Diabetes prevalence and its relationship with education, wealth, and body mass index in twenty-nine low- and middle-income countries

OBJECTIVE
Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship between education, household wealth, body mass index (BMI), and diabetes risk.

RESEARCH DESIGN AND METHODS
We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall, by country, World Bank Income Group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR).

RESULTS
Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI: 7.1% – 8.0%) and of undiagnosed diabetes, 4.9% (4.6% – 5.3%). Diabetes prevalence increased with increasing WBIG: low-income (LICs) 6.7% (5.5% – 8.1%), lower-middle-income (LMIs) 7.1% (6.6% –7.6%), upper-middle-income countries (UMIs) 8.2% (7.5% – 9.0%). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, independent of BMI (LICs RR 1.47 [95% CI:1.22–1.78]; LMIs 1.14 [1.06–1.23]; UMIs 1.28 [1.02–1.61]).

CONCLUSIONS
Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.