine. Specifically, the survey found that the students consumed 1-2 meals per day, more fruits and veggies among women, with fast-food also more appealing for women; smokers were below the national average (14%-15% instead of 30%).

Steps towards narrowing lifestyle medicine and CMBCD knowledge gaps in Romania are already being made through daily televised prompts regarding basic healthy lifestyle principles, free national diabetes screening campaigns, and an increasing online activity of lifestyle intervention specialists such as diabetologists and registered dieticians. On a systemic level, the government has been making efforts to retain physicians and nurses by making public sector engagement more financially rewarding to stop emigration; efforts are also being made to achieve a more even distribution of medical personnel among rural, suburban, and urban areas.

Practice

The Role of White Papers

Practice gaps result from awareness without action. White papers are official documents by an organization and experts on a specific topic. These can take the form of narrative reviews, position papers, consensus reports, conference proceedings, scoping and systematic reviews, and clinical practice guidelines (CPGs). Whereas the first six can narrow knowledge gaps, it is the last that can close practice gaps through evidence-based recommendations and guidance to build infrastructure necessary for successful implementation.

Diabetes education includes lifestyle change at its core. Therapeutic Patient Education (TPE) was defined by the World Health Organization (WHO) in 1998 as a process through which health care professionals would enable patients to proactively manage their condition to ensure the best quality of life while avoiding complications. ²⁷ One of the members of the WHO Working Group on TPE was the Romanian psychologist Mariana Costea from the Institute of Nutrition and Metabolism in Bucharest. An important nursing initiative in diabetes TPE occurred in 2001 when the Romanian Association for Diabetes Education (Asociatia Romana de Educatie in Diabet - ARED) was founded in Craiova, Romania. Parenthetically, in the same year, ARED became one of the founding members of the Romanian Federation of Diabetes, Nutrition and Metabolic Diseases, which was based on the IDF model, becoming the main promoter of diabetes TPE in Romania. Consequently, numerous training courses were organized for nurses working in diabetes centers and clinics that incorporated lifestyle interventions in diabetes education. In more recent years, diabetes TPE adapted to an increased number of patients with diabetes and a shortage of available nurses for delivering education due to increased administrative tasking. As a result, diabetes education campaigns relied more on written and online vehicles. One example is the 2018-2019 campaign “5 in 5” where 10 000 information kits on the importance of multi-factorial control were distributed to patients with T2D. Another example is the Romanian Federation of Diabetes, Nutrition and Metabolic Diseases’ online education program “ABCDia” freely available for all people with diabetes and their family members.

The 2021 Romanian Diabetes CPG ²⁸ incorporates therapeutic education recommendations in which diabetes education should be made available to all patients with diabetes at 4 critical moments: diagnosis, regularly thereafter (up to annually), with complications, and when transitioning care from one team to another. These CPGs also recommend diabetes education program reimbursement by health insurance entities based on accreditation criteria. Unfortunately, diabetes education is not reimbursed by third-party payers in Romania, limiting national guideline implementation. Continuous efforts are made by scientific organizations, patients’ associations, and ARED to advocate for accessibility to diabetes education.

Implementation Tactics

Translating information into action is a common and significant problem in health care. Effective solutions require changes at a systems level and typically involve economic, social, and infrastructural components. Building and operating diabetes and lifestyle medicine centers and their structured programs are key implementation tactics. Historically, the first diabetes care center in Romania was founded in 1949 in Bucharest by Prof. I. Pavel, followed in 1953 by diabetes centers established by Gheorghe Băcanu in Timişoara, Vasile Sfârlează in Craiova, Viorel Gligore in Cluj, and Gheorghe Creţeanu in Iaşi. ²⁹ One of the first initiatives on diabetes education was the organization in Bucharest of The Second Eastern European Diabetes Education Seminar in 1982 by Jean Philippe Assal (Switzerland) and Michael Berger (Germany), two of the pioneers of TPE in Europe. This was followed by a 5-day structured education program in 1984-1987 in Bucharest for T1D, first developed in Düsseldorf, demonstrating the benefits of intensive insulin therapy. ³⁰ This Bucharest-Düsseldorf Study also created the opportunity for nurse involvement in the process of diabetes education and the creation of the first diabetes care teams. By 1993, Romanian diabetes centers included diabetes education departments where individual and group sessions were delivered in outpatient and inpatient settings. A more structured education program named IDEALLY, was in place in 15 diabetes centers by 2011-2013 and was conducted by 20 nurses trained in TPE.

At the time of this writing, the first lifestyle medicine center in Romania (a part of Medlife, the largest medical network in Romania) has opened. Inspiration for this enterprise was based on a series of Romanian symposia on lifestyle medicine organized by one of the authors (AH). ³ Features of the facility include an anthropometric evaluation room, calorimetry and bioimpedance technology, and clinical offices for general practice, diabetes, gastroenterology, cardiology, pneumology, and sleep medicine. The center cooperates with a center for psychological/psychiatric disorders, gym facility, and kinesiotherapy program, all from the same medical network. Of special importance is the nutrition team, which prepares personalized nutrition plans. These plans are calculated in an application with values for all types of food, with details on macronutrients and micronutrients percentages, in line with current CPGs. Patients receive dietary and physical activity plans in the application, available on their phone, with daily reminders. Nutrition plans are realized based on a large group of prespecified models, but they are also personalized. Recommendations are flexible and consider cultural, personal preferences, and Romanian tradition, including religion and local festivities. All comorbidities are managed by the respective health care professional.

Conclusions

Diabetes care paradigms have shifted in recent years from glucose-centric approaches that rely heavily on glucose-lowering medications to comprehensive approaches that are preventive in nature, are more inclusive of the breadth of lifestyle medicine, and target complications, particularly those in the cardiometabolic space. In Romania, lessons learned from epidemiological studies have highlighted the problem of diabetes and CMBCD with potential remedies addressing research, knowledge, and practice gaps. Tactically, research efforts should be monitored and coordinated among stakeholders: academic centers, industry, and government. Relevant clinical trials should be designed based on hypothesis generation from local epidemiological findings. Educational tools should be enhanced to more rapidly incorporate new information, especially in the lifestyle medicine specialty. Most importantly, infrastructure should be built in Romania to accommodate this new knowledge and research/practice demand, with particular emphasis on the use of lifestyle medicine centers.