key: cord-276256-gmlsoo2z
authors: Avilés-Santa, M. Larissa; Monroig-Rivera, Alberto; Soto-Soto, Alvin; Lindberg, Nangel M.
title: Current State of Diabetes Mellitus Prevalence, Awareness, Treatment, and Control in Latin America: Challenges and Innovative Solutions to Improve Health Outcomes Across the Continent
date: 2020-10-10
journal: Curr Diab Rep
DOI: 10.1007/s11892-020-01341-9
sha:
doc_id: 276256
cord_uid: gmlsoo2z
PURPOSE OF REVIEW: Latin America is the scenario of great inequalities where about 32 million human beings live with diabetes. Through this review, we aimed at describing the current state of the prevalence, awareness, treatment, and control of diabetes mellitus and completion of selected guidelines of care across Latin America and identify opportunities to advance research that promotes better health outcomes. RECENT FINDINGS: The prevalence of diabetes mellitus has been consistently increasing across the region, with some variation: higher prevalence in Mexico, Haiti, and Puerto Rico and lower in Colombia, Ecuador, Dominican Republic, Peru, and Uruguay. Prevalence assessment methods vary, and potentially underestimating the real number of persons with diabetes. Diabetes unawareness varies widely, with up to 50% of persons with diabetes who do not know they may have the disease. Glycemic, blood pressure, and LDL-C control and completion of guidelines to prevent microvascular complications are not consistently assessed across studies, and the achievement of control goals is suboptimal. On the other hand, multiple interventions, point-of-care/rapid assessment tools, and alternative models of health care delivery have been proposed and tested throughout Latin America. SUMMARY: The prevalence of diabetes mellitus continues to rise across Latin America, and the number of those with the disease may be underestimated. However, some local governments are embedding more comprehensive diabetes assessments in their local national surveys. Clinicians and public health advocates in the region have proposed and initiated various multi-level interventions to address this enormous challenge in the region.
Within the last couple of decades, non-communicable diseases (NCDs) have gained worldwide attention, especially in low-and middle-income countries (LMIC), where they have been increasingly recognized and prevalent [1, 2] . Among the NCDs, diabetes mellitus has become a global health challenge [1, 3, 4] . Type 2 diabetes mellitus-the most common form of diabetes-due to its rather silent disruption may be a current uninvited companion to over 465 million persons worldwide. In 2019, it was estimated that the number of persons with diabetes in Latin America (LatAm) was 31.6 million [5, 6] and is predicted that by 2030, the number will increase to 40.2 million, and to 49.1 million by 2045 [6] .
Because of its multi-organ and multi-system impact, diabetes has been associated with both acute and long-term complications that affect not only health care needs and costs but also wellbeing and productivity [7, 8] . Within the last decade, it has also been recognized as one of the leading causes of death in some LatAm countries [9] [10] [11] [12] [13] [14] [15] and an important risk factor This article is part of the Topical Collection on Diabetes Epidemiology for cardiovascular diseases (CVD), which is the leading cause of death in LatAm [14, 16] .
Far from being a monolithic group, the LatAm population is highly heterogeneous, with various populations reflecting diverse genetic ancestry, ethnicity, culture of origin, sociopolitical contexts, environmental exposures, and beliefs and practices [17, 18] . Levels of inequality in LatAm remain among the highest in the world [19] [20] [21] [22] . All these factorscoupled with biological susceptibility, income, education, access health care, cultural influences on nutrition, health, selfimage, and self-care-influence the development of diabetes in LatAm.
We conducted a review of the most current publications on the state of prevalence, awareness, treatment, and control of diabetes mellitus across LatAm. By laying out a detailed accounting of what is known, we aim to identify population, clinical, and health care needs, and opportunities for future research studies and potential interventions.
We conducted the search using the PubMed electronic database as the primary scientific literature source. LatAm was defined as the countries in the Western hemisphere which were previously colonized by Spain, Portugal, or France. A combination of keywords was used to define the scope of the searches: diabetes prevalence, awareness, treatment, control, guidelines of care, adherence, retinopathy, nephropathy, neuropathy, foot care, fundoscopic exam, and urine albumin, and searched under LatAm and by each individual country. Hispanics/Latinos living in the USA were not included in the search.
We limited the search to publications since 2000 to reflect the most recent research on the prevalence of diabetes across LatAm countries, assessments of awareness, treatment, and control of diabetes (glycemic control), blood pressure and low-density lipoprotein cholesterol (LDL-C), and adherence to guidelines for care recommended by the American Diabetes Association (ADA) [23] [24] [25] and the Latin American Diabetes Association (ALAD) [26] , and specifically hemoglobin A1c (HbA1c) measurement, fundoscopic exam, foot exam, and urine albumin excretion test. We included literature written in English, Spanish, French, and Portuguese.
In addition to PubMed, when available, we manually searched each country's Ministry of Health and the Pan American Health Organization (PAHO) websites and accessed published and downloadable national health surveys performed during the selected timeframe. Since most available studies did not distinguish between type 1 and type 2 diabetes mellitus, our review is centered on diabetes mellitus (diabetes, henceforth) in general. Because their specific mechanisms of disease and clinical implications, gestational diabetes mellitus, and type 1 diabetes merit separate reviews.
The earliest contemporary reports on the prevalence of diabetes mellitus among adults throughout LatAm date from the 1950s and 1960s [27] [28] [29] , when most countries were beginning to experience epidemiologic transitions [30, 31] . In 2001, Barceló reported an incidence of type 1 diabetes in LatAm in the range 0.1 cases/100,000 in Venezuela to 17.4 cases/ 100,000 in Puerto Rico [32] . However, the authors highlighted a handful of reports on the prevalence of type 2 diabetes and underlined the near absence of surveillance for the disease throughout the LatAm region [32] .
From 2005 to 2020, the prevalence of diabetes mellitus across LatAm has been assessed within individual countries and through multinational studies and ranged between 3 and 36.3% (Fig. 1, Table 1 ). In our review, some national surveys assessed the prevalence of diabetes via population representative samples [33, 36, 38, 40, 42-44, 47, 49, 55, 60, 61, 65, 66, 68, 72, 85-87, 89, 91, 96, 98, 105, 107] and used similar population sampling methods (e.g., multi-stage, clustered, probabilistic sampling), whereas other studies focused on specific geographic regions or communities [34, 35, 37, 45, 46, 48-54, 56-58, 63, 67, 73-75, 77, 82-84, 92-95, 102, 110-112] , recruited participants from clinical settings [51, 59, 62, 69, 95] , or focused on specific age groups [37, 42, 56-58, 75, 109, 112] . Also, the age range of the population surveyed-and consequently, age-adjustment estimates-varied among surveys.
Most of the studies (especially national surveys) reported the overall prevalence of diabetes without differentiating between type 1 and type 2 diabetes mellitus and many estimated the prevalence of the disease based on selfreport (being aware of having diabetes and/or taking antihyperglycemic medications) only. Some national surveys and independent studies estimated the prevalence based on the sum of self-report and identifying individuals without history of diabetes but hyperglycemia within the diabetes range [26, 115] . The latter group was considered to have "suspected," "undiagnosed," or "unknown" diabetes. Hyperglycemia within the diabetes range was assessed by measuring fasting blood or plasma glucose (FBG or FPG) only, FBG/FPG and 2-h oral glucose tolerance test (OGTT), FBG/FPG and hemoglobin A1c (HbA1c), HbA1c only, or the combination of FBG/FPG, OGTT, and HbA1c, or glucose levels in urine. Some studies measured capillary blood glucose (CBG), while most studies measured venous blood or plasma glucose. While multiple studies used the ADA/ALAD-recommended glucose/HbA1c cut points for the diagnosis of diabetes [26, 115] , some studies used different thresholds (e.g., fasting glucose ≥ 100 mg/dL (per CBG), random blood glucose ≥ 140 mg/dL, or random blood glucose ≥ 200 mg/dL).
Although the differences in the methodology described above limit the ability to perform cross-sectional or trend comparisons among countries, we note several commonalities. During 2005-2020, some countries reported an increase in the prevalence of diabetes [33, 36, 38-40, 66, 70-72, 79, 85, 86] , consistent with previously published reviews [5, 15, 32, [116] [117] [118] [119] [120] [121] [122] [123] . Compared with the rest of the region, and as previously reported [5, 15, 32, 124, 125] , diabetes prevalence varies across the region, with higher prevalence in Mexico (13.7%), Haiti (14.1% in women and 8.2% in men), and Puerto Rico (12.5-12.7% in the population aged 18 ≥ years and 26.8% in the population aged ≥ 45 years), and lower in Colombia (3.0% in the population aged 18 ≥ years, but 11.2% in age group ≥ 60 years), Dominican Republic (3.5%), Ecuador (2.7%), Peru (3.7%), and Uruguay (5.5-6.0%) (Fig. 1, Table 1 ). Multiple studies reported a greater prevalence of diabetes among women [36, 38, 40, 42, 44, 47, 49-52, 57, 60, 62, 63, 65, 70, 72, 75, 78, 79, 83-86, 90, 95, 96, 110, 113] , and with increasing age, especially over age 60 years [33, 36, 44, 47, 50, 55, 69-72, 78, 80, 81, 86, 91, 93, 110] . Some studies reported an inverse relationship between diabetes and socioeconomic status (SES) [33, 79, 103] or educational attainment [33, 44, 62, 63, 70, 72, 73, 75, 76, 78, 79, 86, 101] . Other studies reported a direct relationship between having health insurance and self-reported diabetes [42, 70, 97, 100] , implying that persons who have health insurance-proxy of access to health care services-would be aware of their health issues and report them accordingly. This interaction also poses questions about not only the access to health care but also the timeliness and quality of the care, and health literacy (or the lack of) that persons in the lowest SES-and at the highest risk of diabetes-would experience. Some studies reported a lower prevalence of diabetes among indigenous populations [35, 48, 74] , with one study proposing that exposure to urbanicity was associated with an increased prevalence of diabetes among some indigenous communities [83] . Indeed, rural to urban migration (or living in rural compared with urban areas) has been associated with increased prevalence or risk of developing diabetes in Peru [126, 127] , and multiple countries reported a lower diabetes prevalence in rural compared with urban settings [33, 39, 47, 60, 65, 89-91, 99, 103] .
The number of epidemiological studies published since 2005 indicates greater public health awareness about diabetes mellitus across LatAm. Multiple countries have performed at least one national survey on chronic non-communicable diseases in which self-reported diabetes mellitus and/or elevated glycemia has been included (Table 1) . Some surveys have also included at least one laboratory test (i.e., fasting or random blood glucose measurement or HbA1c), which could identify individuals at risk of developing diabetes or those who may have it and are not aware of it. Because hyperglycemia may be mediated by at least two mechanisms of disease-increased hepatic glucose output manifested as fasting hyperglycemia and uncoupled postprandial insulin secretion manifested as postprandial hyperglycemia [115, 128] -a single blood test or measurement may not identify all or most of individuals affected by the disease [115] . Therefore, the actual prevalence of diabetes may still be underestimated in many countries, as highlighted in previous reviews [5, 15, 124] . The etiologies of diabetes mellitus are complex. Thus, the increasing prevalence of diabetes experienced across LatAm may reflect the convergence or interaction of multiple factors [18, 125, 129] . For instance, the increasing prevalence of overweight and obesity documented across LatAm has paralleled the increasing prevalence of diabetes in the region [84, 125, 130, 131] . In addition to increased adiposity, type 2 diabetes mellitus and insulin resistance have also been linked to malnutrition (at different life stages) in some LMICs [130, [132] [133] [134] . Stress associated with chronic poverty, intergenerational poverty, natural disasters, and other adverse events [1, 129, 132, 135] has been linked to chronic systemic inflammation and epigenetic changes, potential common denominators of multiple NCDs [136, 137] . Many LatAm major cities may be epicenters where a fragile built environment and infrastructure and changes in lifestyle and nutrition intersect increasing the cumulative risk of developing diabetes in low-income communities [30, 126, 127, 129, 135, 138, 139] . Increased life expectancy has been associated with increased diabetes prevalence [4, 16, 30, 125, 140] , whereas higher educational attainment, increased access to health care, and higher health literacy level are associated with increased awareness of the disease [117] . These are all factors to consider upon designing comprehensive diabetes prevention and treatment strategies across LatAm countries.
In addition, the growing prevalence of diabetes mellitus across LatAm and the complexity of the disease suggest opportunities to create or strengthen collaborations towards its prevention and early detection [141] [142] [143] [144] . For example, multinational and multidisciplinary researchpublic health-health care policy-clinical care partnerships which already exist in formal or informal platforms may be well-positioned to evaluate the impact of nutrition, health insurance, housing, and other public policies [79, 141, 143, [145] [146] [147] [148] [149] [150] [151] [152] [153] [154] on health outcomes and assess their potential translation into preventive strategies at the public health and clinical care levels. At the same time, the eventual implementation of such strategies will be strengthened by local governments' commitment to prioritize the prevention and treatment of NCDs, in this case, diabetes, as previously voiced by experts and advocates in the region [79, 141, [155] [156] [157] [158] .
Diabetes Awareness, Treatment, and Control
Although fewer than studies focused on prevalence, a considerable number of reports centered on diabetes awareness, treatment, and control across LatAm were published between 2005 and 2020 ( 185, 189] . Most studies did not use the term "diabetes awareness," but equated it (or more appropriately, diabetes unawareness) to "suspected," "undiagnosed," "unknown," or "new" diabetes or "elevated glycemia." "Undiagnosed" diabetes-a proxy for lack of diabetes awareness-ranged widely from 10.3 to 50% across studies and countries ( Table 2 ). The prevalence of undiagnosed diabetes was higher in Guatemala (48.8%), Uruguay (48.7%), Puerto Rico (37.7-50%), Honduras (31.9-53.7% range), Mexico (29.9-50% range), and Nicaragua (43.3%) and lower in Colombia (Bogota) (23.5%), the southernmost countries of South America (20.2%), and Costa Rica (10.3-28.4%). Irazola et al. [189] described that diabetes awareness slightly increased with educational attainment. However, associations between undiagnosed diabetes with age, sex, educational attainment, SES, or geographic location were not published by most studies.
The observed range of undiagnosed diabetes suggests that the actual prevalence of diabetes across LatAm could exceed previous estimates [6, 124] and that a potentially significant proportion of persons with diabetes for whom both macroand microvascular complications may be present but not assessed and treated. Therefore, current estimates of the prevalence of diabetes across continents may not fully account for the necessary resources to provide adequate health care for Latin Americans with diabetes [7, 8, 190, 191] . Considering the workforce and resources needed to screen the millions of persons across the region who are at risk of diabetes or have the disease and are not aware, experts have proposed diabetes predictive models requiring specific easily obtained clinical data points that could be readily used in primary care settings [192] [193] [194] . Also, the Finnish Diabetes Risk Score (FINDRISC) has been proposed, tested, or modified to screen and identify individuals at high risk of developing diabetes in Latin America [195] [196] [197] [198] [199] . Point-of-care tests for HbA1c and urine microalbumin have also been proposed as alternatives to identify persons with "undiagnosed diabetes" and/or those at risk of chronic kidney disease (CKD) in low-resource and remote settings in LatAm [200] [201] [202] [203] . The standardization, reliability, and repeatability of some of these tests, as well as the clinical and public health benefit derived from their integration into the health care systems, may need to be determined [204] . However, these and other emerging diagnostic technologies [205, 206] are promising alternatives that could be incorporated to assess the prevalence of diabetes and implement timely interventions.
The percent of persons with diabetes following any treatment for diabetes ranged from 52.6 to 99% across studies ( Table 2 ). Prescription and/or use of antihyperglycemic medications was mostly assessed via interviews, although a few studies evaluated medical records. Most individuals reported taking oral antihyperglycemic medications either as monotherapy or as a combination of oral medications, while a smaller percent reported using insulin alone or in combination with oral medications. Five (5%) to 12.9% only followed diet/exercise prescription [161, 163, 167, 176, 179, 186] , and 3.2 to 10.1% were not taking any medications [41, 104, 168, 169, 175] . Receiving or adhering to pharmacological treatment was positively associated with having health insurance [71], and receiving medical care in private rather than public health care settings [71, 187] . At least one study observed better pharmacologic treatment adherence with female sex [185] .
Achievement of ADA/ALAD-recommended glycemic goals [23, 207] was assessed by multiple studies. The percentage of persons attaining HbA1c < 7% ranged from 3.5 to 54%. However, some studies defined glycemic control based on fasting or random blood glucose thresholds and reported attainment of glycemic control in the 31.4 to 61.4% range. Attainment of glycemic control was associated with higher socioeconomic status (SES) [160] , having health insurance [160] , and better access and services [208] . Not attaining glycemic control was associated with longer duration of diabetes [163, 187, 209] , taking insulin (alone or in combination with oral antihyperglycemic medications) [176] , forgetfulness (e.g., taking multiple medication for more than one condition) [185] , complex therapeutic regimes [209] , inadequate access to health care services [22] , and availability or health insurance coverage of medications [187] , among other factors.
In addition to glycemic control, a smaller number of studies examined the attainment of ADA/ALADrecommended blood pressure and LDL-C-blood pressure < 130/80 mmHg and LDL-C < 100 mg/dL-for patients with diabetes [24, 207] . The percentage achieving blood pressure goals ranged from 25 to 67%, and the percent achieving LDL-C goals ranged from 12 to 52.6% Table 2 ). The percent achieving optimal glycemic, blood pressure, and LDL-C levels altogether was reported by a handful of studies and up to 9.9% ( Table 2) . The findings described above denote critical aspects of the state of diabetes care in Latin America. The achievement of glycemic goals reported by the studies included in our review is similar to previously published studies [164, 179, 180, 187, 210] . This implies seriously chronic and inadequate glycemic control at the population level across the region.
The inclusion of questions on treatment for glycemic control, medical, and self-care in some national surveys increases our understanding of health-seeking behaviors, both patients' and clinicians' adherence to recommended guidelines of care, and challenges related to the utilization of health care services and availability of medications. The smaller number of studies reporting on the attainment of blood pressure and LDL-C goals and the proportion of patients achieving those goals also poses questions about the prevention of macrovascular complications in persons with diabetes in Latin America, considering the raising prevalence of CVD in the region [16, 211] . Of note, most national surveys report prevalence and treatment and/or control of diabetes, hypertension, and blood cholesterol and the prevalence of tobacco use individually. Since diabetes involves multiple organs and deserves a holistic care approach, reporting on the co-existence of other CV risk factors with diabetes would enhance critical understanding of CV risk and health care needs. Also, some surveys collected biospecimens, but the test results were not included in the reports. It is possible that they are analyzed and published later. Yet including test results in the surveys would offer a more comprehensive picture of the status of diabetes prevention and care needs [180, 212, 213] to plan interventions accordingly.
Various studies included in our review reported on participants' receiving or following ADA/ALAD-recommended guidelines of care [25] for early detection and prevention of microvascular disease-annual fundoscopic exam, examination for peripheral neuropathy and comprehensive foot examination, annual function/urine albumin excretion testing, and HbA1c tested at least 3 times per years [38-40, 72, 96, 159, 160, 165, 166, 168, 169, 171, 172, 175, 176, 180, 182, 186, 214] (Table 3) . Some studies assessed the completion of several guidelines, whereas most studies focused on a few. The completion of the selected ADA guidelines varied, ranging from 14.7 to 97.5% for the foot exam, from 8.6 to 92% for the fundoscopic exam, and from 1.1 to 51.1% for the urine albumin excretion test. Most studies (especially national surveys) inquired about having HbA1c checked within the previous 12 months. The affirmative response ranged from 3.7 to 90.0%. In addition to inquiring about HbA1c testing, some surveys asked whether the participant's blood glucose had been tested (by a health care professional). Having private health insurance was associated with a greater number of affirmative responses to the latter [70, 71, 91] .
Despite the smaller number of studies evaluating the completion of the ADA guidelines for foot care and prevention of microvascular disease, and the varied guideline completion rates previously described (Table 3) , the prevalence of long-term microvascular complications associated with diabetes has been documented across LatAm. For instance, in the studies included on our review and others published during the same time frame, the rate of foot ulcers ranged from 1.2 to 14.8% [40, [214] [215] [216] , and nontraumatic lower extremity amputations attributable to diabetes ranges from 1.2 to 7.3% [40, 184, 214, 215, [217] [218] [219] [220] [221] , and the prevalence of diabetic retinopathy ranged from 11.2 to 48% [40, 184, 214, 222, 223] . CKD has become a major public health concern across Central America [224] [225] [226] , and the increasing prevalence of diabetes could exacerbate the incidence of CKD-and eventually end-stage renal disease and its associated health complications-in the region [227] [228] [229] .
The findings described above underline not just the urgent need to prevent diabetes but also to prevent complications among those with established disease, and the potentially underestimated burden on patients, societies, and health care systems across LatAm. In this regard, several innovative models of health care for patients with diabetes have been proposed and tested throughout LatAm. Combining care of diabetes and other chronic conditions would be expected to maximize time and resources and improve health outcome. Although combining diabetes and chronic pulmonary disease care did not demonstrate a difference in outcomes [230] , this model could be revisited. Also, interventions at the health care system element of the chronic care model might need to be adapted to the local health care system [231] or synchronized with interventions at other levels. Improvement of health care system structure and processes [232] would assure timely access to patient information and enhance clinician decisionmaking. Integrating social determinants of health into diabetes care demonstrated objective improvements in patient knowledge and cardiometabolic parameters [233] . Enhancing medical continuing education [234] , an intervention combining diabetes prevention and self-management [235] , co-creating interventions with community stakeholders and other countries [141, 144] are other examples of alternatives to improve diabetes care throughout the region. Another major regional example of efforts to implement better care for patients with [147] , telehealth, mobile clinics, and other non-traditional health care delivery models. In addition, a non-exhaustive list of examples of past or current interventions, policies, and initiatives is provided in Table 4 [184, 186, 234, [236] [237] [238] [239] [240] [241] [242] [243] [244] [245] [246] [247] [248] [249] [250] [251] [252] . Interventions in the list include tele-ophthalmology [249, 250, 253, 254] , teambased foot self-care education [236] , diabetic retinopathy education and screening at a community pharmacy [255] , rapid assessment/diagnostic tools to screen for or detect retinopathy, nephropathy, and risk of developing foot ulcers [201, [256] [257] [258] [259] [260] [261] [262] and are examples of clinical research and/or implementation activities designed to strengthen the prevention and early detection of diabetes-associated complications and improve health outcomes throughout LatAm.
Many interventions on diabetes care have focused on patients and/or clinicians as the primary recipients or enablers of the interventions. Because of the complex nature of the disease and the multiple factors that mediate treatment effectiveness, interventions involving other levels or elements within the health care organization or system [155, 157, 232, [263] [264] [265] or the health care workforce [158, 263, 266] could be considered. Interventions involving other sectors (e.g., housing, infrastructure, national or local policies) could uncover very valuable and needed strategies to enhance treatment effectiveness and potentially reduce health care costs in the long-term. The feasibility and sustainability of such research efforts-and subsequent policies-would need to be demonstrated and supported locally [143] .
Multiple studies in our review reported a higher prevalence of diabetes among women [36, 38, 40, 42, 44, 47, 49-52, 57, 60, 62, 63, 65, 70, 72, 75, 78, 79, 83-86, 90, 95, 96, 110, 113] . While the mediating factors for this sex difference need further study (e.g., history of GDM, which was outside of the scope of this review), the increased prevalence of diabetes among women in some LatAm countries would be expected to have implications for health and health care, and potentially future generations [267] [268] [269] . Since diabetes may increase women's risk for CVD, including stroke [270] , cognitive decline [271, 272] , or some cancers [273, 274] , timely and comprehensive preventive care for women of all ages would need to be prioritized.
Due to the epidemiologic transition already experienced by some countries throughout LatAm, the population pyramid is also shifting towards a greater proportion of older adults. Studies included in our review consistently reported an increased prevalence of diabetes with age. Diabetes care challenges specific to this age group include risk of obesity or undernutrition [42, 56] , increased risk for disability [57] , economic barriers to appropriate access to health care [42] , disruption in funding of health insurance [275] , disparate completion of diabetes care guidelines based on health insurance coverage [276] , inequalities in access to and utilization of health care services [277] [278] [279] , complex medical care needs and frailty [280] , cultural beliefs, mental health, and lack of family or social support [281] , among others. Prevention of diabetes and its complications and reliable continuity of care and social support [282] need to be especially tailored for this population across the region.
A few studies in our review reported a low prevalence of diabetes among some indigenous populations in LatAm [55, 74, 82] , in parallel to some previous reports [283] [284] [285] [286] about other indigenous groups in the region and in contrast with the higher prevalence of diabetes among American Indians in the USA [287] and the First Nations in Canada [288] . However, other studies in our review and in the current literature have documented elevated diabetes prevalence or risk among indigenous and other socioeconomically disadvantaged ethnic groups [48, 50, 73, 76, 77, 83, 90, 91, 166, [289] [290] [291] [292] [293] . Some of the diabetes prevalence studies included in our review focused on or mentioned participants from indigenous groups [35, 48, 50, 74, 83] and other underrepresented groups (e.g., Garifuna, Afro-Panamanian, Afro-Peruvian, Afro-Ecuadorian) [55, 76, 90, 91, 166] . However, a few studies have evaluated diabetes care, prevalence, and/or prevention of macro-or microvascular complications, diabetes management interventions, other health care needs and access to health care among indigenous populations [241, 244, 246, [294] [295] [296] [297] [298] [299] [300] [301] [302] , and none on the other groups (that we could identify through our search). Understanding the protective mechanisms (e.g., biochemical, immune, epigenetic) against diabetes experienced by some indigenous populations would be relevant to millions at high risk of developing diabetes. At the same time, the increased prevalence of the metabolic syndrome and diabetes experienced by some indigenous groups and other ethnic groups may increase their risk not only for CVD and other diabetes long-term complications but also for re-emerging [239] 2 0 0 9 -2011 Mexico, Honduras Interactive Voice Response (IVR) support calls for chronic disease management for Spanish speakers-The investigators report cumulative findings in Honduras, Mexico, and Spanish-speakers in the U.S. Involvement of caregivers enhanced engagement. By self-report, there was improved medication adherence and self-management was similar across sites. Piette, 2011 [240] 2010 Honduras Cloud-Computing Model -The investigators tested a mobile phone-based intervention of weekly VoIP calls and IVR with patients with diabetes and automated emails to clinicians and voicemail reports to family caregivers for six weeks. Improved self-care and diabetes management and significant improvement in glycemic control were reported. Piette, 2016 [241] 2013 Bolivia Structured caregiver feedback -The investigators assessed whether automated telephone feedback to caregivers ("CarePartners") increased engagement in mobile-health support among patients with diabetes and hypertension in Bolivia. Significantly greater engagement was observed. Patients who spoke indigenous languages at home were more than 3X as likely to complete the IVR calls. Piette, 2014 [242] 2013 Bolivia Mobile health program for chronic disease self-management in Bolivia -Assessment and implementation of IVR for 12 weeks. It was associated with improved medication adherence, self-reported health status, and satisfaction. Prestes, 2017 [243] 2 0 1 6 -2017 Argentina DIAPREMintegrated diabetes care program including systemic changes education, registry and disease management Flood, 2016 [244] 2010 Guatemala Implementation and outcomes of a comprehensive type 2 diabetes program in rural Guatemala through a non-government organization and involving nurse-directed care Flood, 2017 [245] 2012 Rural Guatemala Implementation of a multi-level quality improvement program for ambulatory diabetes care based on input from patients and other stakeholders Flood, 2017 [246] 2 0 1 4 -2016 Rural Guatemala Home-based type 2 diabetes self-managementintervention delivered by diabetes educator at home and synchronized with clinic follow-up. Mayan communities Tapia-Conyer, 2016 [247] Gallardo-Rincón, 2017 [234] 2012 to present Mexico CASALUD Model -is a comprehensive primary health care model implemented in Mexico that enables proactive prevention and disease management using innovative technologies and a patient-centered approach. The program was pilot tested in 2009 and implemented nationwide in 2012.
infectious diseases, like tuberculosis [303] [304] [305] . Therefore, disease prevention and health care models that account and reach these populations need to be considered.
Through this review, we have highlighted the most current reports on prevalence, awareness, treatment, control, and adherence to recommended guidelines of care for diabetes mellitus across LatAm published from 2000 to 2020.
During that time frame, a considerable number of surveys assessing the prevalence of the disease and an increasing body of reports on the achievement of treatment and care goals were identified. Such reports demonstrate the imperative need to garner a more comprehensive understanding of the extent of diabetes across countries, and both past and ongoing efforts to establish effective and sustainable models of prevention and high-quality care able to reach and serve all peoples across the region. During the writing of this manuscript, Latin America had been recognized as the new epicenter of the SARS-CoV-2 (COVID-19) pandemic [306] . The effects of the disease in persons with diabetes in the region are beginning to be uncovered [307] [308] [309] , while some solutions are proposed [310, 311] . The magnitude of the impact of the pandemic on the health and health care needs of persons with diabetes mellitus and other NCDs-let alone on the health care systems infrastructures-in the region are yet to be known. The task ahead is substantial and will require multidisciplinary and cross-sectoral strategies and collaborations to reduce diabetes burden and improve health outcomes across Latin America.
Acknowledgments The authors would like to thank Ms. Jill Pope (Kaiser Permanente Center for Health Research) for her valuable review of the manuscript and the Ponce Health Sciences University for creating the opportunity for AM-R and AS-S to work in this review.
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Cardiovascular risk factors in the urban Mexican population: the FRIMEX study. Public Health
The influence of indigenous status and community indigenous composition on obesity and diabetes among Mexican adults
Prediabetes, undiagnosed diabetes, and diabetes among Mexican adults: findings from the Mexican Health and Aging Study
Epidemiology of diabetes mellitus in Mexico
Prevalence of diabetes and poor glycemic control in Mexico: results from Ensanut
Diabetes mellitus en adultos mayores costarricenses
Metabolic control in a nationally representative diabetic elderly sample in Costa Rica: patients at community health centers vs patients at other health care settings
Prevalence of diabetes and impaired fasting glucose in Costa Rica: Costa Rican National Cardiovascular Risk Factors Survey
Epidemiology of chronic kidney disease in adults of Salvadoran agricultural communities
Epidemiological characteristics of chronic kidney disease of non-traditional causes in women of agricultural communities of El Salvador
Prevalence of risk factors for noncommunicable diseases in an indigenous community in Santiago Atitlán
No Transmisibles y sus Factores de Riesgo en Poblacion de 18 anos o mas. Dominio I: Urbano Metropolitana, Departamento de Guatemala
Diabetes prevalence in rural Indigenous Guatemala: a geographicrandomized cross-sectional analysis of risk
Cardiovascular risk assessment in the resource limited setting of Western Honduras: an epidemiological perspective
Prevalence of hypertension and associated risk factors in six Nicaraguan communities
A population-based study of prevalence and risk factors of chronic kidney disease in León. Nicaragua Can J Kidney Health Dis
Prevalence and risk factors for CKD in the general population of southwestern Nicaragua
Prevalence, sociodemographic distribution, treatment and control of diabetes mellitus in Panama
Nutritional status, health conditions and socio-demographic factors in the elderly of Havana, Cuba: data from SABE survey
Dementia and other chronic diseases in older adults in Havana and Matanzas: the 10/66 study in Cuba
Prevalence of obesity and its association with chronic kidney disease, hypertension and diabetes mellitus. Isle of Youth Study (ISYS)
Cardiovascular risk among older women in a Havana Health Area
III Encuesta Nacional de factores de riesgo y actividades preventivas de enfermedades no trasmisibles
ECIMED -Editorial Ciencias Medicas
Diabetes mellitus and obesity in the French Caribbean: a special vulnerability for women? Women Health
Glucose intolerance and other cardiovascular risk factors in Haiti. Prevalence of diabetes and hypertension in Haiti (PREDIAH)
Prevalence and risk factors for chronic kidney disease in a rural region of Haiti
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Increasing prevalence of diagnosed diabetes-United States and Puerto Rico
High prevalence of diabetes and prediabetes and their coexistence with cardiovascular risk factors in a Hispanic Community
Surveillance for certain health behaviors and conditions among states and selected local areas -behavioral risk factor surveillance system
Prevalence of diabetes mellitus in the surgical population of the University of Puerto Rico Affiliated Hospitals: a study using the surgery database
Diabetes in Bolivia
Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study
Diabetes mellitus: factors associated with prevalence in the elderly, control measures and practices, and health services utilization in São Paulo, Brazil
High prevalence of diabetes and intermediate hyperglycemia -The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)
High prevalence of type 2 diabetes mellitus in Xavante Indians from Mato Grosso
Rio de Janeiro, Brazil: Instituto Brasileiro de Geografia e Estatistica -IBGE
Needed Improvements in Diabetes Prevention and Management in Brazil
Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (VIGITEL BRASIL 2019
Low prevalence of type 2 diabetes despite a high average body mass index in the Aymara natives from Chile
Prevalence of type 2 diabetes and obesity in two Chilean aboriginal populations living in urban zones
Trends in obesity and diabetes prevalence in a Chilean urban population
Encuesta Nacional de Salud
Self-reported prevalence of chronic non-communicable diseases in relation to socioeconomic and educational factors in Colombia: a community-based study in 11 departments
Prevalence of prediabetes and diabetes among older adults in Ecuador: analysis of the SABE survey
Prevalence of diabetes on Santa Cruz Island in Galapagos Archipelago
Ecuador: a pilot study of cardiovascular risk factors in an Isolated Island community
Chronic diseases and associated factors among older adults in
Prevalence of cardiovascular risk factors in an urban ambulatory adult population: AsuRiesgo study
e investigadores del estudio TORNASOL. Factores de Riesgo de las Enfermedades Cardiovasculares en el Peru (Estudio TORNASOL)
Bioquimicos, Socioeconomicos y Culturales Relacionados con las Enfermedades Cronico Degenerativas (ENINBSC-ECNT 2005
Differences in cardiovascular risk factors in rural, urban and rural-to-urban migrants in Peru
Factores de Riesgo de las enfermedades cardiovasculares en el Peru II. Estudio TORNASOL II comparado con TORNASOL I despues de cinco anos
Prevalence of diabetes and impaired fasting glucose in Peru: report from PERUDIAB, a national urban population-based longitudinal study
Geographical variation in the progression of type 2 diabetes in Peru: The CRONICAS Cohort Study
A National surveillance survey on noncommunicable disease risk factors: suriname health study protocol
Diabetes and diabetic retinopathy in people aged 50 years and older in the Republic of Suriname
Barriers and facilitating factors for disease self-management: a qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in
Prevalence of diabetes in three regions of Venezuela. The VEMSOLS study results
Chronic diseases and functional limitation in older adults: a comparative study in seven cities of Latin America and the Caribbean
High prevalence of diabetes and impaired fasting glucose in urban Latin America: the CARMELA Study
Prevalence of diabetes and intermediate hyperglycemia among adults from the first multinational study of noncommunicable diseases in six Central American countries: the Central America Diabetes Initiative (CAMDI)
The Prevalence, correlates, detection and control of diabetes among older people in low and middle income countries
Dementia Research Group Population-Based survey
Multiple cardiometabolic risk factors in the Southern Cone of Latin America: a population-based study in Argentina, Chile, and Uruguay
Primary care and multimorbidity in six Latin American and Caribbean countries
American Diabetes Association. 2. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes-2020
Vision Epidemiologica de la Diabetes Mellitus en Venezuela. Registro Epidemiologico y Propuesta de Registro. Programas de Deteccion Precoz
Increased prevalence of diabetes in Argentina is due to easier health care access rather than to an actual increase in prevalence
Diabetes Care in Brazil
Diabetes Care in Venezuela
Diabetes in Panama: epidemiology, risk factors, and clinical management
Prevalence of diabetes in Brazil over time: a systematic review with meta-analysis
Type 2 diabetes mellitus in peru: a systematic review of prevalence and incidence in the general population
Diabetes in the Americas
Diabetes mellitus in developing countries and underserved communities
Migration, urbanisation and mortality: 5-year longitudinal analysis of the PERU MIGRANT study
Addressing the impact of urban exposure on the incidence of type 2 diabetes mellitus: The PERU MIGRANT Study
Pathophysiology of diabetes mellitus type 2: beyond the duo "insulin resistancesecretion deficit
Non-communicable disease syndemics: poverty, depression
Nutrition transition in Latin America: the case of Chile
The Andean Latin-American burden of diabetes attributable to high body mass index: a comparative risk assessment
Tropical or malnutrition-related diabetes: a real syndrome?
The unitarian hypothesis for the aetiology of diabetes mellitus
Diabetes in the Americas
Chronic stress, inflammation, and glucose regulation in U.S. Hispanics from the HCHS/SOL Sociocultural Ancillary Study
Epidemic of cardiometabolic diseases: a Latin American point of view
The epidemiologic transition in Latin America
Global shifts in cardiovascular disease, the epidemiologic transition, and other contributing factors: toward a new practice of global health cardiology
From epidemiological transition to health transition
Epidemiology in Latin America and the Caribbean: current situation and challenges
Barriers to Clinical Research in Latin America
Controlling cardiovascular diseases in low and middle income countries by placing proof in pragmatism
Lessons learned about co-creation: developing a complex intervention in rural Peru
Washington: The International Bank for Reconstruction and Development / The World Bank ©
Impact of energy intake, physical activity, and population-wide weight loss on cardiovascular disease and diabetes mortality in Cuba
Public Policies and Interventions for Diabetes in Latin America: a Scoping Review
Nutrition policies and interventions for chronic disease risk reduction in international settings: the INTERHEALTH nutrition initiative
Challenges and opportunities for implementation of interventions to prevent and control CVD in low-resource settings: a report from CESCAS in Argentina
Cardiometabolic risk reduction through lifestyle intervention programs in the Brazilian public health system
Programme and policy issues related to promoting positive early nutritional influences to prevent obesity, diabetes and cardiovascular disease in later life: a developing countries view
Developing a cooperative multicenter study in Latin America: lessons learned from the Latin American Study of Nutrition and Health Project
Physical activity and sedentary behavior patterns and sociodemographic correlates in 116,982 adults from six South American countries: the South American physical activity and sedentary behavior network (SAPASEN)
A novel international partnership for actionable evidence on urban health in Latin America: LAC-Urban Health and SALURBAL
Inadequate glycaemic control in LMIC: health system failures in Peru
Health systems research for policy change: lessons from the implementation of rapid assessment protocols for diabetes in low-and middleincome settings
Delivery of Type 2 diabetes care in low-and middle-income countries: lessons from Lima
Call-toaction: timely and appropriate treatment for people with type 2 diabetes in Latin America
Evaluation of a diabetes care program using the effective coverage framework
Quality of Diabetes Care: The challenges of an increasing epidemic in Mexico. Results from two national health surveys
Multicenter international registry to evaluate the clinical practice delivered to patients with type 2 diabetes mellitus: a sub-analysis of the experience in Mexico
Analysis of population survey for determining the factors associated with the control diabetes mellitus in Mexico
Achievement of therapeutic targets in Mexican patients with diabetes mellitus
Poor metabolic control in primary care
Central America Diabetes Initiative (CAMDI): survey of diabetes, hyperntion and chronic disease risk factor
A mixed-methods needs assessment of adult diabetes mellitus (type II) and hypertension care in Toledo
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Iniciativa Centroamericana de Diabetes (CAMDI): Encuesta de Diabetes, Hipertension y Factores de Riesgo de Enfermedades Cronicas
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Evaluation of a program to improve intermediate diabetes outcomes in rural communities in the Dominican Republic
Are adults diagnosed with diabetes achieving the American Diabetes Association clinical practice recommendations? P R
Achievement of national clinical practice recommendations among those in the Puerto Rican population with diabetes mellitus
Treatto-target HbA(1c) and lipid profile to prolong β-cell mass/function and optimize treatment goal attainment
Using mHealth strategies in a Diabetes Management Program to improve the quality of care in Argentina: Study design and baseline data
Prevalence of Type 2 diabetic patients within the targets of care guidelines in daily clinical practice: a multi-center study in Brazil
Prevalence and correlates of inadequate glycaemic control: results from a nationwide survey in 6,671 adults with diabetes in Brazil
Factors associated with glycemic control in a sample of individuals with Diabetes Mellitus taken from the Longitudinal Study of Adult Health, Brazil
Poor glycaemic control in Brazilian patients with type 2 diabetes attending the public healthcare system: a cross-sectional study
Proportion of Brazilian diabetes patients that achieve treatment goals: implications for better quality of care
Prevalence of glycemic control and associated factors in type 2 diabetes mellitus patients at the Hospital Universitario de San Ignacio
Quality and effectiveness of diabetes care for a group of patients in Colombia
Factores de riesgo cardiovascular en 74.420 solicitantes de carne de salud
Evaluation of the quality of care for diabetic patients in Latin America
Cardiovascular risk awareness, treatment, and control in urban Latin America
Registry of people with diabetes in three Latin American countries: a suitable approach to evaluate the quality of health care provided to people with type 2 diabetes
Control of type 2 diabetes mellitus among general practitioners in private practice in nine countries of Latin America
Sex differences and correlates of poor glycaemic control in type 2 diabetes: a cross-sectional study in Brazil and Venezuela
Prevalence, awareness, treatment and control of diabetes and impaired fasting glucose in the Southern Cone of Latin America
Diabetes, a global public health challenge with a high epidemiological and economic burden on health systems in Latin America
Evaluation and cost of the health care process of diabetic patients
Comparison of machine-learning algorithms to build a predictive model for detecting undiagnosed diabetes -ELSA-Brasil: accuracy study
Development and validation of a predictive model for incident type 2 diabetes in middle-aged Mexican adults: the metabolic syndrome cohort
Validation of a type 2 diabetes screening tool in rural Honduras
Diagnostic accuracy of the Finnish Diabetes Risk Score (FINDRISC) for undiagnosed T2DM in Peruvian population
FINDRISC modified for Latin America as a screening tool for persons with impaired glucose metabolism in Ciudad Bolívar
External validation of the Finnish diabetes risk score in Venezuela using a national sample: The EVESCAM. Prim Care Diabetes
FINDRISC in Latin America: a systematic review of diagnosis and prognosis models
Clinical practice guideline for the prevention, early detection, diagnosis, management and follow up of type 2 diabetes mellitus in adults
Assessment of two diabetes point-of-care analyzers measuring hemoglobin A1c in the Peruvian Amazon
Agreement between the 'point of care' tests for microalbuminuria and HbA1c performed in mexican family medicine units and the results of standard laboratory tests
Comparison of three methods for diabetes screening in a rural clinic in Honduras
Utility of the Dipstick Micraltest II in the screening of microalbuminuria of diabetes mellitus type 2 and essential hypertension
High-quality health systems: time for a revolution in research and research funding
Point-of-care blood test for ketones in patients with diabetes: primary care diagnostic technology update
Primary care diagnostic technology update: pointof-care testing for glycosylated haemoglobin
Treatment of type 2 diabetes in Latin America: a consensus statement by the medical associations of 17 Latin American countries. Latin American Diabetes Association
Racial inequities and aging: analysis of the 2010 cohort of the Health
Factors associated with glycemic control in people with diabetes at the Family Health Strategy in Pernambuco
Persistent poor glycaemic control in individuals with type 2 diabetes in developing countries: 12 years of realworld evidence of the International Diabetes Management Practices Study (IDMPS)
Trends and heterogeneity of cardiovascular disease and risk factors across Latin American and Caribbean countries
Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS). Diabetes Care
Barriers to hypertension and diabetes management in primary health care in Argentina: qualitative research based on a behavioral economics approach
Prevalence of previously diagnosed diabetes mellitus in Mexico
Diabetic foot among hospitalized patients in Latin America
Vascular Complications In Patients With Type 2 Diabetes: Prevalence And Comorbidities In 6 Countries of Latin America (a cohort of the discover study program)
Baseline characteristics and risk factors for ulcer, amputation and severe neuropathy in diabetic foot at risk: the BRAZUPA study
Diabetes-related lower-extremity amputation incidence and risk factors: a prospective seven-year study in Costa Rica
Analysis of Diabetes Mellitus-Related Amputations in the State of Espírito Santo
10 years analysis of diabetes-related major lower extremity amputations in Mexico
Demographic and clinical characteristics of dominican adults admitted to a diabetic foot clinic in the Dominican Republic
Frequency and severity of diabetic retinopathy in patients with type 2 diabetes mellitus at the Regional Institute of Ophthalmology
Regional differences in the prevalence of diabetic retinopathy: a multi center study in Brazil
Chronic kidney disease in Latin America: time to improve screening and detection
Nephropathy in low income diabetics: the Mexico City Diabetes Study
Early detection and prevention of diabetic nephropathy: a challenge calling for mandatory action for Mexico and the developing world
Mortality in patients with chronic renal disease without health insurance in Mexico: opportunities for a national renal health policy
Prevalence of diabetic nephropathy in Type 2 Diabetes Mellitus in rural communities of Guanajuato, Mexico. Effect after 6 months of Telmisartan treatment
Integrating primary care of chronic respiratory disease, cardiovascular disease and diabetes in Brazil: Practical Approach to Care Kit (PACK Brazil): study protocol for randomised controlled trials
The impact of an intervention to improve diabetes management in primary healthcare professionals' practices in Brazil
Quality of Care of patients with diabetes in primary health services in Southeast Brazil
Role of social and other determinants of health in the effect of a multicomponent integrated care strategy on type 2 diabetes mellitus
Online continuing medical education as a key link for successful noncommunicable disease self-management: the CASALUD™ Model
Combined diabetes prevention and disease self-management intervention for Nicaraguan ethnic minorities: a pilot study
Ten years of a multidisciplinary diabetic foot team approach in Sao Paulo
Using collaborative learning to improve diabetes care and outcomes: the VIDA project
Algorithm for the treatment of type 2 diabetes: a position statement of Brazilian Diabetes Society
Spanishspeaking patients' engagement in interactive voice response (IVR) support calls for chronic disease self-management: data from three countries
A preliminary study of a cloudcomputing model for chronic illness self-care support in an underdeveloped country
Structured caregiver feedback enhances engagement and impact of mobile health support: a randomized trial in a lowermiddle-income country
Establishing an independent mobile health program for chronic disease self-management support in bolivia. Front Public Health
Improving diabetes care at primary care level with a multistrategic approach: results of the DIAPREM programme
Implementation and outcomes of a comprehensive type 2 diabetes program in rural Guatemala
A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting
A home-based type 2 diabetes self-management intervention in rural Guatemala
CASALUD: an innovative health-care system to control and prevent non-communicable diseases in Mexico
Implementation of a diabetic retinopathy referral network
Teleophthalmology: a strategy for timely diagnosis of sightthreatening diabetic retinopathy in primary care
Management of diabetic retinopathy using telemedicine and network integration
Improvement in medication adherence and self-management of diabetes with a clinical pharmacy program: a randomized controlled trial in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital
Clinical, metabolic and psychological outcomes and treatment costs of a prospective randomized trial based on different educational strategies to improve diabetes care (PRODIACOR)
Collaborative telemedicine between optometry and ophthalmology: an initiative from the University of Houston. Stud Health Technol Inform
Prevalence of diabetic retinopathy in Peruvian patients with type 2 diabetes: results of a hospital-based retinal telescreening program
Diabetic retinopathy education and screening at the community pharmacy in Puerto Rico
Rapid assessment of avoidable blindness and diabetic retinopathy in individuals aged 50 years or older in Costa Rica
Functional low vision in adults from Latin America: findings from populationbased surveys in 15 countries
Rapid assessment of avoidable blindness and diabetic retinopathy in Chiapas
Diabetic retinopathy screening using single-field digital fundus photography at a district level in Costa Rica: a pilot study
A Diabetic Retinopathy Screening Tool for Low-Income Adults in Mexico
Implementation of foot thermometry plus mHealth to prevent diabetic foot ulcers: study protocol for a randomized controlled trial
Human resources for health in Peru: recent trends (2007-2013) in the labour market for physicians, nurses and midwives
Barriers in household access to medicines for chronic conditions in three Latin American countries
A systematic review of innovative diabetes care models in low-and middle-income countries (LMICs). J Health Care Poor Underserved
The quality of primary care services, vocational training and the More Doctors Program in a health region of southwest Goiás
Viva la Familia Study: genetic and environmental contributions to childhood obesity and its comorbidities in the Hispanic population
Exposure to gestational diabetes enriches immune related pathways in the transcriptome and methylome of human amniocytes
Burden of disease in Latin America
Cardiovascular disease in Latin American women
DIABDEM project: a pilot study of prevalence of cognitive impairment in diabetes mellitus in 2 Hispanic countries
Predictors of optimal cognitive aging in 80+ women: the Women's Health Initiative Memory Study
Breast cancer and diabetes mellitus: complex interactions
Sex-and site-specific differences in colorectal cancer risk among people with type 2 diabetes
Aging in Puerto Rico: A Comparison of Health Status Among Island Puerto Rican and Mainland U.S. Older Adults
Disparities in receipt of eye exams among medicare part B fee-for-service beneficiaries with diabetes -United States
Inequalities in access to health care services and utilization for the elderly in São Paulo
Public versus private treatment of chronic diseases in seniors: Argentina, Brazil. Chile and Uruguay Glob Public Health
Quality of care provided to patients with diabetes mellitus in Puerto Rico; managed care versus fee-for-service experience
Socioeconomic inequalities in frailty among older adults in six low-and middle-income countries: results from the WHO Study on global AGEing and adult health (SAGE)
Challenges to diabetes selfmanagement for adults with type 2 diabetes in low-resource settings in Mexico City: a qualitative descriptive study
Relationship between social support and the physical and mental wellbeing of older Mexican adults with diabetes
Lack of diabetes in rural Colombian Amerindians
Prevalence of diabetes mellitus and hyperlipidemia among Otomi indians
Low prevalence of non-insulin-dependent diabetes mellitus in indigenous communities of Durango
Anthropometric and metabolic profile of a Brazilian Amerindian group: The Xikrin (Mebengôkre)
Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the
Diabetes prevalence, incidence and mortality in First Nations and other people in Ontario, 1995-2014: a population-based study using linked administrative data
Cardiovascular risk factors with an emphasis on hypertension in the Mura Indians from Amazonia
Cardiovascular risk factors and acculturation in Yaquis and Tepehuanos Indians from Mexico
Body mass index, waist circumference, body adiposity index, and risk for type 2 diabetes in two populations in Brazil: general and Amerindian
Traditional versus agricultural lifestyle among Shuar women of the Ecuadorian Amazon: effects on leptin levels
Prevalence of overweight and obesity in the adult indigenous population in Brazil: a systematic review with meta-analysis
Interventions to improve access to health services by indigenous peoples in the Americas
Determining adult type 2 diabetes-related health care needs in an indigenous population from rural Guatemala: a mixed-methods preliminary study
Prevalence of Self-Reported Chronic Diseases and Health Services Utilization by Ethnic Minorities in Manaus Metropolitan Region
Socioeconomic and lifestyle factors associated with chronic conditions among older adults in Ecuador
Implementation effectiveness of health interventions for indigenous communities: a systematic review
A community health worker intervention for diabetes self-management among the Tz'utujil Maya of Guatemala
Ongoing challenges in access to diabetes care among the indigenous population: perspectives of individuals living in rural Guatemala
The first national survey of indigenous people's health and nutrition in Brazil: rationale, methodology, and overview of results
Health system and aboriginal communities in the province of Formosa
Diabetes, undernutrition, migration and indigenous communities: tuberculosis in Chiapas
Prevalence of comorbidity tuberculosis and diabetes mellitus in Paraguay, 2016 and 2017Prevalência de comorbidade tuberculose-diabetes mellitus no Paraguai
Co-management of tuberculosis and diabetes: an integrative reviewManejo integrado de la tuberculosis y la diabetes: revisión integrativa
Covid-19 in Latin America
The impact of COVID-19 on people with diabetes in Brazil
Unequal impact of structural health determinants and comorbidity on COVID-19 severity and lethality in older Mexican adults: Considerations beyond chronological aging
COVID-19 impact on people with diabetes in South and Central America (SACA region)
Critical review of social, environmental and health risk factors in the Mexican indigenous population and their capacity to respond to the COVID-19
COVID-19 Pandemic Triggers Telemedicine Regulation and Intensifies Diabetes Management Technology Adoption in Brazil
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