The body mass index as a risk factor for diabetes varies worldwide

BOSTON – The unprecedented increases in overweight and obesity in low and middle income countries (LMICs) has led to an alarming rise in diabetes in these regions. Of the estimated 463 million people with diabetes worldwide, 79% live in LMICs.

However, to date there has been little empirical data to help clinicians and healthcare systems determine which people should be screened for diabetes based on body mass index (BMI). “There are World Health Organization guidelines that recommend screening people 40 years of age and older with a BMI of 25 kg / m2 and above for diabetes,” said Jennifer Manne-Goehler, MD, ScD, faculty member of the Medical Practice Evaluation Center at Massachusetts General Hospital (MGH). “But it has long been suggested that these BMI and age limits may not be optimal for diabetes screening in all regions of the world. Our aim was to assess the relationship between BMI and diabetes risk in many low- and middle-income countries in order to to support the resource. ” Health systems are developing the most effective screening programs for their populations, “says Manne-Goehler, lead author of a new study published in The Lancet.

Manne-Goehler and researchers from 57 countries spent five years compiling and using existing datasets of more than 680,000 people in LMICs that included each person’s weight, height, and a diabetes biomarker – either a blood glucose test or hemoglobin A1c.

The study, the first of its kind, found significant regional differences in the relationship between BMI and diabetes risk. Across all LMICs, people with a BMI of 23 kg / m2 or more had an increased risk of diabetes. However, the optimal BMI for diabetes screening varied depending on the region and gender, from 23.8 kg / m2 for men in East / Southeast Asia to 28.3 kg / m2 for women in the Middle East, North Africa and Latin America and the Caribbean. The researchers also found differences in diabetes risk between BMI categories in several regions. For example, men and women in sub-Saharan Africa and in East / Southeast Asia had a more than 100% increased risk of diabetes between being overweight and obese. These results partially reinforced a growing literature from Asian and South Asian countries recommending the use of lower BMI limits to better characterize metabolic risk in these populations.

And while diabetes increased in middle age and beyond, the proportion of diabetics increased sharply in all regions in the 35-44 age group and among 25-34 year old men in sub-Saharan Africa. “Diagnosing diabetes in younger adults can prevent long-term complications of the disease,” says Manne-Göhler.

“While the data are not authoritative, we hope that policy makers at LMICs will find this evidence useful in trying to decide how they will spend limited resources optimizing diabetes screening for their respective populations,” she adds added.

The research also shows the power of collaboration between countries to create vital evidence for public health guidelines. “It is difficult to draw meaningful global conclusions at a high level when individual countries examine the risk of diabetes in just one survey in one country,” says Manne-Göhler. The World Health Organization is creating a global strategy called the Global Diabetes Compact, for example to improve care for people with diabetes. “We believe that our collaboration with many researchers in these 57 countries can help educate best practices for diabetes screening around the world,” she says.

“LMICs now have evidence-based specific answers to the question ‘Who? When? and how much?’ in relation to diabetes prevention and screening for BMI, “writes Siméon Pierre Choukem, MD, dean of the Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Cameroon, in a related comment in The Lancet.” These results have significant implications public health as the actual diabetes burden in LMICs is likely to be underestimated based on current screening guidelines and to what extent it is unclear. ”

The global research team is now investigating how waist circumference could increase the accuracy of diabetes risk assessment linked to BMI, and is also examining the relationship between behavioral factors – alcohol, smoking, physical activity and diet – and diabetes risk in these 57 countries. In the future, researchers also hope to build collaborations that include surveys from high-income countries to enable direct comparisons across a wider range of global health settings. “The health systems in every country in the world must use their resources optimally in order to improve the health of their population,” says Manne-Göhler.


Manne-Göhler is the attending physician in the Infectious Disease Department at Brigham and Women’s Hospital. First author Felix Teufel is a medical student and research assistant at the Heidelberg Institute of Global Health, Heidelberg University Hospital, Germany. Co-author Jacqueline Seiglie, MD, MSc, is an Endocrinologist and Global Health Fellow at MGH and Lecturer in Medicine at Harvard Medical School (HMS). The other MGH co-authors are James Meigs, MD, MPH, co-director of the Clinical Effectiveness Research Group of the MGH Clinical Research Program and Professor of Medicine at HMS, and Deborah Wexler, MD, MSc, Associate Clinical Director of MGH Diabetes Unit, clinical director of the MGH Diabetes Center and associate professor of medicine at HMS.

Via the Massachusetts General Hospital

Founded in 1811, Massachusetts General Hospital is the original and largest teaching hospital for Harvard Medical School. The Mass General Research Institute runs the largest hospital-based research program in the country, with more than $ 1 billion in annual research and more than 9,500 researchers working in more than 30 institutes, centers, and departments. In August 2020, Mass General was named # 6 on America’s Best Hospitals list by US News & World Report.

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