The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults

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Results

The final pooled sample from the 55 LMICs included 680 102 total individuals and 37 094 individuals with diabetes (table 2; detailed sample characteristics are reported in appendix p 52). Overall, 7·9% of participants were missing data on at least one individual-level characteristic (appendix pp 46–51). Using equal weights for each country, diabetes prevalence by self-report of a glucose-lowering medication or biomarker was 9·0% (95% CI 8·7–9·4), with 43·9% (41·9–45·9) reporting a previous diabetes diagnosis. Diabetes prevalence and the proportion of diagnosed diabetes tended to be greater in countries in higher World Bank income categories (appendix pp 53–55). Among geographical regions, Oceania had the highest diabetes prevalence (19·3%, 95% CI 18·0–20·7) and lowest proportion diagnosed (29·7%, 23·7–36·6). Latin America and the Caribbean had the next highest diabetes prevalence (17·4%, 95% CI 16·1–18·8) but had the highest proportion diagnosed (66·8%, 62·9–70·5).

Table 2Survey characteristics

Data are year, %, n, median (IQR), or range. Country income groups are classified according to the World Bank in the year the survey was done.

Coverage varied by treatment (figure 1 and appendix p 56). Among pharmacological treatments, coverage of glucose-lowering medication was 50·5% (95% CI 48·6–52·5); antihypertensive medication was 41·3% (39·3–43·3); and cholesterol-lowering medication was 6·3% (5·5–7·2). Among non-pharmacological treatments, coverage of diet counselling was 32·2% (30·7–33·7); exercise counselling was 28·2% (26·6–29·8); and weight-loss counselling was 31·5% (29·3–33·7). In the combined analysis, coverage of pharmacological treatment was 8·1% (7·1–9·1) and coverage of non-pharmacological treatment was 25·2% (23·7–26·7). Overall, 4·6% (3·9–5·4) of individuals with diabetes self-reported meeting need for all treatments defined in this study that were recommended for them in WHO PEN.

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Figure 1Diabetes treatment coverage in 55 low-income and middle-income countries

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Coverage, or the proportion of eligible individuals receiving diabetes treatment, in 55 low-income and middle-income countries. Each treatment is a core recommendation for people with type 2 diabetes in the 2020 WHO Package of Essential Noncommunicable Disease Interventions. For the combined interventions, the denominator was all individuals who needed coverage for at least one treatment within the category; the numerator was the number of individuals self-reporting coverage for all treatments indicated for that individual within the category. For example, if an individual was defined to need glucose-lowering medication but not antihypertensive or cholesterol-lowering medication, the individual would be classified as having coverage for the pharmacological treatments if they self-reported use of the glucose-lowering medication (ie, one out of only one indicated treatment). Conversely, if an individual was defined to need both glucose-lowering therapy and antihypertensive therapy, the individuals would not be classified as having coverage for the pharmacological treatments if the individual only self-reported use of the glucose-lowering medication (ie, one out of two indicated interventions). Estimates account for clustering at the country level and equal weights by country. Error bars indicate 95% CIs.

There were substantial differences in coverage by country stratifications of income and geographical region (figure 2 and appendix pp 56–59). Countries in higher-income groups generally had higher coverage across all treatments. For example, coverage of glucose-lowering medication was 40·3% (95% CI 36·4–44·3) in low-income countries, 45·1% (42·0–48·2) in lower-middle-income countries, and 64·1% (60·3–67·7) in upper-middle-income countries. Regionally, coverage was generally highest in Latin America and the Caribbean and lowest in Oceania followed by sub-Saharan Africa. Across all income and geographical stratifications, coverage of glucose-lowering and hypertension medication was higher than coverage of non-pharmacological treatment of diet, exercise, and weight-loss counselling. Antihypertensive medication coverage also was higher than cholesterol-lowering medication coverage across income groups and regions.

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Figure 2Diabetes treatment coverage by country income group and geographical regions

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Data are percentages with 95% CIs accounting for clustering at the country level and equal weights by country. Income categories represent the World Bank’s classification in the year the survey was conducted. Geographical regions were categorised according to the Non-Communicable Disease Risk Factor Collaboration.

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  • Zhou B
  • Lu Y
  • Hajifathalian K
  • et al.
Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants.