Diabetes mellitus and tuberculosis in countries with high tuberculosis burdens: individual risks and social determinants.
BACKGROUND
A growing body of evidence supports the role of type 2 diabetes as an individual-level risk factor for tuberculosis (TB), though evidence from developing countries with the highest TB burdens is lacking. In developing countries, TB is most common among the poor, in whom diabetes may be less common. We assessed the relationship between individual-level risk, social determinants and population health in these settings.


METHODS
We performed individual-level analyses using the World Health Survey (n = 124,607; 46 countries). We estimated the relationship between TB and diabetes, adjusting for gender, age, body mass index, education, housing quality, crowding and health insurance. We also performed a longitudinal country-level analysis using data on per-capita gross domestic product and TB prevalence and incidence and diabetes prevalence for 1990-95 and 2003-04 (163 countries) to estimate the relationship between increasing diabetes prevalence and TB, identifying countries at risk for disease interactions.


RESULTS
In lower income countries, individuals with diabetes are more likely than non-diabetics to have TB [univariable odds ratio (OR): 2.39; 95% confidence interval (CI): 1.84-3.10; multivariable OR: 1.81; 95% CI: 1.37-2.39]. Increases in TB prevalence and incidence over time were more likely to occur when diabetes prevalence also increased (OR: 4.7; 95% CI: 1.0-22.5; OR: 8.6; 95% CI: 1.9-40.4). Large populations, prevalent TB and projected increases in diabetes make countries like India, Peru and the Russia Federation areas of particular concern.


CONCLUSIONS
Given the association between diabetes and TB and projected increases in diabetes worldwide, multi-disease health policies should be considered.
Department of Medicine, Stanford Health Policy, CHP/PCOR, Stanford University School of Medicine, Stanford, CA, USA. jeremygf@stanford.edu
Jeremy D
JD
Goldhaber-Fiebert
Christie Y
CY
Jeon
Ted
T
Cohen
Megan B
MB
Murray
D000328:Adult; D003906:Developing Countries; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors; D012959:Socioeconomic Factors; D014376:Tuberculosis / Q000150:complications / Q000453:epidemiology*
J Am Optom Assoc. 1998 Nov;69(11):695-8
9844321
Diabetes Care. 2004 May;27(5):1047-53
15111519
J Clin Epidemiol. 2004 Oct;57(10):1096-103
15528061
Trans R Soc Trop Med Hyg. 2009 Jan;103(1):1-2
18809194
Public Health. 2000 Mar;114(2):137-42
10800154
Int J Tuberc Lung Dis. 2006 Nov;10(11):1185-7
17131774
Chest. 1996 Feb;109(2):420-3
8620716
Chest. 2006 Jan;129(1 Suppl):197S-201S
16428710
Milbank Mem Fund Q. 1971 Oct;49(4):509-38
5155251
J Clin Epidemiol. 2003 Feb;56(2):148-54
12654409
Soc Sci Med. 2009 Jun;68(12):2240-6
19394122
AIDS. 2009 Jun 19;23(10):1227-34
19444074
J Assoc Physicians India. 1973 Oct;21(10):875-81
4793277
Chronic Illn. 2007 Sep;3(3):228-45
18083679
AIDS. 2007 Aug 20;21(13):1739-45
17690572
Clin Infect Dis. 2005 Aug 1;41(3):281-8
16007521
J Infect. 2005 May;50(4):331-7
15845431
Med Care. 1997 Sep;35(9):932-47
9298082
BMC Public Health. 2007 Sep 06;7:234
17822539
Tubercle. 1990 Jun;71(2):135-8
2219464
Lancet. 2007 Sep 8;370(9590):851-8
17826170
J Acquir Immune Defic Syndr. 2007 May 1;45(1):66-71
17245229
J Infect Dis. 2007 Aug 15;196 Suppl 1:S86-107
17624830
PLoS Med. 2008 Jul 15;5(7):e152
18630984
Recenti Prog Med. 2000 Feb;91(2):78-85
10748653
Stat Med. 2005 Jun 15;24(11):1657-82
15736283
Eur J Public Health. 2007 Apr;17(2):199-205
16887835
PLoS One. 2009;4(5):e5602
19440346
J Clin Epidemiol. 2007 Dec;60(12):1271-9
17998082
Arch Intern Med. 2003 May 12;163(9):1009-21
12742798
Lancet. 1999 Jun 19;353(9170):2093-9
10382692
Bull World Health Organ. 2009 Sep;87(9):683-91
19784448
N Engl J Med. 1999 Dec 16;341(25):1906-12
10601511
Popul Health Metr. 2009 Sep 25;7:16
19781056
Diabetes Care. 1998 Sep;21(9):1414-31
9727886