Alberto Barceló

The cost of diabetes in Latin America and the Caribbean

OBJECTIVE To measure the economic burden associated with diabetes mellitus in Latin America and the Caribbean. METHODS Prevalence estimates of diabetes for the year 2000 were used to calculated direct and indirect costs of diabetes mellitus. Direct costs included costs due to drugs, hospitalizations, consultations and management of complications. The human capital approach was used to calculate indirect costs and included calculations of forgone earnings due to premature mortality and disability attributed to diabetes mellitus. Mortality and disability attributed to causes other than diabetes were subtracted from estimates to consider only the excess burden due to diabetes. A 3% discount rate was used to convert future earnings to current value. FINDINGS The annual number of deaths in 2000 caused by diabetes mellitus was estimated at 339,035. This represented a loss of 757,096 discounted years of productive life among persons younger than 65 years (> billion US dollars). Permanent disability caused a loss of 12,699,087 years and over 50 billion US dollars, and temporary disability caused a loss of 136,701 years in the working population and over 763 million US dollars. Costs associated with insulin and oral medications were 4720 million US dollars, hospitalizations 1012 million US dollars, consultations 2508 million US dollars and care for complications 2,480 million US dollars. The total annual cost associated with diabetes was estimated as 65,216 million US dollars (direct 10,721 US dollars; indirect 54,496 US dollars). CONCLUSION Despite limitations of the data, diabetes imposes a high economic burden to individuals and society in all countries and to Latin American and the Caribbean as whole.

A century of trends in adult human height

Being taller is associated with enhanced longevity, and higher education and earnings. We reanalysed 1472 population-based studies, with measurement of height on more than 18.6 million participants to estimate mean height for people born between 1896 and 1996 in 200 countries. The largest gain in adult height over the past century has occurred in South Korean women and Iranian men, who became 20.2 cm (95% credible interval 17.5–22.7) and 16.5 cm (13.3–19.7) taller, respectively. In contrast, there was little change in adult height in some sub-Saharan African countries and in South Asia over the century of analysis. The tallest people over these 100 years are men born in the Netherlands in the last quarter of 20th century, whose average heights surpassed 182.5 cm, and the shortest were women born in Guatemala in 1896 (140.3 cm; 135.8–144.8). The height differential between the tallest and shortest populations was 19-20 cm a century ago, and has remained the same for women and increased for men a century later despite substantial changes in the ranking of countries. DOI: http://dx.doi.org/10.7554/eLife.13410.001

Incidence and prevalence of diabetes mellitus in the Americas

OBJECTIVE To present the incidence and prevalence of diabetes mellitus in the Americas as found through a thorough review of published information on the subject. METHODS Data were obtained through a comprehensive review using the MEDLINE and BIREME bibliographical databases. In addition, government publications, conference reports, and meeting documents were identified by contacting government and nongovernmental organizations and other institutions. Incidence and prevalence rates were adjusted by age and sex, when possible, by the direct method using the world Segi population as the standard. The 95% confidence intervals were calculated using the Poisson distribution or the normal distribution. RESULTS Diabetes mellitus represents a major public health problem in the Americas, and there is evidence that its prevalence is increasing in some countries. CONCLUSIONS Given that most Latin American and Caribbean nations are experiencing a demographic transition, it is expected that the prevalence of diabetes will continue to increase rapidly in the near future. Despite the economic constraints faced by the countries of the Americas, there is a clear need for more efforts in the area of diabetes prevention and control.

Diabetes in Bolivia

OBJECTIVE To measure the prevalence of diabetes mellitus (DM), hypertension, obesity, and related risk factors in major cities in Bolivia. METHODS A population-based survey was conducted in four Bolivian cities: La Paz, El Alto, Santa Cruz, and Cochabamba. The total sample size was chosen to be 2,948 persons. The overall response rate was 86%, with the rate varying somewhat among the four cities. DM was diagnosed through an oral glucose tolerance test (OGTT) 2 hours after an overload of 75 grams of glucose, using World Health Organization criteria. RESULTS The overall prevalence of DM in the four urban areas combined was 7.2% (95% confidence interval (CI): 6.2%-8.3%) and of impaired glucose tolerance (IGT) was 7.8%. A total of 73.1% (95% CI: 65.0%-81.0%) of those previously diagnosed with DM and 73.7% (95% CI: 61.0%-86.4%) of newly diagnosed cases were overweight, according to measurements of body mass index. Hypertension was found in 36.5% (95% CI: 27.6%-45.5%) of known diabetics and in 36.6% (95% CI: 23.0%-50.1%) of newly diagnosed cases, compared to only 15.9% (95% CI: 14.3%-17.5%) among people without DM. The disease was most common among older persons and those with little education. CONCLUSIONS Diabetes is a genuine public health problem in Bolivia. Further, the high prevalence of IGT that was found suggests that diabetes prevalence will increase in the near future in the country unless prevention strategies are implemented.

Using collaborative learning to improve diabetes care and outcomes: The VIDA project

UNLABELLED The prevalence of diabetes in Mexico among those 20-64 years of age has increased from 7.2% in 1993 to 10.7% in 2000. National population-based surveys in Mexico demonstrated that 50% of the total population with diabetes had blood glucose levels of 200mg/dl or higher. Thus, diabetes care has become one of the most important public health challenges in this country. The aim of the study was to improve the quality of diabetes care in primary health care centers using the chronic care model and the breakthrough series (BTS) collaborative methodology. METHODS Ten public health centers in the cities of Xalapa and Veracruz were randomly selected to participate in the project. Five of the health centers were randomly assigned to receive the intervention (intervention group) and the other five followed usual care (usual care group). The intervention was evaluated by A1c test before and after the intervention in both groups of patients. Patients were followed for 18 months from November 2002 to May 2004. Results were adjusted for the clustering of patients within practices and baseline measure. RESULTS The proportion of people with good glycemic control (A1c<7%) among those in the intervention group increased from 28% before the intervention to 39% after the intervention. The proportion of patients achieving three or more quality improvement goals increased from 16.6% to 69.7% (p<0.001) among the intervention group while the usual care group experienced a non-significant decrease from 12.4% to 5.9% (p=0.118). The focus on the primary care team and the participation of people with diabetes were strategic elements incorporated into the methodology, expected to ensure sustainability of continued improvement of health outcomes. CONCLUSIONS The intervention introduced modifications to solve problems identified by health teams in their practice and improved process and outcome measures of quality diabetes care. Most of the actions were directed at four components of the chronic care model: self-management support, decision support, delivery system design, and clinical information systems.

The Prevalence of Diagnosed Diabetes Among the Elderly of Seven Cities in Latin America and the Caribbean: The Health Wellbeing and Aging (SABE) Project

Objective: To examine the relation of diagnosed diabetes mellitus (DM) to the level of education and body mass index (BMI) among the elderly of seven cities using data from SABE. Methods: The SABE survey was based on a probabilistic sample of the elderly population. Results of various logistic regression models were applied to prevalence rates to adjust for age, gender, and BMI by the covariate method given the variability of these parameters. Results: The prevalence of diagnosed diabetes among the elderly was 15.7% (95% CI 14.7-16.8), with the highest prevalence reported in Bridgetown and the lowest in Buenos Aires. Discussion: There was a high prevalence of diagnosed DM among the elderly of the seven cities. The prevalence of diagnosed DM was strongly associated with BMI and low education. The inclusion of these factors in policies and programs aiming to reduce the prevalence of diabetes among the elderly is recommended.

Campanha nacional de detecção de casos suspeitos de diabetes mellitus no Brasil: relatório preliminar

Para reduzir a morbi-mortalidade associada ao diabetes, o Ministerio da Saude do Brasil esta implantando o Plano de Reorganizacao da Atencao a Hipertensao Arterial e ao Diabetes Mellitus. Como parte desse plano (composto de quatro etapas), realizou-se, em marco e abril de 2001, a campanha nacional de deteccao de casos suspeitos de diabetes, o primeiro levantamento desse tipo realizado pelos servicos publicos de saude no Brasil. Os resultados preliminares sao descritos no presente artigo. De um total de 5 507 municipios participantes, 4 446 (81%) enviaram dados ao Ministerio da Saude. Foram testados 20 milhoes de pessoas (71% da populacao-alvo), identificando-se 3,3 milhoes de suspeitos de diabetes. A campanha contribuira para a reestruturacao do atendimento sistematico e resolutivo aos portadores de diabetes no Sistema Unico de Saude. Os resultados preliminares confirmam o diabetes como um dos principais problemas de saude no Brasil. A prevencao de diabetes tipo 2 deve receber prioridade.

Risk factors associated with uncontrolled hypertension: findings from the baseline CARMEN survey in Cienfuegos, Cuba.

Objectives Identifying methods to improve pharmacologic control of elevated blood pressure remains the most urgent challenge in clinical research on hypertension. The probability of having inadequate control varies widely in the population and better understanding of the factors responsible could help to focus treatment strategies. Methods A population-based community survey of 1475 persons aged 25–74 years, in Cienfuegos, Cuba, was used to identify these factors in a low-resource setting. Results While half of women with hypertension were controlled, only one-third of men were receiving successful treatment. Gender differences were not seen, however, among those currently taking medications. The largest burden of hypertension in absolute terms was concentrated in the age range 45–64, emphasizing the heavy burden of uncontrolled high blood pressure that falls on middle-aged men. Race-ethnicity was not a determinant of treatment and control status, nor was inability to obtain medication. Conclusions These findings largely confirm the pattern observed in industrialized countries and demonstrate the near-universal challenge confronting primary-care systems in physician-based control of cardiovascular risk factors.

Una intervención para mejorar el control de la diabetes en Chile

Objetivos. Investigaciones anteriores han demostrado que el control de la glucemia mejora los desenlaces a corto y largo plazo de los pacientes con diabetes de tipo 1 y 2. El objetivo de este estudio consistio en investigar en un pais en desarrollo la eficacia de una intervencion que incluyo la educacion del paciente, la automonitorizacion de la glucemia y la determinacion de la hemoglobina glucosilada (HbA1c). Metodos. Los pacientes fueron agrupados en tres categorias, teniendo en cuenta caracteristicas clinicas tales como la duracion de la diabetes, su tratamiento y los antecedentes de hospitalizacion. Los que cumplieron los criterios de inclusion y exclusion fueron asignados aleatoriamente a un grupo que recibio la intervencion educativa (210 pacientes) o a un grupo de control que recibio la asistencia habitual (206 pacientes). El grupo de intervencion recibio la informacion educativa necesaria para la automonitorizacion de la glucemia y para la autoevaluacion de las conductas positivas y negativas relacionadas con el control metabolico de la enfermedad. Resultados. Los dos grupos eran similares con respecto a la edad (media de 52,3 y 50,5 anos) y a la proporcion de pacientes con diabetes de tipo 1 (13,8% y 16,0%). Inicialmente no habia diferencias entre las concentraciones medias de HbA1c de los dos grupos (8,9 ± 0,1 y 8,9 ± 1,4%). Cincuenta pacientes (un 14,8% del grupo de intervencion y un 9,2% del grupo de control) abandonaron el estudio de forma prematura. En el grupo de intervencion, el cumplimiento de las recomendaciones dieteticas aumento del 57,5% al principio del estudio al 82,5% al final del mismo, lo cual representa un cambio porcentual del 43,5% (P < 0,001); en el grupo de control el cambio registrado no fue significativo. Aunque los pacientes con concentraciones iniciales elevadas de HbA1c estaban subrepresentados en este estudio, la concentracion media de HbA1c disminuyo significativamente en el grupo de intervencion (-0,4 ± 1,1%; P = 0,001), pero no en el grupo de control (-0,1 ± 0,1%). Conclusiones. En un pais en desarrollo, la educacion diabetologica del paciente consiguio mejorar el control metabolico, hecho atribuible principalmente a su impacto positivo sobre la dieta.

Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon

Background: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health. Methods: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought. Results: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym “SCIENCE”: Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation. Conclusion: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.