Rising diabetes prevalence in low-income countries ‘alarming and discouraging’
The prevalence of diabetes is increasing faster in some low-income countries than elsewhere in the world, generating concerns about health care infrastructure and access to treatment for people in those regions.
In November, the WHO Collaborating Centre for Noncommunicable Disease (NCD) Surveillance, Epidemiology and Modelling published a study in The Lancet with estimates of the global diabetes prevalence and treatment coverage from 1990 to 2022. Data were obtained from 1,108 studies that enrolled 141 million adults. The researchers concluded that approximately 828 million adults worldwide had diabetes in 2022, which was an increase from an estimated 630 million adults with diabetes in 1990.
Source: Sandra Kicman, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo. Printed with permission.
The recent study caught the attention of many in the diabetes community, including Edward W. Gregg, PhD, professor of population health at the Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences and Imperial College London. Gregg said the Lancet study is the best available global estimate of diabetes prevalence.
“I would say it was alarming and discouraging,” Gregg told Healio | Endocrine Today. “In the last 10 years, there has been good news from some high-income countries where you start to see decreases in the incidence of diagnosed diabetes. That started to suggest to us that maybe we turned the corner, or maybe [the incidence of diabetes] had plateaued. This paper ... shows that prevalence is still increasing, it’s not decreasing and the increase is greater than I expected.”
Some of the largest increases in diabetes prevalence were observed among low- and middle-income countries located in Southeast Asia, the Middle East, North Africa, Latin America and the Caribbean.
Several factors have contributed to the rise in global diabetes prevalence in those areas, according to Osagie Ebekozien, MD, MPH, CPHQ, chief medical officer at T1D Exchange.
“Some of the diets that high-income countries had for a while are now becoming staples in [low-income countries],” Ebekozien told Healio | Endocrine Today. “Also, there are changes in physical activity levels. These are factors that the science is very clear have a direct impact on diabetes.”
The rising prevalence of diabetes is especially challenging for lower-income countries, as many do not have a health care infrastructure that is as robust as higher-income nations, according to Leonard Egede, MD, MS, the Charles and Mary Bauer Endowed Chair and professor of medicine at Jacobs School of Medicine and Biomedical Sciences at University at Buffalo and president and CEO of UBMD Internal Medicine.
“I break it down into three main challenges,” Egede told Healio | Endocrine Today. “One is having enough providers to provide care. Because these areas are remote, things like screening and clinical care become more difficult. The second is testing and treatment challenges. When you live in environments where transportation is challenging, getting supplies like test strips, medications and even [food] is a challenge. Third is financial challenges. [Lower-income] countries are financially challenged or not very well resourced. Diabetes then puts a huge burden on the economy.”
The challenges lower-income countries face affect people around the world, according to James R. Gavin III, MD, PhD, chief medical officer at Healing Our Village Inc., senior consultant for chronic diseases at Centers for Health Promotion LLC and Healio | Endocrine Today Co-editor. Gavin said health care professionals need to think creatively about solutions and the private sector may need to step up to help close inequity gaps.“This is bad news for everybody, because of the dreadful implications, particularly the health economic and resources implications,” Gavin told Healio | Endocrine Today. “With the banner line on inequities and their persistence in those targeted communities, the implication side, which should be one of the motivations for strategicaction, has to be given some real serious weight.
Shivani Agarwal, MD, MPH, associate professor of medicine at Albert Einstein College of Medicine and senior director for health equity at Montefiore Medical Center in the Bronx, New York, in comments similar to some of Gavin’s concerns, said rising diabetes rates could lead to fewer adults being able to work due to complications. This could have effects in certain industries and could lead to challenges around the world due to the globalization of the economy.
“I’m hopeful that more attention to this issue will start getting the necessary change makers in place to actually do something about this,” Agarwal told Healio | Endocrine Today. “We’re going to reach a tipping point. ... It’s going to be scary, and we won’t be able to dial that back. I just hope we, as a society, can address this head-on in a preventive fashion.”
Diabetes disparities worsening
Several data points in the Lancet paper revealed how the diabetes burden is worsening in many parts of the world. From 1990 to 2022, 131 countries had an increase in diabetes prevalence for women and 155 nations saw diabetes prevalence rise among men. Conversely, only France, Japan and Spain had a decrease in diabetes prevalence for women and only the Pacific Island nation of Nauru had a decrease in diabetes prevalence for men.
“There’s a huge increase in gestational diabetes, type 1 diabetes and type 2 diabetes independently happening with a wide variation of contributors,” Ebekozien said. “You have natural population increase. Another component to think about is increased life expectancy in many of these countries; that also impacts prevalence.”
Some of the highest diabetes prevalence rates are in under-resourced low- and middle-income regions, such as Polynesia, Micronesia, the Caribbean, the Middle East and North Africa, according to the Lancet report. Several experts attributed these trends to increasingly homogenous diets across the globe and changes in physical activity.
Egede said diabetes prevalence trends in some countries are similar to trends seen in the global prevalence of obesity. The WHO Collaborating Centre for NCD Surveillance, Epidemiology and Modelling also published a study in 2024 in The Lancet that examined global trends in the prevalence of underweight and obesity from 1990 to 2022. The study found obesity prevalence rose in 94% of countries for women and in every country but one for men. “As societies are becoming more developed, what happens is people are moving from traditional diets to processed foods that tend to have more additives to them,” Egede said. “It also increases glucose, which leads to more weight gain.”
Agarwal added that air pollution in some countries and climate change also play a role in rising diabetes prevalence.
“There are very clear data to show that even very mild temperature increases and air pollution are directly associated with diabetes prevalence and severity,” Agarwal said.
In 2023, Agarwal, Ebekozien and Egede were co-authors on a paper in the Lancet that examined interventions to address increases in global diabetes disparities. One of their key takeaways was that geographical inequity in the availability and allocation of resources, along with demographic shifts, are leading to rising diabetes prevalence in low and middle-income countries vs. high-income countries.
Health care gaps
As the prevalence of diabetes rises worldwide, the proportion of adults who are receiving diabetes treatments is falling. The Lancet report estimated about 59% of adults with diabetes aged 30 years or older did not receive any diabetes treatment in 2022, a percentage that has more than tripled since 1990.
Gregg said a reason for undertreatment is the rising number of people with undiagnosed diabetes. The Lancet report considered people to have treated diabetes if they were using insulin or an oral hypoglycemia drug, and untreated diabetes was defined as a fasting plasma glucose of 7 mmol/L or higher or an HbA1c of 6.5% or higher without receiving diabetes medication.
“Getting diagnosed is the necessary step to getting treatment,” Gregg said. “Then you have the problem that once people are diagnosed, how do they receive the medications, whether oral medications or insulin?”
One issue with screening people for diabetes in lower-income countries is a lack of available health care professionals. Ebekozien cited an article published in The New England Journal of Medicine by Fitzhugh Mullan, MD, in 2005 that estimated between 40% and 75% of international medical graduates in the U.S., U.K., Canada and Australia came from lower-income countries. Ebekozien said this “brain drain” has had a negative impact on health care access for lower-income nations.
“There’s been a huge impact of the brain drain on health outcomes in a lot of the Caribbean countries and a lot of the African countries,” Ebekozien said.
For adults who can receive care in lower-income countries, diabetes management may look different than it does in the U.S. Access to supplies such as glucose test strips, diabetes devices and insulin is limited in some nations and even when an adult may have access to a therapy, they may not be able to afford it, Egede said.
“Most of the new medications we use right now, the GLP-1s and all the novel medications, are not affordable in those environments,” Egede said. “I can imagine there are many patients who get a diagnosis, they’re given prescriptions, but they can’t afford to fill the prescription. So that adds to that challenge.”
Gavin said medication affordability is a huge concern and an increased emphasis on generic drugs may help solve some of these issues.
“In the area of SGLT2 inhibitors, we have this explosive body of evidence on how effective these agents can be, and yet we have so few people [on them] still, with 10 years-plus on the market,” Gavin said. “Few people are getting access to them. Now, there are some very potent generics available, eminently affordable. What do you do? How do you marry those two issues, the evidence base and the barriers of economic affordability, to get to the point where you level the playing field with respect to access and benefit of this new therapy?”
A global issue
Multiple research groups have examined strategies to reduce global diabetes disparities. In 2023, Gregg and colleagues published a paper in the Lancet to set target diabetes goals as part of the WHO Global Diabetes Compact, an initiative to lower diabetes risk and improve access to care around the world. The paper detailed five goals for all countries to meet:
- have at least 80% of all people with diabetes clinically diagnosed;
- have 80% of people diagnosed with diabetes achieve an HbA1c of less than 8%;
- have 80% of people with diagnosed diabetes achieve a systolic blood pressure below 140 mm Hg and a diastolic BP of less than 90 mm Hg;
- provide access to statins for at least 60% of people with diabetes aged 40 years or older; and
- provide continuous access to insulin, blood glucose meters and test strips to all people with type 1 diabetes.
When setting the goals, the researchers wanted to establish metrics that could meaningfully improve diabetes outcomes and quality of life while also being attainable in lower-income countries, Gregg said.
“The hope is that [the paper] would drive countries to maybe set their own targets incrementally to get there,” he told Healio | Endocrine Today. “It’s not like this is mandating that these are your targets. But this is a goal-setting approach.”
The paper on global diabetes disparities that Agarwal, Ebekozien and Egede co-authored detailed a socioecological model for developing interventions that involved changing the ecosystem, building capacity and improving the clinical practice environment.
Interventions should be tailored to individual countries and populations, but higher-income countries must step up and help lower-income nations improve their health care infrastructure, Egede said, citing efforts to make COVID-19 vaccines available to low-income countries during the pandemic as an example of how collaboration can improve health care on a global scale.
“What we can do is make medications available at subsidized rates so people can get access to them,” Egede said. “Make testing supplies subsidized in a reasonable fashion so that more of the less privileged can have access to them. Then there’s this concept of training health care workers ... where nurses and community health workers can go around and provide care.”
Ebekozien said telemedicine is a tool that could reduce global diabetes disparities as people in many countries have access to smartphones or computers. “Right now, you can have a provider in Canada or in Sweden connect with a primary care, doctor in Uganda or in Zimbabwe through telehealth,” Ebekozien said. “We have the technology infrastructure for that. What we need is the political willpower.”
Expanded access to diabetes technology such as continuous glucose monitoring may make telehealth a viable option in many low-income countries, according to Agarwal.
“CGM could revolutionize the way people self-manage their diabetes and enable telehealth or population-level care,” Agarwal said. “In addition to SGLT and GLP-1 therapeutics, the way we monitor diabetes could have large-scale impacts both to bridge inequity and to have population-level improvement.”
The question of how to solve global diabetes disparities remains a perplexing one for many health care experts. Gavin said the private sector may be a champion for making more affordable medications available to people in low-income countries.
“There are opportunities now available to help level the playing field with respect to access to some of these proven interventions in the area of persistent inequities in the diabetes space,” Gavin said. “Even if you only looked at the space of the SGLT2 inhibitors and the growing prominence of the GLP-1s, those are two areas that where now there has been this intrusion of generics in a fairly serious way that puts some boundaries on the affordability issues, which have by and large been a huge hurdle with inequities in treatment. Sometimes people don’t get these things prescribed because prescribers with implicit bias don’t believe that they’re going to be affordable for their patients.”
Egede said governments in higher-income countries and stakeholders in the health care industry must both play a role and assist lower-income countries with diabetes treatment and prevention.
“Many of these [low-income] countries are doing the best that they can, but obviously they don’t manufacture the medications,” Egede said. “They don’t manufacture the testing supplies and equipment. So that is an area where [high-income countries] can help and provide some subsidy to address this.”
- References:
- Agarwal S, et al. Lancet. 2023;doi:10.1016/S0140-6736(23)00909-1.
- Gregg EW, et al. Lancet. 2023;doi:10.1016/S0140-6736(23)00001-6.
- Gregory GA, et al. Lancet Diabetes Endocrinol. 2022;doi:10.1016/S2213-8587(22)00218-2.
- Mullan F. N Engl J Med. 2005;doi:10.1056/NEJMsa050004.
- NCD Risk Factor Collaboration. Lancet. 2024;doi:10.1016/S0140-6736(23)02750-2.
- NCD Risk Factor Collaboration. Lancet. 2024;doi:10.1016/S0140-6736(24)02317-1.
- Walker AF, et al. Lancet. 2023;doi:10.1016/S0140-6736(23)00914-5.
- For more information:
- Shivani Agarwal, MD, MPH, can be reached at shivani.agarwal@einsteinmed.edu.
- Osagie Ebekozien, MD, MPH, CPHQ, can be reached at oebekozien@td1exchange.org; X (Twitter): @ebekozien.
- Leonard E. Egede, MD, MS, can be reached at legede@mcw.edu.
- James R. Gavin III, MD, PhD, can be reached at jrgavin3@yahoo.com or jgavin@chp-health.com.
- Edward W. Gregg, PhD, can be reached at edwardgregg@rcsi.ie.
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