The Central American Diabetes Initiative (CAMDI) conducted a series of surveys in Central America, with the following objectives:
- Determine the prevalence of diabetes mellitus and hypertension in people 20 years of age and older in a sample taken from six Central American populations (urban areas of San José, Costa Rica; Santa Tecla, San Salvador, El Salvador; Villanueva, Guatemala City, Guatemala; Tegucigalpa, Honduras; and Managua, Nicaragua; and the national population of Belize).
- Determine the prevalence of major risk factors diabetes and hypertension in six Central American populations.
Introduction: Most developing countries of Latin America are in a stage of epidemiologic, demographic, and nutritional transition. Changes in lifestyle are associated with mass migration from the rural areas to the urban areas, the phenomena of globalization, and exchanges between cultures (1). These changes are occurring rapidly in Central America; consequently, protein-calorie malnutrition is observed most frequently in conjunction with obesity, hypertension, diabetes mellitus, and hypercholesterolemia (2).
The health situation in Central America is evolving from one in which the epidemiologic profile is dominated by infectious diseases and nutritional deficiencies to an elevation of the importance of chronic noncommunicable diseases (CNCDs) as principal causes of morbidity. For example, data from around the year 2002 demonstrated that among women in Central America of 20—59 years the first cause of death is cancer of the uterus, with diabetes, stroke, and ischemic heart disease being the third, four and fifth causes respectively (2). During the same period, among those of age 60 years and older in both genders, ischemic heart disease and stroke were the first and second causes of death, respectively, while congestive heart disease and diabetes were among the five main causes of deaths (4).
Furthermore, the ratio of mortality due to chronic noncommunicable and communicable causes in Central America rose from 1.0 to 3.1 between the periods of 1980—1985 and 1990—1995, respectively.
Despite the importance of NCD in the health profile of Central America, information on the prevalence of major chronic diseases such as diabetes and hypertension and their risk factors are not available. Obesity, physical inactivity, and diet are considered major factors in the etiology of diabetes mellitus and hypertension. Obesity can contribute significantly to heart disease and resulting disabilities. For this reason, the present study examined the effects of epidemiologic transition on the health profile of various populations of Belize, Costa Rica, El Salvador, Honduras, Guatemala and Nicaragua.
(forthcoming in English and Spanish)
The present report is the first epidemiological study on the prevalence of diabetes mellitus and hypertension in Central America with a representative sample of a geographic area of each participating country. We found a combined prevalence of diabetes mellitus of 8.5% and hypertension of 25.3%, half of which were undiagnosed.
The prevalence of diabetes and hypertension were the highest in Belize, while Tegucigalpa and Guatemala City had the lowest prevalence of diabetes and hypertension respectively. The combined prevalence of diabetes in participating sites was comparable to the prevalence reported in the United States (3) (8.1%) and Mexico City (4) in 2000 (8.4%), and higher than the prevalence reported in four Bolivian cities in 1998 (5).
The national prevalence of diabetes in Belize is comparable to prevalence of diabetes reported in Jamaica (6) in 1999 and New York (7) (12.5%) in 2008. The CARMELA study for example, reported prevalence of diabetes between 4.4% in Lima and 8.9% in Mexico City (8). The proportion of cases of diabetes diagnosed in the combined sample (5%) was comparable to that reported in the United States (5%) in 2000 and Bolivia (5.2%) in 1998. The proportion of undiagnosed cases of diabetes was higher in Belize and Managua than in the other sites.
Diabetes and hypertension occurred most frequently among people over 39 years of age, particularly among women. These results correspond with the greater prevalence of risk factors found in these population groups, such as overweight, large waist circumference, sedentary life style, and hypercholesterolemia.
In the United States, a prevalence of hypertension lower than that reported in the combined sample (25%) has been reported (9). Cuba has recently reported hypertension prevalences of 22.4% and 24.2% in men and women of African origin, respectively (10). The prevalence of overweight/obesity in Central America (61%) was similar to the prevalence reported in Bolivia in 1998 (5) and the United States (66.3%) in 2000-2001 (11). The CARMELA study reported prevalence of obesity ranging from 16.3% in Quito to 31.0% in Mexico City (8). The prevalence of obesity (34.9%) or overweight/obesity (66.3%) reported here for Belize was higher than that reported for the Mexico City (8) and equal to the United States (7) respectively.
The higher prevalence of diabetes mellitus and hypertension in people with a lower level of education and income is consistent with findings from the U.S. as well as other areas of the Americas, including Bolivia (5). In New York people with reported annual income <$20,000 were more likely to be found with diabetes than those with income of $20,000 and greater (17.0% vs. 9.1% respectively) (14). This phenomenon may be related to a reduced availability of and access to information, education, health services, and access to healthy food.
The high prevalence of diabetes observed across cities in Central America has important implications for the health status of the population of these countries, particularly in light of the relatively young age structure of the population in the sampled areas. Diabetes leads to numerous microvascular complications, making it a major cause of blindness, non-traumatic amputation, and end-stage renal disease.
Diabetes also more than doubles the risk of coronary heart disease, stroke, and peripheral vascular disease. The collective impact of these complications erodes quality of life and imposes a substantial direct and indirect economic burden.
Because of the complexity of effectively managing diabetes, along with the diverse burden created by the disease, a multi-disciplinary public health response is needed to reduce its impact. Diabetes education is considered essential to ensure that people with diabetes engage in preventive health behaviors and adequate diabetes self-management. The development of integrated health systems that systematically encourage clinical guidelines, track levels of care, provide feedback to patients and clinicians, and then continuously improve the quality of care delivery, is considered essential to reducing risk of diabetes complications.
Numerous randomized clinical trials now indicate that diabetes can be prevented or delayed by applying multi-disciplinary lifestyle modification to people with impaired glucose tolerance. These data provide justification for health systems, communities, and ministries of health to provide wide scale education about the risk factors and effective interventions to prevent diabetes. In addition, these data point to a need to develop community programs to facilitate exercise and diet improvement among high risk people in the community.
These surveys were conducted in or near capital cities and cannot necessarily be generalized to the nationwide populations of these countries. People living in rural areas are likely to have lower prevalence levels. However, there has been a steady urbanization in countries of Central America, so that 40% to 55% of the population now lives in urban areas. Nevertheless, the fact that these urban estimates may overestimate prevalence of the country indicates a need for follow-up surveillance efforts applied more broadly to the countries.
In conclusion, the prevalence of diabetes mellitus and hypertension found in the combined Central America sample was higher than the prevalence reported in most countries of Latin America. It is particularly important that, despite having a younger population, Central America had a prevalence of diabetes similar to the prevalence in the United States. The data presented indicate that diabetes affects people with a lower educational level, which suggests that the poorest people bear the greatest burden. This means that in the future there will be an important increase in the prevalence of diabetes as the population ages, unless preventive strategies are introduced.
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