Prevalence of diabetes among Indigenous women in Guatemala: A retrospective chart review study of 13 643 patients between 2015-2022

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Prevalence of diabetes among Indigenous women in Guatemala: A retrospective chart review study of 13 643 patients between 2015-2022 Stephen Alajajian , Jenny Bartolimin , Yolanda Juarez Martin , Caitlin Scott , Peter Rohloff , David Flood doi: https://doi.org/10.1101/2024.01.08.24300932 Stephen Alajajian a Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, 2da Avenida 3-48 Zona 3 Barrio Patacabaj , Tecpán, Chimaltenango, Guatemala Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: stephenalajajian{at}gmail.com Jenny Bartolimin a Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, 2da Avenida 3-48 Zona 3 Barrio Patacabaj , Tecpán, Chimaltenango, Guatemala Find this author on Google Scholar Find this author on PubMed Search for this author on this site Yolanda Juarez Martin a Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, 2da Avenida 3-48 Zona 3 Barrio Patacabaj , Tecpán, Chimaltenango, Guatemala Find this author on Google Scholar Find this author on PubMed Search for this author on this site Caitlin Scott b Friendship Bridge , 405 Urban St. Ste. 140, Lakewood, Colorado, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Peter Rohloff a Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, 2da Avenida 3-48 Zona 3 Barrio Patacabaj , Tecpán, Chimaltenango, Guatemala c Division of Global Health Equity, Brigham and Women’s Hospital , 75 Francis St, Boston, MA, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site David Flood a Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, 2da Avenida 3-48 Zona 3 Barrio Patacabaj , Tecpán, Chimaltenango, Guatemala d Department of Internal Medicine, University of Michigan , 500 S State St, Ann Arbor, MI, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT There are limited data on diabetes among Indigenous populations in Guatemala. In a retrospective chart review of a clinical program serving more than 13 000 primarily Indigenous women in Guatemala, age-adjusted diabetes prevalence was 7.9% (95% CI: 7.3 to 8.5), and 37.9% (95% CI: 35.1 to 40.8%) of women were undiagnosed. INTRODUCTION Guatemala is a middle-income, Central America nation in which nearly half of the population are Indigenous. 1 Modeling studies suggest that the diabetes burden is rising rapidly in Guatemala. 2 , 3 However, like other Latin American countries with large numbers of Indigenous people, in Guatemala there is limited data on the epidemiology of diabetes in this marginalized population. The objective of this study is to investigate the prevalence of diabetes in a clinical sample of primarily Indigenous women in Guatemala. METHODS We conducted a retrospective chart review using data from a non-governmental, community-based primary care program serving adult women in nine Central and Western departments in Guatemala. Program details previously have been described. 4 , 5 Upon enrollment in the program, patients were queried if they had a history of diabetes and, if not, were screened for diabetes using random or fasting glucose capillary measurements. For this analysis, we extracted electronic health record and administrative data between July 1, 2015, and December 31, 2022. We defined diabetes by (1) self-reported prior history, (2) current use of a glucose-lowering medication, or (3) an elevated blood glucose (fasting ≥126 mg/dl or random ≥200 md/dl) using the last available recorded glucose value. We calculated diabetes prevalence in the overall sample and by patient characteristics including body mass index (BMI) categories, ethnicity, language, residence, and economic status. We age-standardized estimates to the World Health Organization (WHO) reference population. 6 Economic status was assessed using the Poverty Probability Index, which uses asset ownership to predict the probability that a household was below the national poverty line. 7 Absolute differences and relative differences (as risk ratios) in diabetes prevalence were computed within levels of each characteristic. We used multiple imputation with chained equations to impute missing data on patient characteristics (50 iterations). Results were reported with logit-transformed 95% confidence intervals. 8 We used Stata version 17. Ethics approval was obtained from the Wuqu’ Kawoq Institutional Review Board (WK-2022-004). RESULTS The final analytic sample was 13,643 patients after excluding those with no glucose data recorded (n=387) and without a legitimate medical record number (n=3). Among the sample, the last available glucose was fasting glucose for 2,172 women (16.0%) and was random glucose for 11,471 women (84.1%). The median age was 36 years (interquartile range [IQR]: 28-47). The median BMI was 27.3 kg/m 2 (IQR: 24.1-30.9); 38.7% of the sample were overweight, and 30.2% were obese. The sample was predominantly Indigenous (90.3%) and lived in rural areas (85.1%). Overall, 44.4% of the sample were living in poverty. Missingness was high for area of residence (43.9%) and economic status (42.3%). Across the overall sample, there were 1,126 women with diabetes. The crude diabetes prevalence was 8.3% (95% Confidence Interval [CI]: 7.8 to 8.7), and the age-adjusted diabetes prevalence was 7.9% (95% CI: 7.3 to 8.5). Among those with diabetes, 62.1% (95% CI: 59.2 to 64.5%) of women self-reported a prior diagnosis and 37.9% (95% CI: 35.1 to 40.8%) of women were newly diagnosed. By patient characteristics, diabetes prevalence rose sharply with increasing age, reaching nearly 20% in women who were 50 years of age or older. Compared to the reference of normal BMI, women who were obese had an age-standardized diabetes prevalence that was 3.2% (95% CI: 1.1 to 5.2) greater in absolute magnitude and approximately 40% greater in relative magnitude (risk ratio: 1.4 [95% CI: 1.1 to 1.8). Age-standardized diabetes was higher among non-Indigenous versus Indigenous women and among Spanish versus Mayan language speakers. Compared to those most likely to be in poverty, women least likely to be in poverty had an age-standardized diabetes prevalence that was 6.0% (95% CI: 3.7 to 8.3) greater in absolute magnitude and 100% greater in relative magnitude (risk ratio: 2.0 [95% CI: 1.5 to 2.6). DISCUSSION In a retrospective chart review of a clinical program serving more than 13 000 primarily Indigenous women in Guatemala, we found that the diabetes prevalence was approximately 8% and that approximately 38% of people with diabetes were undiagnosed. Across patient characteristics, women who were obese had a 40% higher risk and women in the highest economic quartile had nearly a 2-fold higher risk of having diabetes. At the same time, diabetes prevalence was sizeable even among women who were Indigenous (8.4%), lived in rural areas (8.1%), or were in the lowest economic quartile (5.9%). To our knowledge, this study leverages the largest programmatic or survey dataset of primarily Indigenous people with diabetes in Guatemala. A few prior household surveys conducted in select predominantly Indigenous areas have reported diabetes prevalence ranging from 3.0% to 13.5%. 9 - 11 Differences in these survey estimates may be explained by variations in diabetes definition, time period of assessment, or differences in the underlying population. A national survey conducted from 2018 to 2019 among approximately 2,500 reproductive aged women aged 15-49 years reported diabetes prevalence of approximately 6%. 12 Unfortunately, to date, there is no other Guatemalan national health survey—such as a WHO STEPS survey—that includes diabetes assessments. The strength of the current study is our large sample size and use of repeat testing to confirm diabetes among newly diagnosed women with elevated random glucose. The large number of women in our sample gives us added power to investigate differences in diabetes prevalence across meaningful subgroups of the population. The main limitation of the study is that our sample of patients is restricted to women and was not drawn from a representative sampling frame. At the same time, our clinical sample is quite similar in population age structure, language preference, and economic status as the overall Indigenous population of women in these geographic areas of Guatemala. 13 In conclusion, we report diabetes prevalence of diabetes approximately 8% in a large clinical sample of Indigenous women living in Guatemala. Our data reinforce the need to strengthen the rural health system in Guatemala to deliver high-quality care not only for maternal and child health conditions but also non-communicable diseases such as diabetes. View this table: View inline View popup Download powerpoint Table 1. Demographic characteristics of a cohort of 13 643 primarily Indigenous women in Guatemala Download figure Open in new tab Figure 1. Prevalence of diabetes among a cohort of 13 643 primarily Indigenous women in Guatemala, overall and by demographic characteristic [Figure not embedded, see separate file entitled “ Figure 1 .jpg”] For economic status quartiles, the probabilities of poverty were as follows: quartile 1, ≥78.2%; quartile 2, ≥46.6% to <78.1%; quartile 3, ≥15.6% to <46.5%; quartile 4, <15.6%. Declaration of Competing Interest We declare no competing interests. Funding DF was supported by the U.S. National Institutes of Health (NIH) under Award Number K23HL161271. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Author contributions PR and DF conceptualized the study with input from SA. PR extracted data from relevant sources. SA and PR cleaned the data and sorted variables. SA ran statistical analyses with oversight from DF and PR. SA and DF created tables and figures and drafted the manuscript. JB, YJM and CS collected the data, reviewed the work and provided feedback. All authors reviewed the results and approved the final article. Data availability statement The datasets generated during and/or analyzed during the current study are not publicly available as they are proprietary data of the collaborating microfinance institution but may be made available from the corresponding author with permission from the institution upon reasonable request. Statistical code is available at the Harvard Dataverse ( https://doi.org/10.7910/DVN/GA8JEA ). REFERENCES 1. ↵ Instituto Nacional de Estadística Guatemala . Resultados del XII Censo Nacional de Población y VII de Vivienda: Principales Resultados Censo 2018 . 2019 . https://www.censopoblacion.gt/archivos/Principales_resultados_Censo2018.pdf . Accessed 29 May 2023 . 2. ↵ Ong KL , Stafford LK , McLaughlin SA , Boyko EJ , Vollset SE , Smith AE et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021 . Lancet . 2023 ; doi: 10.1016/S0140-6736(23)01301-6 . OpenUrl CrossRef PubMed 3. ↵ International Diabetes Federation . IDF Diabetes Atlas, 10th edn. Brussels, Belgium : 2021 . https://www.diabetesatlas.org . Accessed 9 Nov 2023 . 4. ↵ Garcia Garcia A , Juarez M , Sacuj N , et al. Loss to Follow-Up and the Care Cascade for Cervical Cancer Care in Rural Guatemala: A Cross-Sectional Study . JCO Glob Oncol . 2022 ; doi: 10.1200/GO.21.00286 . OpenUrl CrossRef 5. ↵ Colom M , Austad K , Sacuj N , Larson K , Rohloff P. Expanding access to primary healthcare for women through a microfinance institution: A case study from rural Guatemala . Healthc (Amst) . 2018 ; doi: 10.1016/j.hjdsi.2017.12.003 . OpenUrl CrossRef 6. ↵ Ahmad OB , Boschi-Pinto C , Lopez AD , Murray CJ , Lozano R , Inoue M. Age Standardization of Rates: A New WHO standard . Geneva : World Health Organization . 2001 . https://cdn.who.int/media/docs/default-source/gho-documents/global-health-estimates/gpe_discussion_paper_series_paper31_2001_age_standardization_rates.pdf . Accessed 1 Jan 2024 . 7. ↵ Innovations for Poverty Action (IPA ). Poverty Probability Index: Guatemala . 2023 . https://www.povertyindex.org/country/guatemala . Accessed 16 July 2023 . 8. ↵ Brown LD , Cai TT , DasGupta A. Interval Estimation for a Binomial Proportion . Statist Sci . 2001 ; doi: 10.1214/ss/1009213286 . OpenUrl CrossRef Web of Science 9. ↵ Chen Chen D , Rivera-Andrade Á , González J , et al. Prevalence of risk factors for noncommunicable diseases in an indigenous community in Santiago Atitlán, Guatemala . Rev Panam Salud Publica . 2017 ; doi: 10.26633/RPSP.2017.7 . OpenUrl CrossRef 10. Steinbrook E , Flood D , Barnoya J , Montano CM , Miller AC , Rohloff P. Prevalence of Hypertension, Diabetes, and Other Cardiovascular Disease Risk Factors in Two Indigenous Municipalities in Rural Guatemala: A Population-Representative Survey . Glob Heart . 2022 ; doi: 10.5334/gh.1171 . OpenUrl CrossRef 11. ↵ Bream KDW , Breyre A , Garcia K , Calgua E , Chuc JM , Taylor L. Diabetes prevalence in rural Indigenous Guatemala: A geographic-randomized cross-sectional analysis of risk . PLoS One . 2018 ; doi: 10.1371/journal.pone.0200434 . OpenUrl CrossRef PubMed 12. ↵ Instituto de Nutrición de Centro América y Panamá (INCAP ). Informe del Sistema de Vigilancia Epidemiológica de Salud y Nutrición (SIVESNU) agosto 2018 – abril 2019: Módulo 1: Introducción y datos del hogar . 2020 . https://portal.siinsan.gob.gt/wp-content/uploads/SIVESNU-2018-MODULO-1-PARA-SESAN-2020-1.pdf . Accessed 9 Nov 2023 . 13. ↵ Instituto Nacional de Estadística Guatemala . Resultados Censo 2018 . 2019 . https://www.ine.gob.gt/sistema/uploads/2021/11/19/202111192139096rGNQ5SfAlepmPGfYTovW9MF6X2turyT.pdf . Accessed 9 Nov 2023 . View the discussion thread. Back to top Previous Next Posted January 09, 2024. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Prevalence of diabetes among Indigenous women in Guatemala: A retrospective chart review study of 13 643 patients between 2015-2022 Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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