Pattern of Diabetes in Developing Countries

Some unique aspects (Table 2) of the diabetes epidemic in developing countries include: 1) younger age group, 2) female gender preponderance, and 3) rural-to-urban area step-up in diabetes prevalence. In developing countries, the majority of people with diabetes are in the age range of 45-64 years, as compared to aged >65 years in the developed countries. This demographic pattern will be amplified by the year 2025. Thus, diabetes in developing countries targets persons in the peak professional/productive years, whereas persons retired or nearing retirement age will be targeted in the developed world. The economic implications of this pattern are staggering. Moreover, the National Health and Nutrition Examination Survey (NHANES) 1999-2000 survey data showed a decreasing trend in age at diagnosis of diabetes for U.S. residents; a similar trend in developing countries will further magnify the problem of economic incapacitation by diabetes. In developed countries, there are more men than women with diabetes, whereas the gender ratios are reversed in developing countries.

The combination of younger age and female preponderance increases the likelihood of intrauterine fetal exposure to diabetes in developing countries. Studies have indicated that exposure to an intrauterine diabetic environment increases the risk of developing future metabolic disorders. Recent diabetes surveys in Jamaica, Barbados and other Caribbean islands confirm the same trends of younger age, female preponderance and rural-to-urban drift (Dr. Laurence Watkins, personal communication). In addition to these demographic patterns, the well-known complications of diabetes lead to predictably high morbidity and mortality in developing countries.

Table 2. Features of type-2 diabetes by world region*

Developed Countries

Developing Countries

Number of cases (1995)

51 million 84 million

Projected cases (2025)

72 million 228 million

Rate of increase

42% 170%

Gender

Male > Female Female > Male

Peak age

>65 years 45-64 years
* Data from King H, Aubert RE, Herman WH, 19987

Rationale for Aggressive Diabetes Prevention in Developing Countries

There are compelling reasons why primary prevention of type-2 diabetes should be the dominant strategy for developing countries. These include the prohibitive costs of treating established diabetes and multiple socioeconomic gaps in developing countries that predict poor outcome of diabetes management. There are gaps in health and social infrastructure, as well as health literacy. Then there are competing national priorities that relegate glycemic control in diabetic persons to second-tier concerns.

Prohibitive Costs of Glucose Control

Once diabetes has developed, it is expensive to treat because of the costs associated with routine medications, endless clinic visits, laboratory testing, supplies for home glucose monitoring, and treatment of complications. Local manufacture of drugs and devices used in the management of diabetes is nonexistent or limited in most countries of the developing world. This handicap makes for insecure availability of antidiabetes medications, including insulin, in local drug stores; frequent life-threatening shortages of insulin are not unusual in some poorer countries. Even when available, these medications often are unaffordable: one vial of the least expensive brand of insulin costs 5-10% of average annual income in Africa. Costs of diabetes medications and medical supplies are not underwritten by government or reimbursed by third-party insurers in many such countries.

Many of the core paradigms of optimal diabetes management, including self-monitoring of blood glucose (SMBG) and routine measurement of hemoglobin Ale (HbAlc), are not feasible in poorer countries. In such countries, the majority of diabetes patients, because of economic constraints, cannot implement SMBG. Similarly, HbAlc, the “gold standard” test for evaluating glycemic control, is not available in most hospital laboratories due to lack of reagents, and many patients cannot afford routine measurement in a private laboratory. Tragically, the lack of day-to-day (SMBG) or long-term (HbAlc) feedback information on glycemic trends renders the state of diabetes control unknowable in most patients. As a result of inadequate healthcare infrastructure and socioeconomic limitations, the degree of glycemic control necessary to prevent blindness, renal failure, amputation and heart disease may be beyond reach for patients in many developing countries. Therefore, poor glycemic control is pervasive, and the complications of diabetes are almost inevitable.

Category: Diseases / Tags: developing countries, Diabetes, prevention

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