Diabetes – a Rural Snapshot

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Peter Rohloff has training in parasitology, internal medicine and pediatrics. He practices in Boston, MA at Brigham and Women's Hospital and Boston Children's Hospital. Since 2003, Peter has been working in Guatemala, where he serves as the medical director for a health systems NGO – Wuqu’ Kawoq | Maya Health Alliance. Peter’s interests include the management of chronic diseases of children and adults in resource poor settings and how indigeneity, cultural, and language barriers impact access to and utilization of health care. @wuqukawoq

Last month I wrote a bit about the emerging global burden of diabetes and gave some specific reflections on the case of Guatemala, where we have been working to develop programs for indigenous and rural communities with diabetes.

At that time, I remarked that one of the challenges of this kind of work is that we know very little about the actual prevalence or profile of diabetes and diabetes patients in these marginalized geographic and social spaces. What we do know, at least, is that diabetes is not just a disease of urban environments where sedentarism and dietary changes are most rampant. For example, we know that worldwide the prevalence of diabetes has gone up five-fold in rural communities over the last 25 years (1).

Understanding more about diabetes in these rural settings is important, because it will help usedevelop more effective educational and clinical programs for prevention and treatment. Recently, we’ve been trying to flesh out the story a bit in the communities we work for in rural Guatemala. What we’ve been able to do, thanks to the recent implementation of an electronic medical record system, is go back and closely analyze some of the basic characteristics of our patient population. This is clearly by no means hard-hitting science, since all of the data that emerge are heavily skewed by the type of patients we attract to our clinics, who tend to have more diabetes-related complications than the general population.

Nevertheless, as a first approximation to understanding the health of this rural population, we think that the experience has been very instructive. What has been particularly helpful has been the recent publication of a great public health study of diabetes in urban Guatemala by our colleagues at INCAP (2) which has allowed us to make some comparisons between the “typical” urban diabetic patient in Guatemala and the ourl rural diabetic patients.

For example, in our communities, the average diabetic patient is around 55 years of age and is diagnosed with diabetes in their late 40s. This is similar to findings from urban Guatemala, and it suggests that in both settings the bulk of our effort at screening for diabetes likely needs to be focused somewhere in the fourth decade of life. On the other hand, one of the ways in which the rural population is very different from the urban population is in terms of educational achievement. Nearly three quarters of our patients have three years of primary school or less. This is a very important finding, even though it is not particularly surprising, because it underscores how strategies to educate about diabetes in this population need to be appropriate for the educational level.

Another very interesting finding for us was the very low rates of ever using tobacco (0% !) in the rural population, obviously much, much lower than the urban population (~40%). We had always suspected this number was low, but these rates were even lower than we had thought. The fact that there is basically no tobacco use at all in the rural population is excellent news, as this helps to reduce the overall burden of cardiovascular disease. Guatemala became a signatory of the WHO Convention on Tobacco Control in 2005, and implemented comprehensive tobacco control legislation in 2008 (3). I wonder if (and hope that) rural Guatemala may have been able to dodge the tobacco bullet through the implementation of comprehensive tobacco legislation before tobacco ever managed to “catch on.” Indeed, in lower income countries around the world, where the WHO Convention on Tobacco Control has been adopted, the early implementation of anti-tobacco legislation (prior to growth in actual consumer demand for tobacco) may be one of the great global health triumphs of the coming decades.

One final interesting detail from our small study was the fact that obesity rates in the rural population were some 15% higher than in the urban population. At first glance this seem very counterintuitive. How can obesity be higher in a population that is less sedentary and has more traditional foodstuffs in the diet? This finding has led us to reflect on the large body of emerging literature that demonstrates a close association between chronic childhood malnutrition and adiposity in adult life (4). Since Guatemalan rural populations have one of the highest rates of child malnutrition in the world (5), could this be what is driving the emerging diabetes epidemic (more than, say dietary change or sedentarism)? It seems like an hypothesis worth investigating closely because it would mean that, from a public health perspective, preventing diabetes in Guatemala (and similar marginalized settings) would require also and simultaneously fixing the problem of childhood undernutrition.

(1) Hwang CK, Han PV, Zabetian A, Ali MK, Venkat Narayan KM. Rural diabetes prevalence quintuples over twenty-five years in low- and middle-income countries: A systematic review and meta-analysis. Diab Res Clin Pract 2012, doi:10.1016/j.diabres.2011.12.001.

(2) Central America Diabetes Initiative: Survey of Diabetes, Hypertension and Chronic Disease Risk Factors: Villa Nueva, Guatemala 2006. Washington: Pan American Health Organization; 2007.

(3) Gobierno de Guatemala (2008). Decreto 74-2008: Creacion de los Ambientes Libres de Humo de Tabaco.

(4) Vieira VCR, Fransceschini SdCC, Fisberg M, Priore SE: Stunting: its relation to overweight, global or localized adiposity and risk factors for chronic non-communicable diseases. Rev Bras Saude Mater Infant 2007, 7:365-372.

(5) De Onis M, Blössner M: The World Health Organization global database on child growth and malnutrition: Methodology and applications. Int J Epidemiol 2003, 32:518-526.