Abstract
Objective
On June 18 2018, Japan experienced the North Osaka Earthquake. The shaking intensity was recorded as level 6 of the Japan Meteorological Agency Seismic Intensity Scale. Despite the severe shaking, damages of lifelines and transportation networks were limited, and they were completely recovered within several days. We investigated whether the glycemic control in patients with diabetes was deteriorated over months after the earthquake.
Methods
We retrospectively analyzed diabetic outpatients attending the department of Metabolic Medicine, Osaka University Hospital, close to the epicenter of the earthquake, in 2018 (n = 1940), and those in 2017 (n = 1908) as a control. Whether glycated hemoglobin (HbA1c) levels were elevated after the earthquake, and whether the post-earthquake HbA1c elevation was more prevalent in areas with a higher seismic intensity were investigated using the mixed effects model.
Results
Compared to the same periods in 2017, mean HbA1c levels in 2018 were significantly higher 3–6 months after the earthquake (P < 0.05). The risk of HbA1c ≥ 7.0% was 1.6 (95% confidence interval 1.2–2.2) and 1.7 (1.2–2.4) times higher 3–4 and 5–6 months after the earthquake. Furthermore, the proportion of HbA1c deterioration after the earthquake was higher in areas with a higher seismic intensity (P for trend = 0.025).
Conclusion
Glycemic control was significantly deteriorated over months after the 2018 North Osaka Earthquake despite limited damage of lifelines and transportation networks. The deterioration was more prevalent in areas with a high seismic intensity.
Electronic supplementary material
The online version of this article (10.1007/s13340-020-00438-6) contains supplementary material, which is available to authorized users.
Keywords: Natural disaster, Earthquake, Diabetes, Glycemic control
Introduction
Natural disasters will injure and kill people, but also affect control of chronic diseases in survivors. Previous studies reported that glycemic control in survivors with diabetes was exacerbated for months after catastrophic natural disasters that severely damaged lifelines and transportation networks, as well as nearby medical facilities [1–3]. Such heavy damages caused subsequent shortages of medical supplies and difficulties in following a healthy and balanced diet for a long time, which reasonably affected the survivors’ glycemic control [1–4]. On the other hand, it remained so far unknown whether glycemic control of individuals with diabetes would be deteriorated for months after a natural disaster at which the damages of lifelines and transportation networks are limited and promptly restored.
On June 18 2018, Japan experienced the North Osaka Earthquake, which recorded level 6− of the Japan Meteorological Agency (JMA) Seismic Intensity Scale (maximum of level 7). Despite the severe shaking, damages of lifelines, transportation networks, and nearby medical facilities were limited, and soon back to normal. Osaka University Hospital, Suita, Japan, was located close to the epicenter, and most of the people attending the hospital experienced the earthquake as the neighbors.
The aim of the current study was to reveal (1) whether glycemic control would be deteriorated over months after the 2018 North Osaka Earthquake and (2) whether the deterioration would be more prevalent in area with a higher seismic intensity.
Materials and methods
Study participants
The current retrospective study analyzed glycated hemoglobin (HbA1c) levels in people with diabetes attending the department of Metabolic Medicine, Osaka University Hospital, Suita, Japan, before and after the 2018 North Osaka Earthquake. The earthquake occurred at 7:58 am on Monday, 18 June 2018. The epicenter was located in a residential area in Takatsuki City, Osaka Prefecture, Japan, with the focal depth of the earthquake 13 km, and the magnitude 6.1, according to the JMA’s official report [5]. The shaking intensity was recorded as level 6− of the JMA Seismic Intensity Scale [5]. At the earthquake, a total of four people died, and 434 people were injured [6]. Nine houses were completely destroyed, whereas 87 were partially destroyed [6]. A maximum of 170,000, 94,000, and 110,000 houses experienced a temporal power outage, water, and gas supply, respectively [6]. The restoration was, however, completed as rapidly as on the day of the earthquake, and 1 and 6 days later, respectively [6]. Highways were temporarily closed for inspection, but were soon reopened on that day [7]. All public roads were also free from damage except for two, which were reopened by the next day [7]. No interruption of pharmaceutical supplies was reported [6].
Osaka University Hospital is located approximately 9 km west from the epicenter of the earthquake. Although the hospital restricted the outpatient service to that for emergency on the day of the earthquake, the damage was limited, and the service was fully resumed on the next day.
The current study population was people with diabetes attending the hospital in 2018, and those in 2017 as a control. People whose HbA1c levels were measured at the hospital both before and after June 18 (the date of the earthquake) were included. All data were extracted from the existing electronic medical records. Extracted information included participants’ sex, date of birth, home address, medical diagnosis codes, prescribed medications, and HbA1c levels.
We determined participants with diabetes when they were diagnosed as diabetes (E10-E14 in the International Classification of Diseases [ICD]-10 codes) and met one or more of the following criteria: (1) antidiabetic medications were prescribed, (2) they had a history of HbA1c levels ≥ 6.5% during the past 2 years, and (3) they were registered in the Japan Diabetes compREhensive database project based on an Advanced electronic Medical record System (J-DREAMS). The J-DREAMS is an ongoing nationwide registry of people with diabetes attending the diabetes care departments in Japan [8]; the registrants, therefore, meant that they had diabetes. Participants with type 1 diabetes were determined when they were diagnosed as type 1 diabetes (E10 in the ICD-10 codes) and treated with insulin alone. People who lived in regions outside of the Kinki region (around > 100 km away from the epicenter) and those with unknown home address were excluded. The study was in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Osaka University Hospital (date of approval, June 13, 2019; approval number, 16136-4). On the grounds that the current study was an observational research study using only existing materials, the study was considered exempt from informed consent of participants, in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects in Japan. Instead, relevant information regarding the study was open to the public, and opportunities for refusal were ensured.
Public Information regarding 2018 North Osaka Earthquake
Data on the seismic intensity were derived from the official website of the JMA [9]. The seismic intensity was recorded with the JMA Seismic Intensity Scale, grading the intensity from level 0 (none) to level 7 (maximum), with levels 5 and 6 further subdivided into upper and lower [10]. In the Kinki region (3.3 × 104 km2), seismic intensity is monitored at 548 observation points (6.0 points/km2) [11], and in North Osaka (1.0 × 103 km2), 52 observation points (20.0 points/km2) [12]. The highest intensity recorded at the 2018 North Osaka Earthquake was level 6− of the JMA Scale, and all the observation points in the North Osaka area, where more than 80% of the people attending our hospital lived, recorded level 4 or higher intensity [9]. The seismic intensity at the place each participant lived in was determined as that measured at the nearest observation point.
Statistical analysis
Data on baseline characteristics are shown as means ± standard deviations for continuous variables or percentages for discrete variables. P < 0.05 was considered statistically significant, and 95% confidence intervals (CIs) are reported when appropriate. To assess the influence of the earthquake on glycemic control, we first compared annual changes in HbA1c levels between 2018 and 2017, with the year divided every 2 months (Jan–Feb, Mar–Apr, May–Jun, Jul–Aug, Sep–Oct, and Nov–Dec). Mean HbA1c levels at each term were analyzed using the linear mixed model in which random effects for participants and their antidiabetic medication regimens were included. To minimize the influence of the change of medication regimens and hospitalization, HbA1c data measured within 3 months after any change of antidiabetic medication regimens (e.g., change in dose, switch, start, add-on, and discontinuation) and those during and within 3 months after hospitalization were excluded from the analysis. The change of HbA1c levels from May–Jun in each year, and its difference between 2018 and 2017 were estimated from the fitted model. The risk of HbA1c ≥ 7% in 2018 compared to in 2017 was analyzed using the generalized linear mixed model with a logit link function in which random effects for participants and their antidiabetic medication regimens were included.
We subsequently investigated the association between the seismic intensity and the deterioration of HbA1c levels after the earthquake in 2018. The post-earthquake HbA1c deterioration was defined as a higher HbA1c level after the earthquake (time window up to October 2018) under the same antidiabetic medication compared to the time before the earthquake (time window from March 2018). We extracted every pair of pre- and post-earthquake HbA1c levels under an antidiabetic medication regimen per patient and judged whether each pair satisfied the definition of the HbA1c deterioration. The judgements were entered as the dependent variable in a generalized linear mixed model with a logit link function in which the seismic intensity and patient characteristics were included as the fixed effect, whereas the intersubject variability was treated as the random effects. During the analysis, patients who had no pair of pre- and post-earthquake under an antidiabetic medication regimen were excluded. To check whether the findings were unique to 2018 (the year of earthquake), we applied the same analysis to the data of 2017. As a sensitivity analysis, we performed the same analyses using all HbA1c measurements, without excluding those within 3 months after a medication change or hospitalization. We also investigated the change of other lifestyle-related biomarkers, including serum high-density lipoprotein (HDL) cholesterol, triglycerides (TG), low-density lipoprotein (LDL) cholesterol, aspartate transaminase (AST), alanine transaminase (ALT), and uric acid levels, in 2018 and 2017. All statistical analysis was performed using R version 3.6.1 (R Development Core Team, Vienna, Austria).
Results
A total of 1940 and 1908 patients were extracted in 2018 and 2017, respectively, of which 1745 had the data in both 2018 and 2017. The baseline characteristics of the study population are shown in Table 1. The population in 2018 had mean age of 68.4 ± 11.7 years and mean HbA1c levels of 7.2 ± 1.0%. A total of 192 participants (9.9%) were determined as type 1 diabetes. Among patients with non-type 1 diabetes, i.e., type 2 and other types of diabetes, 281 (14.5%) had no antidiabetic medications, and 439 (22.6%) were treated with insulin. People aged < 65 years had a higher prevalence of insulin injection than those aged ≥ 65 years (39% vs 30%, p < 0.01). Baseline characteristics were similar to the control population in 2017. HbA1c was measured at a mean interval of 58 ± 25 days in both years. A total of 3745 of 12,795 HbA1c measurements in 2018 and 3356 of 12,926 in 2017 were within 3 months after a medication change or hospitalization and were excluded from the current analysis. Consequently, the remaining 9439 HbA1c measurements in 2018 and 9181 in 2017 were analyzed; 981 patients in 2018 and 887 patients in 2017 had no excluded HbA1c measurements, whereas all patients had at least one measurement both before and after June 18 (the date of the earthquake).
Table 1.
Clinical characteristics of study population
| 2018 (Year of earthquake) | 2017 (Previous year) | |
|---|---|---|
| N | 1940 | 1908 |
| Participants’ attributes | ||
| Men, n (%) | 1087 (56.0) | 1063 (55.7) |
| Age, years | 68.4 ± 11.7 | 67.3 ± 11.7 |
| Type of diabetes and antidiabetic medication | ||
| Type 1 diabetes (with insulin use), n (%) | 192 (9.9) | 182 (9.5) |
| Type 2 diabetes and other types | ||
| No medication use, n (%) | 281 (14.5) | 284 (14.9) |
| OHA use, n (%) | 1277 (65.8) | 1273 (66.7) |
| GLP1-RA use, n (%) | 122 (6.3) | 82 (4.3) |
| Insulin use, n (%) | 439 (22.6) | 408 (21.4) |
| HbA1c, % | 7.2 ± 1.0 | 7.2 ± 0.9 |
| HbA1c ≥ 7%, n (%) | 1010 (52.1) | 1081 (56.7) |
| Living place | ||
| Distance from epicentre of 2018 North Osaka Earthquake, km | 15.0 ± 10.7 | 15.2 ± 10.9 |
| Seismic intensity scale at 2018 North Osaka Earthquake | ||
| Level 6−, n (%) | 583 (30.1) | 575 (30.1) |
| Level 5 (5− and 5 +), n (%) | 996 (51.3) | 962 (50.4) |
| Level 4 or lower, n (%) | 361 (18.6) | 371 (19.4) |
Date are shown as mean ± standard deviation or frequency (percentage). Seismic intensity scale; the Japan Meteorological Agency (JMA) Seismic Intensity Scale, grading from level 0 (minimum) to level 7 (maximum), with levels 5 and 6 further subdivided into upper and lower. The maximum seismic intensity scale at 2018 North Osaka Earthquake was level 6−
OHA oral hypoglycemic agent, GLP1-RA glucagon-like peptide-1 receptor agonist
Figure 1a shows the annual change in HbA1c levels in 2018 versus 2017. Similarly, to 2017, HbA1c levels were transiently decreased after May–Jun in 2018. However, HbA1c levels after May–Jun were higher in 2018 than in 2017. As demonstrated in Fig. 1b, the relative risk ratio of HbA1c ≥ 7% in Sep–Oct versus May–Jun was 0.47 (95% CI 0.37–0.59) in 2017, whereas it was 0.76 (0.60–0.85) in 2018, being 1.6 (1.2–2.2) times higher than in 2017 (P = 0.034). The corresponding fold difference in Nov–Dec was 1.7 (1.2–2.4) times in 2018 compared to 2017 (P = 0.031).
Fig. 1.
Annual change in HbA1c levels in 2018 versus 2017. a The change of HbA1c levels from May–Jun of each year. b The risk of HbA1c ≥ 7% in every 2 months to May–Jun. Error bars represent 95% confidence intervals. Asterisks indicate P < 0.05 versus 2017
As shown in Fig. 2a, in 2018, the seismic intensity at the place where patients lived was positively associated with HbA1c deterioration after June 18 (P = 0.031). On the other hand, there was no significant association in 2017 (P = 0.345) (Fig. 2b). The seismic intensity was still positively associated with HbA1c deterioration in 2018 after adjustment for patient backgrounds including type of diabetes and antidiabetic medications (P = 0.030). Furthermore, old age was inversely associated with the HbA1c deterioration (P = 0.005), whereas these factors had no significant association in 2017 (Table 2).
Fig. 2.
Deterioration of HbA1c levels after the date of the 2018 North Osaka Earthquake (June 18) in 2018 (a) and after the same date in 2017 (b). The population was categorized by living place according to the seismic intensity scale at 2018 North Osaka Earthquake. Error bars represent 95% confidence intervals. In 2018, 1920 HbA1c measurements of 260 patients in the area with the seismic intensity scale of 4 or lower, 5208 measurements of 748 patients in the scale of 5, and 3088 measurements of 445 patients in the scale of 6 were analyzed. In 2017, the corresponding numbers were 1954 measurements of 269 patients in the scale of 4 or lower, 4800 measurements of 679 patients in the scale of 5, and 2884 measurements of 414 patients in the scale of 6 were analyzed
Table 2.
Association with HbA1c deterioration after June 18 (date of the earthquake)
| 2018 (Year of Earthquake) |
2017 (Previous year) |
|
|---|---|---|
| Seismic intensity scale of living place at the 2018 North Osaka Earthquake | 1.25 (1.02–1.53)* | 1.12 (0.91–1.37) |
| Male sex | 0.94 (0.72–1.25) | 0.91 (0.68–1.22) |
| Old age (≥ 65 years) | 0.63 (0.46–0.87)* | 0.88 (0.64–1.22) |
| Type of diabetes and antidiabetic treatment (versus non-type 1 diabetes with no medication use) | ||
| Non-type 1 diabetes with OHA and/or GLP1-RA | 1.40 (0.94–2.07) | 1.09 (0.73–1.63) |
| Non-type 1 diabetes with insulin use | 1.36 (0.85–2.18) | 1.47 (0.90–2.38) |
| Type 1 diabetes (with insulin use) | 0.63 (0.36–1.10) | 1.01 (0.56–1.83) |
Data are adjusted odds ratio and their 95%CIs. In 2018, 10,126 HbA1c measurements of 1453 patients were analyzed, whereas 9638 HbA1c measurements of 1362 patients were analyzed in 2017
OHA oral hypoglycemic agent, GLP1-RA glucagon-like peptide-1 receptor agonist
*P < 0.05
Almost same results were shown when the analyses were performed without excluding HbA1c measurements within 3 months after a medication change or hospitalization (Supplementary Fig. 1, Supplementary Fig. 2, and Supplementary Table 1).
As illustrated in Supplementary Fig. 3, HDL cholesterol and AST levels were significantly lower and higher, respectively, after June in 2018 than in 2017. However, HDL cholesterol levels were also lower in Mar–Apr in 2018 than in 2017, and triglycerides, LDL cholesterol, ALT, and uric acid levels were not different between 2018 and 2017. Furthermore, the seismic intensity and age were not associated with the post-earthquake deterioration of HDL cholesterol, TG, LDL cholesterol, AST, ALT, or uric acid levels (all P > 0.05).
Discussion
The current study revealed that (1) the glycemic control evaluated by HbA1c after the 2018 North Osaka Earthquake was significantly deteriorated for months compared to the previous year, and that (2) the proportion of HbA1c deterioration after the earthquake was higher in areas with a higher seismic intensity. The deterioration was more likely observed in younger patients.
A few previous studies reported the change of glycemic control after a catastrophic earthquake with serious damages of lifelines [3, 13–16]. Some observed an increase of HbA1c levels after the earthquake, and attributed it to difficulties in following a healthy and balanced diet and shortages of antidiabetic agents, resulting from the disruption of lifelines, as well as the destruction of nearby medical facilities [3, 13–15]. On the other hand, others observed a decrease of HbA1c levels after the earthquake, and hypothesized that it might be a result of food shortage [16]. In contrast to those earthquakes addressed in the previous literature, the 2018 North Osaka Earthquake inflicted only small damage of lifelines and transportation networks. To the best of our knowledge, this was the first study reporting long-term glycemic control after a natural disaster accompanied by apparently small damage of social and medical systems.
Our study showed that in 2018, mean HbA1c levels after the earthquake were apparently lower than those before the earthquake, which would be reasonably explained by the seasonal variation of HbA1c levels [17–19]. We, therefore, compared the change of HbA1c levels to the same time in the previous year. Consequently, the glycemic control after May–Jun was deteriorated in the year of the earthquake (Fig. 1). Furthermore, the post-earthquake HbA1c deterioration was correlated with the seismic intensity in 2018, and the trend was not seen in 2017 (Fig. 2, Table 2). These findings would further strengthen the implication that the post-earthquake deterioration of glycemic control in patients with diabetes in 2018 would be possibly associated with the 2018 North Osaka Earthquake.
As is well known, HbA1c levels reflect the previous 2–3 months of glycemic control [20]. The HbA1c deterioration would mean that the change of glycemic control would last over months, despite small damages on lifelines and transportation networks, as well as medical facilities. Given that the damages were so small, the HbA1c deterioration would not be attributed to difficulties in following a balanced diet or shortages of antidiabetic agents; some other mechanisms might be involved.
One possible explanation might be participants’ psychological response to the earthquake. Generally, psychological stress deteriorates glycemic control of people with diabetes [21]. Previous studies reported that after a big earthquake, survivors suffered from psychological stress, caused by injuries and deaths of family members and relatives as well as financial losses [3, 14, 16], and it lasted for a long time [22]. Furthermore, a nearby big disaster will arise vague fears that another disaster might happen in the near future, and such fears could last for months [23]. The damage of the current earthquake was, however, not so serious; such psychological responses might have a relatively small impact on long-term glycemic control in the study population.
Another possible explanation would be that the earthquake might restrict opportunities for leisure-time exercise, especially in areas with a higher seismic intensity. The restrictions of exercise might not only induce HbA1c deterioration by itself, but also subsequently cause psychological distress [24], and potentially accompanying intemperance in eating [25, 26]. Unfortunately, no data were available on each patient’s leisure-time exercise. Alternatively, as an indirect evidence, we surveyed the closure of public gyms and pools after the earthquake by phone call to the facilities or city offices, or through their official websites. The survey was conducted between January and February 2019, and the data were finally available on a total of 111 out of the 112 facilities in North Osaka. This survey revealed that, in the areas with level 6 of the JMA seismic scale, 33% of gyms and pools were still partially or fully closed even 3 months after the earthquake, whereas the corresponding proportion was 11% and 6% in the areas with level 5 and 4 of the JMA seismic scale, respectively (data not shown). Although we were unable to collect the information of each patient’s leisure-time exercise, and to directly investigate the association between the restriction of exercise and HbA1c deterioration, this result of the survey suggested that some participants might lose such opportunities after the disaster, especially in areas with a higher seismic intensity. Other patients might lose opportunities of participation in community involvements and activities at such facilities. These disturbances might lead to the post-disaster deterioration of their glycemic control over months. Some previous studies reported that younger age was associated to higher physical activity in patients with type 2 diabetes in Japan [27]. The inverse association of old age with the HbA1c deterioration (Table 2) might indicate that younger people might be more likely influenced by the disturbance of daily exercise. Supplementary analyses showed that some lifestyle-related biomarkers were also deteriorated after June in 2018 compared to 2017. This finding seemed at least partially consistent with the findings of the HbA1c deterioration, and would possibly support the hypothesis that lifestyles might be changed after the earthquake. However, the seismic intensity was not associated with their post-earthquake deterioration, and neither were other lifestyle-related biomarkers deteriorated after the earthquake. HbA1c levels in diabetic patients might be sensitive even to such a slight change of lifestyles that would have little impact on other laboratory markers. The current study did not assess the change of lifestyles in individual patients, and, therefore, it remained inconclusive whether or not their lifestyles were really changed after the earthquake, and whether or not the post-earthquake HbA1c deterioration came from the lifestyle changes.
Our study has some limitations. First, this was a single-center study, although the sample size was much larger compared to previous studies on the association of an earthquake and glycemic control [3, 13–16]. Second, the current study was an observational one and did not prove the causal relationship between the earthquake (or its damage) and glycemic control. The current findings might be confounded by some unobserved factors including other social or environmental changes. Third, limited data were available on the participants attributes. Data on some important indices, including body weight, body mass index, blood pressure, pulse, and insulin secretory capacity, were not available. Furthermore, we did not collect the data on the participants’ exercise, diet, or psychological stress. It remained unknown whether the closure of public gyms and pools would accurately reflect the lessened chance of daily exercise and community activities of the participants living at the nearby areas. We neither collected the data on other life events that potentially affected their glycemic control. Future studies collecting more detailed information on individuals’ lifestyles and psychological responses will be needed to validate the current findings.
In conclusion, the present study revealed that glycemic control was significantly deteriorated over months after the 2018 North Osaka Earthquake, and that the proportion of HbA1c deterioration after the earthquake was higher in areas with a higher seismic intensity.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
The current study was self-funding.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflicts of interests associated with this manuscript.
Human rights statement
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revision.
Footnotes
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Change history
10/23/2021
A Correction to this paper has been published: 10.1007/s13340-021-00554-x
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