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Diabetes in the tropics: prevalent, increasing and a major public health problem.

Diabetes mellitus is no longer confined to the developed nations of the temperate zone, but has attained epidemic proportions in the developing nations of the tropics as well. The latter group of nations’ unique challenges include low rates of disease detection and limited access to preventive and therapeutic measures. Lessons learned from the experiences of the developed world need to be appropriately adapted and applied to these populations in order to prevent the spread of the diabetes epidemic in a cost-effective manner in developing countries of the world where 80% of all people with diabetes currently live. Tropical regions of the world, comprising large parts of Asia and most of Africa and Latin America, harbor a larger population with diabetes mellitus than any other region of the world. 1 Even so, diabetes is not often considered when enumerating the major ‘tropical’ diseases. The chronic and insidious nature of the disease, and the misplaced (yet widespread) belief that the disease is a preserve of the prosperous temperate zone, underlie this misconception. In 1967, Dodu 2 assumed diabetes prevalence rates of 0.1 to 2% among the general adult population in most tropical countries, at a time when the rates in developed nations were nearly thrice as high. A glance at the latest statistics released by the International Diabetes Federation 1 will reveal that the prevalence rates in the tropics now rival or even surpass those of the developed western nations in the temperate regions. The Indian subcontinent, China and the Pacific Islands have been hardest hit by the epidemic of diabetes. China has more than 100 million people with diabetes and India nearly 70 million. Out of the ten countries harboring the most people with diabetes, six are in the tropics; of the ten countries with the highest prevalence of diabetes in the world, seven are Pacific Island nations and the remaining three are located in the Middle East. All in all, more than 75% of the world’s population with diabetes resides in low- and middle-income nations, almost exclusively located in the tropics and sub-tropics. It has long been recognized that there are considerable differences between diabetes in the tropics and diabetes in the rest of the world. Indeed, a workshop was conducted in 1995 to stimulate further research into types of diabetes specific to tropical regions of the world. 3 At this workshop, special emphasis was made to diabetes associated with malnutrition (malnutrition modulated diabetes mellitus) and diabetes secondary to tropical pancreatitis (fibrocalculous pancreatic diabetes). Less attention was paid to type 2 diabetes (then termed non-insulin dependent diabetes mellitus) occurring in the tropics, but it is this type of diabetes that is the most common in these regions today as is the case in the rest of the world. Much of the research on ‘tropical’ type 2 diabetes has been carried out in India. Type 2 diabetes in Asian Indians, be they resident in India or part of the widespread diaspora in the US, Europe, Middle East, South Africa or the Caribbean, presents certain distinctive features, 4 such as development of the disease at younger ages and at lower levels of obesity compared to white Caucasians. The prevalence of undiagnosed diabetes is also high, with nearly three out of four individuals in certain parts of rural India with diabetes being unaware of their condition. 5 Development of diabetes at younger ages implies that many of these individuals will suffer morbidity due to diabetes complications during the prime of their productive lives, which can have serious societal and economic consequences. Developing countries face additional problems in their efforts against diabetes, including poor levels of awareness of disease among the population, 6 unavailability of modern diagnostic and therapeutic modalities and trained healthcare personnel, and consequent poor control of diabetes. 7