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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
Open accessAbstract
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 [HbA 1c]); 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 HbA 1c 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/m 2], upper-normal [23·0-24·9 kg/m 2], overweight [25·0-29·9 kg/m 2], or obese [≥30·0 kg/m 2]), 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/m 2 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/m 2. 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/m 2 among men in east, south, and southeast Asia to 28·3 kg/m 2 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.
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“Although obesity is theoretically reversible28, 51, 52 and addressing it could provide the biggest opportunity to limit the advance of diabetes, current trends suggest that obesity rates are likely to continue to climb.45”
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Metadata
- Authors
- Teufel, F., Seiglie, J. A., Geldsetzer, P., Theilmann, M., Marcus, M. E., Ebert, C., Arboleda, W. A. L., Agoudavi, K., Andall-Brereton, G., Aryal, K. K., Bicaba, B. W., Brian, G., Bovet, P., Dorobantu, M., Gurung, M. S., Guwatudde, D., Houehanou, C., Houinato, D., Jorgensen, J. M. A., Kagaruki, G. B., Karki, K. B., Labadarios, D., Martins, J. S., Mayige, M. T., McClure, R. W., Mwangi, J. K., Mwalim, O., Norov, B., Crooks, S., Farzadfar, F., Moghaddam, S. S., Silver, B. K., Sturua, L., Wesseh, C. S., Stokes, A. C., Essien, U. R., De Neve, J.-W., Atun, R., Davies, J. I., Vollmer, S., Bärnighausen, T. W., Ali, M. K., Meigs, J. B., Wexler, D. J., & Manne-Goehler, J.
- Affiliations
- Heidelberg University (DE)
- Harvard University (US)
- University of Göttingen (DE)
- RWI – Leibniz Institute for Economic Research (DE)
- Togolese Ministry of Health (TG)
- Abt Associates (Nepal) (NP)
- Ministère De La Santé (BF)
- Fred Hollows Foundation (AU)
- Ministry of Health (SC)
- Ministry of Health (BT)
- Makerere University (UG)
- Université d'Abomey-Calavi (BJ)
- University of Copenhagen (DK)
- National Institute for Medical Research (TZ)
- Tribhuvan University (NP)
- Stellenbosch University (ZA)
- Costa Rican Department of Social Security (CR)
- University of Geneva (CH)
- Endocrinology and Metabolism Population Sciences Institute (IR)
- National Center for Disease Control and Public Health (GE)
- Ministry of Health and Social Welfare (LR)
- Boston University (US)
- University of Pittsburgh (US)
- University of the Witwatersrand (ZA)
- Emory University (US)
- ORCID
- Teufel, Felix
- Seiglie, Jacqueline A
- Geldsetzer, Pascal
- Theilmann, Michaela
- Marcus, Maja E
- Ebert, Cara
- Agoudavi, Kokou
- Aryal, Krishna K
- Bicaba, Brice Wilfried
- Brian, Garry
- Bovet, Pascal
- Gurung, Mongal Singh
- Guwatudde, David
- Houinato, Dismand
- Jorgensen, Jutta M Adelin
- Kagaruki, Gibson B
- Karki, Khem B
- Labadarios, Demetre
- Mayige, Mary T
- Mwalim, Omar
- Farzadfar, Farshad
- Moghaddam, Sahar Saeedi
- Sturua, Lela
- Stokes, Andrew C
- Essien, Utibe R
- Atun, Rifat
- Davies, Justine I
- Bärnighausen, Till W
- Ali, Mohammed K
- Meigs, James B
- Wexler, Deborah J
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2021-07
- Volume
- 398
- Issue
- 10296
- Pages
- 238-248
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC8336025
- OpenAlex
- W3179285483
- Cited by
- 159
- References
- 27
- Citations by year
- 2026: 17 · 2025: 29 · 2024: 32 · 2023: 47 · 2022: 30 · 2021: 4
- FWCI
- 21.09
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.elsevier.com/tdm/userlicense/1.0/ (tdm)
- www.elsevier.com/legal/tdmrep-license (tdm)
- www.elsevier.com/open-access/userlicense/1.0/ (am, 381 d)
- doi.org/10.15223/policy-017 (stm-asf)
- doi.org/10.15223/policy-037 (stm-asf)
- doi.org/10.15223/policy-012 (stm-asf)
- doi.org/10.15223/policy-029 (stm-asf)
- doi.org/10.15223/policy-004 (stm-asf)
- Locations
- The Lancet (acceptedVersion)
- PubMed (publishedVersion)
- University of Birmingham Research Portal (University of Birmingham) (publishedVersion, cc-by-nc-nd)
- Research at the University of Copenhagen (University of Copenhagen) (publishedVersion, cc-by-nc-nd)
- PubMed Central (acceptedVersion)
- HAL (submittedVersion, other-oa)
- IRIS (submittedVersion)
- GoeScholar The Publication Server of the Georg-August-Universität Göttingen (Georg-August-Universität Göttingen) (submittedVersion, other-oa)
- SERVAL (Université de Lausanne) (submittedVersion)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases
- National Center for Advancing Translational Sciences
- Harvard University Harvard Catalyst
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Health Sciences › Medicine › Oncology › Cancer Risks and Factors
- Keywords
- body mass index, diabetes risk, obesity, overweight, low- and middle-income countries, HbA1c, fasting blood glucose, diabetes prevalence, sex differences, WHO STEPS survey, health care financing, health system performance, health system resilience, health system sustainability, health system preparedness
- MeSH terms
- Adult, Cross-Sectional Studies, Developing Countries, Diabetes Mellitus, Female, Health Surveys, Glycated Hemoglobin, Humans, Male, Middle Aged, Obesity, Poverty, Global Health, Body Mass Index, Prevalence
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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