Division of Hospital Medicine, Department of Internal Medicine, National Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA; Center for Indigenous Health Research, Wuqu' Kawoq; Tecpán, Guatemala; Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala.
Diabetes Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
Lancet Healthy Longev. 2021 Jun;2(6):e340-e351. doi: 10.1016/s2666-7568(21)00089-1. Epub 2021 May 21.
Approximately 80% of the 463 million adults worldwide with diabetes live in low- and middle-income countries (LMICs). A major obstacle to designing evidence-based policies to improve diabetes outcomes in LMICs is the limited nationally representative data on the current patterns of treatment coverage. The objectives of this study are (1) to estimate the proportion of adults with diabetes in LMICs who receive coverage of recommended pharmacological and non-pharmacological diabetes treatment and (2) to describe country-level and individual-level characteristics that are associated with treatment.
We conducted a cross-sectional analysis of pooled, individual data from 55 nationally representative surveys in LMICs. Our primary outcome of self-reported diabetes treatment coverage was based upon population-level monitoring indicators recommended in the 2020 World Health Organization Package of Essential Noncommunicable Disease Interventions. We assessed coverage of three pharmacological and three non-pharmacological treatments among people with diabetes. At the country level, we estimated the proportion of individuals reporting coverage by per-capita gross national income and geographic region. At the individual level, we used logistic regression models to assess coverage along several key individual characteristics including sex, age, BMI, wealth quintile, and educational attainment. In the primary analysis, we scaled sample weights such that countries were weighted equally.
The final pooled sample from the 55 LMICs included 680,102 total individuals and 37,094 individuals with diabetes. Using equal weights for each country, diabetes prevalence was 9.0% (95% confidence interval [CI], 8.7-9.4), with 43.9% (95% CI, 41.9-45.9) reporting a prior diabetes diagnosis. Overall, 4.6% (95% CI, 3.9-5.4) of individuals with diabetes self-reported meeting need for all treatments recommended for them. Coverage of glucose-lowering medication was 50.5% (95% CI, 48.6-52.5); antihypertensive medication, 41.3% (95% CI, 39.3-43.3); cholesterol-lowering medication, 6.3% (95% CI, 5.5-7.2); diet counseling, 32.2% (95% CI, 30.7-33.7); exercise counseling, 28.2% (95% CI, 26.6-29.8); and weight-loss counseling, 31.5% (95% CI, 29.3-33.7). Countries at higher income levels tended to have greater coverage. Female sex and higher age, BMI, educational attainment, and household wealth were also associated with greater coverage.
Fewer than one in ten people with diabetes in LMICs receive coverage of guideline-based comprehensive diabetes treatment. Scaling-up the capacity of health systems to deliver treatment not only to lower glucose but also to address cardiovascular disease risk factors such as hypertension and high cholesterol are urgent global diabetes priorities.
全球 4.63 亿糖尿病患者中，约有 80%生活在中低收入国家（LMICs）。在这些国家设计基于证据的政策以改善糖尿病患者的预后，主要障碍是缺乏关于当前治疗覆盖范围的全国代表性数据。本研究的目的是：(1) 估计 LMICs 中接受推荐的药物和非药物治疗的糖尿病患者比例；(2) 描述与治疗相关的国家和个体特征。
我们对来自 LMICs 的 55 项具有全国代表性的调查的汇总个体数据进行了横断面分析。我们的主要结局指标是自我报告的糖尿病治疗覆盖率，该指标基于 2020 年世界卫生组织基本非传染性疾病干预包中推荐的人群监测指标。我们评估了糖尿病患者中三种药物和三种非药物治疗的覆盖情况。在国家层面，我们根据人均国民总收入和地理区域估计了报告覆盖率的个体比例。在个体层面，我们使用逻辑回归模型评估了包括性别、年龄、BMI、财富五分位数和教育程度在内的几个关键个体特征与覆盖率的关系。在主要分析中，我们对样本权重进行了调整，以使各国权重相等。
来自 55 个 LMICs 的最终汇总样本包括 680102 名个体和 37094 名糖尿病患者。使用各国等权重，糖尿病患病率为 9.0%（95%置信区间[CI]，8.7-9.4），其中 43.9%（95%CI，41.9-45.9）报告有既往糖尿病诊断。总体而言，有 4.6%（95%CI，3.9-5.4）的糖尿病患者自述符合他们所需的所有治疗方案。降糖药物的覆盖率为 50.5%（95%CI，48.6-52.5）；降压药物为 41.3%（95%CI，39.3-43.3）；降脂药物为 6.3%（95%CI，5.5-7.2）；饮食咨询为 32.2%（95%CI，30.7-33.7）；运动咨询为 28.2%（95%CI，26.6-29.8）；体重减轻咨询为 31.5%（95%CI，29.3-33.7）。收入水平较高的国家的覆盖率往往较高。女性和较高的年龄、BMI、教育程度和家庭财富也与较高的覆盖率相关。
中低收入国家不到十分之一的糖尿病患者接受基于指南的全面糖尿病治疗。扩大卫生系统的能力，不仅要降低血糖，还要解决高血压和高胆固醇等心血管疾病风险因素，是全球糖尿病的紧迫优先事项。
