Health Surveillance and Disease Management / Noncommunicable Diseases
Survey of Diabetes, Hypertension and Chronic Disease Risk Factors: Villa Nueva, Guatemala 2007
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References (from the Introduction and the Discussion to the right)
1. Ministerio de Salud Pública y Asistencia Social. Boletín Epidemiológico Nacional No. 20. Guatemala. marzo de 2003.
Most developing countries of Latin America are in a stage of epidemiologic transition, which is the transition from infectious to chronic diseases as major sources of morbidity and mortality. These countries are also experiencing demographic transition, a shift from a pattern of high fertility and high mortality to one of low fertility and low mortality, and a nutritional transition, a shift from traditional dietary patterns to one high in saturated fat, sugar and refined foods and low in fiber. Changes in lifestyle are associated with urbanization, or the mass migration from the rural areas to the urban areas, the phenomena of globalization, and exchanges between cultures, among others. These changes are occurring rapidly in countries like Guatemala, consequently, protein-calorie malnutrition is observed most frequently in conjunction with obesity, hypertension, diabetes mellitus, and hypercholesterolemia.
The health situation in Guatemala is evolving from one in which the epidemiologic profile is characterized by the predominance of infectious diseases and disorders due to nutritional deficiencies to one in which chronic noncommunicable diseases (NCD) are prevalent. For example, between 1986 and 1999, the mortality due to communicable and perinatal diseases declined from 40% to 27% (1), while mortality from NCD increased. In 1969, mortality from cardiovascular diseases (CVD) in men was 65.9 per 100 000 inhabitants and in 1986 it increased to 80 per 100 000 inhabitants; in women, CVD mortality also increased, from 66.2 per 100 000 inhabitants in 1969 to 73.5 per 100 000 inhabitants in 1986. More recently, in the period between 1986 and 1999, the proportion of deaths due to CVD increased from 7% to 13%.
According to data compiled by the National Institute of Statistics of Guatemala for 2000, the department of Zacapa, in the east of the country, is the department with the highest mortality attributed to NCD (2). In this department, NCD mortality was approximately 60%, including 38% of deaths due to CVD and 22% to diabetes. The department of Guatemala had a NCD mortality of 39%, with 23% of mortality due to CVD and 16% to diabetes. Jutiapa, another department in eastern Guatemala, also had a high relative mortality due to NCD (32%) and the second highest mortality due to CVD in the country (26%). In departments such as Alta Verapaz and Sololá, the mortality attributed to NCD was only 10%.
It is estimated that in coming years the burden of mortality due to NCDs will continue to increase in Guatemala. Increased life expectancy, which has already reached 64.7 years in men and 69.8 years in women, will contribute to this. Furthermore, the process of urban development and changes in lifestyle and the profile of risk factors that many communities of Guatemala are experiencing will also tend to increase the NCD load in this country.
Guatemala and neighboring countries in Central America can be considered to be in the initial stage of the epidemiologic transition that developing countries are experiencing throughout the world. Unfortunately, available information is limited. Two sources of information that preceded this study, however, support this argument. The first refers to changes in the causes of general mortality. According to unpublished data of the National Institute of Statistics and the Ministry of Health of Guatemala, the percentage of deaths due to acute myocardial infarction reported in 1964 was 0.1% of all deaths, whereas it was 1.7% in 1984 and 4.2% in 2001; in 2001 myocardial infarction had reached fourth place among the leading specific causes of general mortality. Furthermore, mortality due to infectious diseases has only recently begun to decline.
The ratio between mortality due to communicable/noncommunicable causes in Central America rose from 1.0 to 3.1 between the periods of 1980–1985 and 1990–1995 (3). However, not only do mortality figures refer to the outcome of a series of health disorders, but there are also problems of ill-defined diagnoses, underreporting, and incomplete information, all of which complicate interpretation.
Overweight in the adult population is the only NCD risk factor that has been measured at the national level in Guatemala (4, 5). The National Survey of Demography and Health of 1995 showed that 34% of women 15 to 49 years of age were overweight. In 2000, the National Survey on Living Conditions revealed a prevalence of overweight of 48% in adult women, while it was 34% in men. Other studies conducted in the last 10 years in specific population groups supported these results, showing that the incidence of overweight in young women (19 to 30 years of age) was similar among those who lived in rural areas and those who migrated to Guatemala City (28% and 30%, respectively) (6). The prevalence among rural and urban young men was 7% and 16%, respectively. Ramírez-Zea and Torún also reported that in a group of low-income salaried workers, 25% of men and 45% of women were overweight (7). Finally, another study in middle-class urban workers found that the prevalence of overweight was 26% in women and 42% in men (8).
Obesity, as well as physical inactivity and diet, are considered major factors in the etiology of diabetes mellitus and hypertension. Obesity can contribute significantly to heart disease and resulting disabilities. In Guatemala, there is little information about the influence of changes in lifestyle, such as the reduction of physical activity and inadequate diet, on the prevalence of chronic noncommunicable diseases such as diabetes and hypertension. For this reason, the present study examined the effects of epidemiologic transition on the health profile of a municipality in the department of Guatemala, near the capital city.
The present report is the first epidemiologic study on the prevalence of diabetes mellitus and hypertension to be carried out in Guatemala with a representative sample of a geographic area of the country. The general prevalence of diabetes mellitus (8.4%) and hypertension (13%) that we found mean that among the inhabitants over 19 years of age in the town of Villa Nueva there are about 7,000 people with diabetes and 13,000 people with hypertension, half of which are undiagnosed.
The prevalence of diabetes in Villa Nueva was comparable to the prevalence reported in the United States in 2000 (8.1%) (13) and Mexico City in 2000 (8.4%) (14), and higher than the prevalence reported in four Bolivian cities in 1998 (15). Most of the studies in cities of South America (16, 17, 18) have reported prevalences lower than that reported here (8.4%). The proportion of cases of diabetes diagnosed in Villa Nueva (4.3%) was lower than reported in the United States (5%) in 2000 and Bolivia (5.2%) in 1998.
Diabetes and hypertension occurred most frequently in people over 39 years of age, particularly women. These results correspond with the greater prevalence of risk factors found in these population groups, such as overweight, large waist circumference, sedentary life style, and hypercholesterolemia.
With respect to the criteria for defining diabetes mellitus, this study used the blood glucose results obtained in both fasting and two hours after a 75-g load of glucose, according to the criteria established by the ADA (19).
In the United States, a prevalence of hypertension similar to the prevalence reported in Villa Nueva (14.9%) has been reported (20). Cuba has recently reported hypertension prevalences of 22.4% and 24.2% in men and women of African origin, respectively. This figure is much higher than the prevalence reported in Villa Nueva (20).
The higher prevalence of diabetes mellitus and hypertension in people with a lower level of schooling, and probably lower socioeconomic level, supports the results found in studies conducted in other countries, such as Bolivia (21) and Brazil (22). This phenomenon may be related to a reduced availability and access to information, education, and health services. For this reason, these diseases should now be considered a public health problem that affects poorer sectors and requires immediate action to prevent and control the epidemic that is expected to appear in the next 10 to 15 years.
A large proportion of the people who had diabetes and hypertension showed abnormal blood glucose and blood pressure levels. It has been demonstrated that the appearance of certain chronic complications of diabetes and mortality can be prevented by better metabolic control in people with type 1 diabetes (23) and type 2 diabetes (23).
In conclusion, the prevalence of diabetes mellitus found in the town of Villa Nueva is higher than the prevalence reported in most countries of Latin America; the prevalence of hypertension reported here is comparable to that reported in most Latin American studies. It is particularly important that, despite having a younger population, Villa Nueva had a prevalence of diabetes similar to the prevalence in the United States. This means that in the future there will be an important increase in the prevalence of diabetes as the population ages, unless preventive strategies are introduced. The data presented indicate that diabetes affects people with a lower educational level, which suggests that the poorest people bear the greatest burden.