Body-mass index and diabetes risk in 57 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 685 616 adults

• Type of Material: Article
• Authors: Mohammed Ali, Emory University; Felix Teufel, Heidelberg University; Jacqueline A Seiglie, Harvard Medical School; Pascal Geldsetzer, Heidelberg University; Michaela Theilmann, Heidelberg University; Maja E Marcus, University of Goettingen; Cara Ebert, RWI-Leibniz Institute for Economic Research, Essen (Berlin Office); William Andres L Arboleda, Heidelberg University; Kokou Agoudavi, Togo Ministry of Health; Glennis Andall-Brereton, Caribbean Public Health Agency; Krishna K Aryal, Abt Associates Inc; Garry Brian, The Fred Hollows Foundation New Zealand; Pascal Bovet, Ministry of Health, Victoria; Maria Dorobantu, University of Medicine and Pharmacy Carol Davila; Mongal Singh Gurung, Ministry of Health, Bhutan; David Guwatudde, Makerere University; Corine Houehanou, University of Abomey Calavi; Dismand Houinato, University of Abomey Calavi; Jutta Adelin M Jorgensen, University of Copenhagen; Gibson B Kagaruki, National Institute for Medical Research; Khem B Karki, Tribhuvan University; Demetre Labadarios, Stellenbosch University; Joao S Martins, National University of East Timor; Mary T Mayige, National Institute for Medical Research; Roy Wong McClure, Caja Costarricense Seguro Social; Joseph Kibachio Mwangi, Ministry of Health, Nairobi, Kenya; Omar Mwalim, Zanzibar Ministry of Health; Bolormaa Norov, National Center for Public Health; Sarah Crooks, Caribbean Public Health Agency; Farshad Farzadfar, Tehran University of Medical Sciences; Sahar Saeedi Moghaddam, Tehran University of Medical Sciences; Bahendeka K Silver, St. Francis Hospital, Uganda; Lela Sturua, National Center for Disease Control and Public Health, Tbilisi, Georgia; Chea Stanford Wesseh, Liberia Ministry of Health, Monrovia, Liberia; Andrew C Stokes, Boston University; Utibe R Essien, University of Pittsburgh; Jan-Walter De Neve, Heidelberg University; Rifat Atun, Harvard University; Justine I Davies, Stellenbosch University; Sebastian Vollmer, University of Goettingen; Till W Bärnighausen, Heidelberg University; James B Meigs, Harvard Medical School; Deborah J Wexler, Harvard Medical School; Jennifer Manne-Goehler, Harvard Medical School
• Language: English
• Date: 2021-07-17
• Publisher: ELSEVIER SCIENCE INC
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2021 Elsevier Ltd. All rights reserved.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/S0140-6736(21)00844-8
• Title of Journal or Parent Work: LANCET
• Volume: 398
• Issue: 10296
• Start Page: 238
• End Page: 248
• Grant/Funding Information: Jennifer Manne-Goehler was supported by Grant Number K23DK125162 from the NIDDK.; Pascal Geldsetzer was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number KL2TR003143.; This manuscript was also part of research funded under the European Union’s Research and Innovation program Horizon 2020 (project 825823).; The STEPS survey in Uganda was co-funded by the Uganda government, the World Health Organization, the World Diabetes Foundation, and the United Nations Development Program. The contents of this research are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.; Jan-Walter De Neve was supported by the Alexander von Humboldt Foundation, funded by Germany’s Federal Ministry of Education and Research.; Jacqueline Seiglie was supported by Grant Number T32DK007028 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Grant Number 5KL2TR002542-03 (Harvard Catalyst), and by the Massachusetts General Hospital Endocrine Division John T. Potts Jr. Pilot Award.; Gibson Kagaruki received partial support from the Afrique-ONE Aspire (funded by Wellcome Trust) and East African Consortium for Clinical Research (funded by EDCTP2) while preparing the manuscript.; Funding to support this analysis was provided by the Harvard T.H. Chan School of Public Health McLennan Fund: Dean’s Challenge Grant Program.
• Keywords: WAIST CIRCUMFERENCE; BMI; Medicine, General & Internal; OVERWEIGHT; Science & Technology; OBESITY; General & Internal Medicine; Life Sciences & Biomedicine

Abstract

Background: The prevalence of overweight, obesity, and diabetes is rising rapidly in low-income and middle-income countries (LMICs), but there are scant empirical data on the association between body-mass index (BMI) and diabetes in these settings. Methods: In this cross-sectional study, we pooled individual-level data from nationally representative surveys across 57 LMICs. We identified all countries in which a WHO Stepwise Approach to Surveillance (STEPS) survey had been done during a year in which the country fell into an eligible World Bank income group category. For LMICs that did not have a STEPS survey, did not have valid contact information, or declined our request for data, we did a systematic search for survey datasets. Eligible surveys were done during or after 2008; had individual-level data; were done in a low-income, lower-middle-income, or upper-middle-income country; were nationally representative; had a response rate of 50% or higher; contained a diabetes biomarker (either a blood glucose measurement or glycated haemoglobin [HbA1c]); and contained data on height and weight. Diabetes was defined biologically as a fasting plasma glucose concentration of 7·0 mmol/L (126·0 mg/dL) or higher; a random plasma glucose concentration of 11·1 mmol/L (200·0 mg/dL) or higher; or a HbA1c of 6·5% (48·0 mmol/mol) or higher, or by self-reported use of diabetes medication. We included individuals aged 25 years or older with complete data on diabetes status, BMI (defined as normal [18·5–22·9 kg/m2], upper-normal [23·0–24·9 kg/m2], overweight [25·0–29·9 kg/m2], or obese [≥30·0 kg/m2]), sex, and age. Countries were categorised into six geographical regions: Latin America and the Caribbean, Europe and central Asia, east, south, and southeast Asia, sub-Saharan Africa, Middle East and north Africa, and Oceania. We estimated the association between BMI and diabetes risk by multivariable Poisson regression and receiver operating curve analyses, stratified by sex and geographical region. Findings: Our pooled dataset from 58 nationally representative surveys in 57 LMICs included 685 616 individuals. The overall prevalence of overweight was 27·2% (95% CI 26·6–27·8), of obesity was 21·0% (19·6–22·5), and of diabetes was 9·3% (8·4–10·2). In the pooled analysis, a higher risk of diabetes was observed at a BMI of 23 kg/m2 or higher, with a 43% greater risk of diabetes for men and a 41% greater risk for women compared with a BMI of 18·5–22·9 kg/m2. Diabetes risk also increased steeply in individuals aged 35–44 years and in men aged 25–34 years in sub-Saharan Africa. In the stratified analyses, there was considerable regional variability in this association. Optimal BMI thresholds for diabetes screening ranged from 23·8 kg/m2 among men in east, south, and southeast Asia to 28·3 kg/m2 among women in the Middle East and north Africa and in Latin America and the Caribbean. Interpretation: The association between BMI and diabetes risk in LMICs is subject to substantial regional variability. Diabetes risk is greater at lower BMI thresholds and at younger ages than reflected in currently used BMI cutoffs for assessing diabetes risk. These findings offer an important insight to inform context-specific diabetes screening guidelines. Funding: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program.