Journal Article

Estimated Effect of Increased Diagnosis, Treatment, and Control of Diabetes and Its Associated Cardiovascular Risk Factors among Low-Income and Middle-Income Countries: A Microsimulation Model

The Lancet Global Health, Volume 9, Issue 11, Pages e1539-e1552

Background: Given the increasing prevalence of diabetes in low-income and middle-income countries (LMICs), we aimed to estimate the health and cost implications of achieving different targets for diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among LMICs.

Methods: We constructed a microsimulation model to estimate disability-adjusted life-years (DALYs) lost and health- care costs of diagnosis, treatment, and control of blood pressure, dyslipidaemia, and glycaemia among people with diabetes in LMICs. We used individual participant data—specifically from the subset of people who were defined as having any type of diabetes by WHO standards—from nationally representative, cross-sectional surveys (2006–18) spanning 15 world regions to estimate the baseline 10-year risk of atherosclerotic cardiovascular disease (defined as fatal and non-fatal myocardial infarction and stroke), heart failure (ejection fraction of <40%, with New York Heart Association class III or IV functional limitations), end-stage renal disease (defined as an estimated glomerular filtration rate <15 mL/min per 1∙73 m² or needing dialysis or transplant), retinopathy with severe vision loss (<20/200 visual acuity as measured by the Snellen chart), and neuropathy with pressure sensation loss (assessed by the Semmes-Weinstein 5∙07/10 g monofilament exam). We then used data from meta-analyses of randomised controlled trials to estimate the reduction in risk and the WHO OneHealth tool to estimate costs in reaching either 60% or 80% of diagnosis, treatment initiation, and control targets for blood pressure, dyslipidaemia, and glycaemia recommended by WHO guidelines. Costs were updated to 2020 International Dollars, and both costs and DALYs were computed over a 10-year policy planning time horizon at a 3% annual discount rate.

Findings: We obtained data from 23 678 people with diabetes from 67 countries. The median estimated 10-year risk was 10∙0% (IQR 4∙0–18∙0) for cardiovascular events, 7∙8% (5∙1–11∙8) for neuropathy with pressure sensation loss, 7∙2% (5∙6–9∙4) for end-stage renal disease, 6∙0% (4∙2–8∙6) for retinopathy with severe vision loss, and 2∙6% (1∙2–5∙3) for congestive heart failure. A target of 80% diagnosis, 80% treatment, and 80% control would be expected to reduce DALYs lost from diabetes complications from a median population-weighted loss to 1097 DALYs per 1000 population over 10 years (IQR 1051–1155), relative to a baseline of 1161 DALYs, primarily from reduced cardiovascular events (down from a median of 143 to 117 DALYs per 1000 population) due to blood pressure and statin treatment, with comparatively little effect from glycaemic control. The target of 80% diagnosis, 80% treatment, and 80% control would be expected to produce an overall incremental cost-effectiveness ratio of US$1362 per DALY averted (IQR 1304–1409), with the majority of decreased costs from reduced cardiovascular event management, counterbalanced by increased costs for blood pressure and statin treatment, producing an overall incremental cost- effectiveness ratio of $1362 per DALY averted (IQR 1304–1409).

Interpretation: Reducing complications from diabetes in LMICs is likely to require a focus on scaling up blood pressure and statin medication treatment initiation and blood pressure medication titration rather than focusing on increasing screening to increase diabetes diagnosis, or a glycaemic treatment and control among people with diabetes.


Sanjay Basu
David Flood
Pascal Geldsetzer
Michaela Theilmann
Maja E Marcus
Cara Ebert
Mary Mayige
Roy Wong-McClure
Farshad Farzadfar
Kokou Agoudav
Bolormaa Norov
Corine Houehanou
Glennis Andall-Brereton
Mongal Gurung
Garry Brian
Pascal Bovet
Joao Martins
Rifat Atun
Till W Bärnighausen
Sebastian Vollmer
Jennifer Manne-Goehler
Justine I Davies


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