Analysis of the Determinants of Diabetes Mellitus in Indonesia: A Case Study of the 2014 Indonesian Family Life Survey

Background: Diabetes mellitus (DM) is a disease of excessive blood sugar levels. Data from the Indonesian Ministry of Health shows that several DM survivors have had DM for over 15 years reached 19.98 million or 10.9% of the Indonesian population in 2019 with population data according to the Central Bureau of Statistics Republic of Indonesia. This research aimed to determine factors affecting DM in Indonesia. Method: This was a study with a crosssectional design. The data used in this study came from the fifth wave of the Indonesian Family Life Survey (IFLS). A total of 34,257 individuals aged 14 or over as samples. The dependent variable was diabetes mellitus, while independent variables were obesity, hypertension, quality of sleep, and socio-economic factors. The data measurement was performed by logistic regression. Results: The research found that obesity, hypertension, and poor sleep quality will increase the risk of DM and also the risk will increase due to socioeconomic factors like age, education, household income, urban, and marital status. Conclusion: This study found that the driving force for DM in Indonesia is obesity, hypertension, and sleep quality.


Introduction
Diabetes Mellitus (DM) is a disease that occurs as a result of excessive levels of sugar in the blood (hyperglycemia) in response to the inability of the pancreas to produce insulin [1]. When the pancreas cannot produce insulin, the body will have difficulty maintaining blood sugar levels, leading to excess sugar levels or hyperglycemia. Diabetes mellitus is divided into diabetes mellitus type I and diabetes mellitus type II [2]. Type I diabetes mellitus occurs when the body is unable to produce insulin, while type II diabetes mellitus occurs when the body is unable to receive and process insulin effectively. This second type will lead to obesity and a lack of physical activity.
According to a report from the International Diabetes Federation (IDF), in 2019, people >20years old with diabetes mellitus worldwide reached 463 million people or 9.3% of the world's population [3]. The death rate caused by diabetes reaches 4.6 million people. In Asia and Australia (West Pacific), the number of people with diabetes mellitus aged 20 years has reached 162.6 million people or equivalent to 9.6% of the entire population in Southeast Asia with 1.2 million deaths. Meanwhile, Indonesia is the 6th highest ranked country with cases of people with diabetes mellitus aged 15 years and over with a prevalence of 10.9% [4]. The prevalence of diabetes mellitus in Indonesia based on the doctor's diagnosis for age 15 is 2%. There was an increase of 1.5% compared to the prevalence of diabetes mellitus in Indonesia in 2013. DKI Jakarta, East Kalimantan, DI Yogyakarta, North Sulawesi, and East Java were the top five provinces with the highest diabetes mellitus cases in Indonesia [5].

Method
The method used in this study was a quantitative method with a cross-sectional design. The data source was from the Indonesia Family Life Survey (IFLS) 5, representing individuals and households in Indonesia in 2014. The population in this study was 34,257 people, with IFLS 5 respondents who answered the module on health conditions and chronic diseases. The research sample amounted to 29,786 people with inclusion criteria, which respondents were willing to answer questions related to diabetes status in the IFLS 5 2014 health and chronic disease module. The independent variables in this study were hypertension disease status, BMI, and sleep quality (deficient, adequate, or good). In addition, the individual characteristic variables; age (15-64 years), gender, socio-economic factors, the status of area of residence, marital status, and education level. Data were analyzed multivariate with logistic regression with marginal effects using Stata 14. .  Table 2 shows the results of the variables of hypertension (95% CI= 0.004-0.013; p˂0.05), age (95% CI= 0.001-0.001; p˂0.05), urban residence (95% CI= 0.007-0.015; p˂0.05 ), married (95% CI= 0.013-0.038; p˂0.05), education level (95% CI= 0.002-0.013; 0.000-0.013; 0.003-0.015; 0.007-0.022; p˂0.05), per capita expenditure (CI 95 %= 0.005-0.011; p˂0.05), and nutritional status (95% CI= 0.003-0.013; 0.011-0.022; 0.013-0.023; 0.009-0.021; p˂0.05), positively related to the incidence of DM. While the variable of adequate sleep quality was negatively related to the incidence of DM (95% CI = -0.014-(-0.003); p˂0.05).

Discussion
Someone who has bad behavior in maintaining their health increases the risk of developing diabetes [16]. Based on the study results, a person's probability of developing diabetes increases with the individual's age (0.1%). A similar study previously conducted in Spain in 2018 showed that both men and women at an older age had more diabetes cases. The prevalence of someone experiencing obesity is also higher over time, where obesity is a risk factor for diabetes [17].
Based on the results of the study, hypertension showed a positive and significant relationship to diabetes. A person can be said to have hypertension if the blood pressure measured using a sphygmomanometer shows a systolic of 140 mmHg or a diastolic of 91 mmHg. If blood pressure exceeds these criteria, it can cause insulin resistance which triggers hyperinsulinemia. If not treated, it will cause Impaired Glucose Tolerance (TGT) which causes damage to pancreatic beta cells, resulting in type 2 diabetes [18]. The regression results carried out in this study also found that individuals who suffer from hypertension have a 2.3% higher probability of developing diabetes than those who do not suffer from hypertension. Another study using 5-year IFLS data stated that an increase in body fat in obese people with type 2 diabetes would have a harmful effect on hypertension, with a prevalence value of 1.3 times, so obese people with type 2 diabetes are more likely to suffer from hypertension [19].
BMI is a measurement that considers weight and height to classify an adult's body weight as too low, normal, overweight, or already obese. An increase in BMI will increase the risk of diseases, one of which is diabetes [20]. When an individual is at the highest BMI level, the individual is classified as obese, and people with excess weight or obesity tend to have insulin resistance. Insulin resistance causes an increase in fatty acids in plasma, which impacts decreasing glucose transport into muscle cells and increasing fat breakdown, which in turn causes an increase in liver glucose production. Insulin resistance also causes hyperinsulinemia which will cause diabetes [21]. The results showed a positive and significant relationship between BMI and diabetes. The higher the BMI level, the higher the probability of the individual developing diabetes. According to BMI calculations, individuals included in the obesity criteria 1 and 2 have a higher probability of developing Then, the results showed that the place of residence had a positive and significant influence on the prevalence of diabetes. Someone who lives in an urban area has a 1.13% higher probability of developing diabetes than someone in a rural area. Urbanization can affect the prevalence of diabetes because the urban environment is considered potentially obesogenic and diabetogenic [22]. Urbanization can also encourage changes in a person's lifestyle. Another study also explained that people living in urban areas have a higher risk of obesity, increasing the risk probability of type 2 diabetes [23].
Based on the study results, married people would have a 2.6% higher chance of developing diabetes than not married people. The number of married women respondents influenced this. The results of another study stated that married women tend to be obese due to an indifferent attitude to changes in body weight [24]. Moreover, during pregnancy, glucose needs tend to increase and affect the work of the hormone insulin, which causes high blood glucose, although, after delivery, it will return to normal glucose, the potential to transfer DM II can occur in later life [25].
The following study results showed the significance of the level of education on the incidence of DM. The regression results indicate that the higher the education level of an individual (especially high school and university/equivalent), the higher the probability of that individual suffering from diabetes. Another study found that individuals who have a high level of education have a higher risk of obesity [23]. Another study also stated that individuals with higher education tend to be passive smokers, which also increases the risk of suffering from diabetes [26].
Income is a wage or salary obtained from completing a job by someone both during work and outside working hours (overtime). A person's income is one of the factors that a person has diabetes. High income can increase the opportunity to consume excessive food, causing obesity [27]. This condition is in line with the results of this study which stated that an increase in income (per capita expenditure) would increase a person's probability of developing diabetes by 0.7%. In addition to excessive food consumption, a high-income level will trigger a person to have an unhealthy lifestyle, especially in alcohol consumption [28]. Another study found that people with lower incomes tend to have a lower risk of developing diabetes than people with higher incomes [29]. This risk is due to changes in people's lifestyles in an unhealthy direction. People with high-income levels tend to have low physical activity [30]. People tend to eat food according to taste and eventually leave a balanced diet [31].
As the implementing agency implementing the health insurance program, the Health Insurance Administration Agency has started running the Chronic Disease Management Program or Program Pengelolaan Penyakit Kronis (Prolanis). Prolanis is a health program that focuses on managing patients with type 2 DM and hypertension. In general, 54.3 percent of the Prolanis participants have benefited from this activity [32]. However, the implementation of Prolanis has not been optimal until now. Because the number of sufferers often exceeds Prolanis health workers, lack of training for Prolanis health workers, lack of budget for Prolanis activities, and the absence of written Service Operational Standards regarding Prolanis activities [33][34][35]. The same thing also happened to a more community-based government program, the Integrated Non-Communicable Disease Development Post (Posbindu PTM), which is still not widely used by the community [36,37].

Conclussion
Based on the research results from IFLS data in 2014, it can be concluded that Indonesian people with a history of hypertension, obesity, and poor sleep quality have a higher tendency to suffer from DM. Moreover, age, marital status, residency area, whether in a suburban or rural area, level of education, and income also affect the likelihood of developing diabetes mellitus risk.
Build upon the study results, researchers recommend establishing more health services that can facilitate the community in checking DM through blood tests, the need for family supervision to change lifestyles to become healthier, provide counseling about the prevention and risk of DM, and hold physical activity activities for the community. Such as healthy exercise together. In addition, Puskesmas also need to provide more effective services, especially in preventive, promotive, and educative programs, to improve the community's health status around the Puskesmas.