Objective Waist circumference–based measures can improve diabetes risk assessment beyond body mass index (BMI). Yet, evidence to guide their integration into screening guidelines in low- and middle-income countries (LMICs) is limited, particularly to assess risk among individuals at intermediate BMI ranges. We evaluated the associations of waist circumference (WC), relative fat mass (RFM), and BMI with diabetes across 82 LMICs. Research Design and Methods We analyzed individual-level data from nationally representative surveys across 82 LMICs, comprising 598,883 adults aged ≥25 years with a BMI of 18.5–29.9 kg/m². Associations of anthropometric measures with diabetes were estimated as risk ratios using Poisson regression and area under the curve (AUC), stratified by sex and geographic region. Results Pooled diabetes prevalence was 9.1% (95% confidence interval: 8.51–9.68). Overall, risk of diabetes was greatest for WC and RFM at the highest quintile, compared to BMI. The AUC for WC and RFM as a classifier of diabetes status was higher than the AUC for BMI in men (AUC: WC 0.69, RFM 0.69, BMI 0.64) and women (AUC: WC 0.69, RFM 0.69, BMI 0.63). Generally, the AUC for RFM was higher than the AUC for BMI and either higher or equal to WC across regions and sex. Conclusions WC and RFM outperformed BMI as classifiers of diabetes status among adults with a BMI of 18.5–29.9 kg/m2 across 82 LMICs. Inclusion of WC-based measures in diabetes screening guidelines could improve timely diabetes detection and resource allocation in LMICs among individuals at intermediate BMI ranges.

OBJECTIVE:Undiagnosed diabetes leads to delayed treatment and increased risk of complications, exacerbating global disease burdens. In this study, we estimated the prevalence and absolute numbers of individuals with undiagnosed diabetes globally and across regions and quantified gaps in national diabetes detection efforts. RESEARCH DESIGN AND METHODS:We systematically compiled estimates of biomarker-based diabetes prevalence and self-reported diabetes diagnosis using 2003-2024 data from all eligible population-based studies and gray literature. We calculated proportions of individuals with undiagnosed diabetes and case numbers among adults aged 20-79 years. For countries without data, we extrapolated estimates using available data within the same geographic region and country income group. Country-level estimates were benchmarked against the World Health Organization 80% diagnosis target. RESULTS:We identified 193 data sources on undiagnosed diabetes from 109 countries. Across all 215 countries/territories, 42.8% of individuals with diabetes were undiagnosed in 2024, equating to 251.7 million (95% uncertainty interval [UI] 250.4-253.0 million) adults. Proportions undiagnosed ranged from 16.2% in Colombia to 90.4% in Burkina Faso and 29.1% in North America and the Caribbean to 72.6% in Africa. A larger proportion of individuals were undiagnosed in low-income (58.7%) compared with high-income countries (28.9%). Middle-income countries accounted for 206.0 million (95% UI 202.3-209.7 million) adults with undiagnosed diabetes (81.8% of all individuals), including 127.1 million (95% UI 121.2-133.0 million [or 50.5%]) adults in China, India, and Indonesia alone. Less than 5% of all countries attained diabetes diagnosis levels ≥80%. CONCLUSIONS:Substantial global variability in undiagnosed diabetes indicates opportunities to close existing care gaps, likely requiring context-specific solutions and investments.

Objective: Care cascade indicators are widely used to monitor national diabetes control efforts. However, diabetes definitions used to derive care cascades vary across studies, which may markedly affect results and subsequent policy decisions. Here, we examine the magnitude of resultant differences between approaches. Research Design and Methods: We analyzed nationally representative, cross-sectional data of 800,348 individuals aged ≥25 years from 88 countries in 2008-2021. We employed two different diabetes definitions: elevated biomarkers (HbA1c≥6.5%; fasting plasma glucose ≥7.0mmol/L; or random plasma glucose ≥11.1mmol/L) or self-reported diagnosis (“diagnosis-based definition”) versus elevated biomarkers or self-reported treatment (“treatment-based definition”). Care cascade estimates included (1) proportions of diabetes cases who were diagnosed, and proportions of diagnosed diabetes cases who (2) received treatment and (3) attained glycemic control. We benchmarked results against World Health Organization (WHO) diabetes targets. Results: Diabetes prevalence was 12.9% (95%-CI: 12.1-13.8) applying the diagnosis-based definition and 11.3% (95%-CI: 10.5-12.1) with the treatment-based definition. Using the diagnosis-based rather than treatment-based diabetes definition to derive care cascades consistently increased percentages who attain diagnosis and control stages but decreased percentages receiving treatment. Across countries, median differences between approaches were 11.3% (IQR: 5.1-24.7) for diabetes diagnosis, 21.6% (IQR: 14.5-37.8) for treatment, and 16.4% (IQR: 7.8-26.8) for control. The WHO 80%-glycemic control target was met by 22% versus 6% of countries when using the diagnosis-based versus treatment-based definition, respectively. Conclusions: Care cascade estimates diverged substantially and consistently across diabetes definitions, skewing policy implications in predictable ways. Harmonizing diabetes performance metrics may improve decision-making and facilitate cross-country comparisons.

Objective: Undiagnosed diabetes leads to delayed treatment and increased risk of complications, exacerbating global disease burdens. In this study, we estimated the prevalence and absolute numbers of undiagnosed diabetes globally and across regions, and quantified gaps in national diabetes detection efforts. Research Design and Methods: We systematically compiled estimates of biomarker-based diabetes prevalence and self-reported diabetes diagnosis using 2003–2024 data from all eligible population-based studies and grey literature. We calculated proportions with undiagnosed diabetes and case numbers among adults aged 20-79 years. For countries without data, we extrapolated estimates using available data within the same geographic region and country-income group. Country-level estimates were benchmarked against the World Health Organization 80%-diagnosis target. Results: We identified 193 data sources on undiagnosed diabetes from 109 countries. Across all 215 countries/territories, 42.8% of individuals with diabetes were undiagnosed, equating to 251.7 million [95%-uncertainty interval (UI): 250.8–252.6 million] adults. Proportions undiagnosed ranged from 16.2% in Colombia to 90.4% in Burkina Faso, and 29.1% in North America and the Caribbean to 72.6% in Africa. A larger proportion of individuals were undiagnosed in low-income (58.7%) compared to high-income countries (28.9%). Middle-income countries accounted for 206.0 million [95%-UI: 202.3–209.7 million] adults with undiagnosed diabetes (81.8% of all cases), including 127.1 million [95%-UI: 121.2–133.0 million; or 50.5%] adults in China, India, and Indonesia alone. Under 5% of all countries attained diabetes diagnosis levels above 80%. Conclusions: Substantial variability in undiagnosed diabetes globally indicates opportunities to close existing care gaps, likely requiring context-specific solutions and investments.

INTRODUCTION:Despite 1.3 million cumulative preexposure prophylaxis (PrEP) initiations in South Africa, 150 000+ people newly acquire HIV every year. A significant proportion of these are middle-aged adults, a population not previously prioritized for PrEP. Evidence on how many middle-aged and older adults in South Africa may benefit from PrEP services is needed. METHODS:We estimate the need for PrEP counseling in a sample of 40+ year-old, rural South Africans in 2018 and 2022, using "Health and Aging in Africa: A Longitudinal Study in South Africa (HAALSI)" data. We first identify potential PrEP eligibility based on a negative HIV status and a body weight of 35+ kg. Within this sample, we define the population that should be counselled on PrEP as per South African Guidelines for the Provision of PrEP based on a recent history of having had sex without a condom. We estimate cross-sectional and longitudinal need for PrEP counseling at the pooled level and disaggregated by sex and age. RESULTS:Of the 1654 individuals considered potentially eligible for PrEP in 2022, 39.6% overall, 55.7% of men, 26.7% of women, and 63.3% of 40-49 year-olds should be counseled on PrEP. Longitudinally, 29.9 and 22.9% should be counseled on PrEP in both waves or only one wave respectively. Further, we found significantly higher odds of need for PrEP counseling in male, younger, and married individuals. CONCLUSION:We find a high need for PrEP counseling among middle-aged and older South Africans, calling for greater attention to HIV prevention, including targeted PrEP for these age groups.

Diabetes and hypertension are major global health crises, yet Indonesia is lagging behind in achieving care outcomes compared to other middle-income countries. We examined barriers to screening uptake, a key care entry point, in 40–70-year-old adults in Aceh, Indonesia. We assessed individual-level data on diabetes and hypertension screenings in Banda Aceh and Aceh Besar in 2019. Using two-stage random sampling, we collected survey data on 2080 adults that are indicated for, but had not undergone diabetes screening as per World Health Organization’s Package of Essential Noncommunicable Disease Intervention guidelines. Using this, we adjusted the data for complex survey design to describe (1) the share of respondents with screening indication and presence of risk factors; (2) disease-related knowledge, attitude, and practices, as well as (3) estimate associations of screening with socioeconomic characteristics, knowledge, and attitudes using multivariable linear and logistic regression. We found that while respondents were aware of diabetes and hypertension, a majority lacked knowledge about leading risk factors, the conditions’ potentially asymptomatic nature, and screening needs. About 41

Objective:To assess the pattern of traditional medicine use globally for treating hypertension, diabetes and hypercholesterolaemia. Methods:We pooled individual-level data from 309 745 non-pregnant people aged ≥ 15 years from 71 nationally representative surveys conducted in low- and middle-income countries between 2005 and 2021. We identified individuals with diagnosed hypertension, diabetes and hypercholesterolaemia who reported use of traditional medicine. For each condition, we estimated the prevalence of traditional medicine use at the global, regional and country-income level and the proportion using traditional medicine and biomedicine. We estimated the association between traditional medicine use and individual characteristics. Findings:The prevalence of traditional medicine use was 14.7% (95% confidence interval, CI: 12.7-16.9) for diabetes, 12.4% (95% CI: 10.0-15.3) for hypercholesterolaemia and 8.1% (95% CI: 7.3-9.0) for hypertension. Most individuals using traditional medicine for diabetes or hypercholesterolaemia also used biomedicine. Associations between sociodemographic characteristics and traditional medicine use varied between regions and health conditions. In the World Health Organization's (WHO) Western Pacific Region, traditional medicine use for diabetes was significantly higher in males and younger adults, whereas use for hypertension was significantly higher in females and older adults. In the WHO African Region, traditional medicine use for diabetes and hypertension was higher in males and individuals with lower education. Conclusion:Our study shows a high prevalence of traditional medicine use for treating hypertension, diabetes and hypercholesterolaemia in low- and middle-income countries. Our results highlight the need to better understand the clinical interactions and risks of traditional medicine for improved cardiometabolic treatment.

Given rising diabetes prevalence globally, access to diabetes treatments is gaining urgency. Yet, it remains unknown which glucose-lowering medication types people with diabetes across low- and middle-income countries (LMICs) use. In this cross-sectional analysis, we pooled nationally representative data of 223,283 adults aged ≥25 years in 62 LMICs from 2009 to 2019. We found that 51.9% [95%-CI: 49.6%, 54.2%] of 21,715 individuals with diabetes were undiagnosed. Among individuals with diagnosed diabetes, 18.6% [95%-CI: 14.5%, 23.4%] reported using no glucose-lowering medication, 57.3% [95%-CI: 53.1%, 61.4%] only used oral medication, 19.5% [95%-CI: 17.6%, 21.5%] used oral medication and insulin, and 4.7% [95%-CI: 3.9%, 5.6%] used insulin alone. In low-income countries, fewer individuals with diabetes were diagnosed and treated than in middle-income countries. Yet, among individuals who did get diagnosed, insulin use was two-thirds higher in low-income countries (38.9% [95%-CI: 31.6%, 46.7%]) compared to middle-income countries (23.2%; 95%-CI: 21.0%, 25.5%]). This finding could suggest a need for earlier diagnosis and treatment initiation. Our results can inform national and regional drug procurement efforts across LMICs.

As cardiovascular diseases (CVD) become the leading cause of death in low- and middle-income countries (LMICs), this raises new challenges for health systems. Regular screening is a key measure to manage CVD risk, but the uptake of such services remains low. We conducted a randomized controlled trial in Indonesia to assess whether personalized and targeted text messages increase the usage of public screening services for diabetes and hypertension in the at-risk population. Our intervention increased screening uptake by 6.6 percentage points. We show that text messages can be effective in the context of a relatively new disease burden in LMICs, where population responses may still be shaped by low salience and missing screening routines.

Global Heart is the official and primary publication of the World Heart Federation, offering a platform for the dissemination of knowledge on research, developments, trends, solutions and public health programmes in the area of cardiovascular disease. Global Heart welcomes research results, points of view and educational material on the prevention, treatment and control of cardiovascular disease with a special focus on low and middle-income countries which are facing the brunt of epidemiological transition.Global Heart strongly encourages authors to adhere to CONSORT, STROBE, STARD, and PRISMA guidelines for reporting of clinical trials, observational studies, diagnostic test accuracy papers, and systematic reviews or meta-analyses. Authors are required for submission to download and complete the appropriate Equator Network checklist: http://www.equator-network.org/.

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009-2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40-69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8-66.4]) than those with hypertension only (47.4% [45.3-49.6]) or diabetes only (46.7% [44.1-49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8-41.8] using antihypertensive and 42.3% [95% CI: 39.4-45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1-27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4-18.8]), followed by diabetes (13.3% [10.7-15.8]) and hypertension-diabetes (6.6% [5.4-7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors.

Objective: The relationship between depression, diabetes, and access to diabetes care is established in high-income countries (HICs) but not in middle-income countries (MICs), where contexts and health-systems differ and may impact this relationship. In this study we investigate access to diabetes care for individuals with and without depressive symptoms in MICs. Research Design and Methods: We analyzed pooled data from nationally representative household surveys across Brazil, Chile, China, Indonesia, and Mexico. Validated survey tools (CESD-R-10, CESD-9, CIDI-SF, PHQ-9) identified participants with depressive symptoms. Diabetes, defined per WHO PEN guidelines, included self-reported medication use and biochemical data. The primary focus was on tracking diabetes care progression through stages: (1) diagnosis, (2) treatment, and (3) glycemic control. Descriptive and multivariable logistic regression analyses, accounting for gender, age, education, and BMI, examined diabetes prevalence and care continuum progression. Results: The pooled sample included 18,301 individuals aged 50 and above; 3,309 (18.1%) had diabetes, and 3,934 (21.5%) exhibited depressive symptoms. Diabetes prevalence was insignificantly higher among those with depressive symptoms (28.9%) compared to those without (23.8%, p=0.071). Co-occurrence of diabetes and depression was associated with increased odds of diabetes detection (OR 1.398, p<0.001) and treatment (OR 1.344, p<0.001), but not with higher odds of glycemic control (OR 0.913, p=0.377). Conclusions: In MICs, individuals aged 50 years and older with diabetes and depression showed heightened diabetes identification and treatment probabilities, unlike patterns seen in HICs. This underscores the unique interplay of these conditions in different income settings.

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

Importance:Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. Objective:To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries. Design, Setting, and Participants:Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years. Exposures:Countries' per capita income levels and world region; individuals' socioeconomic demographics. Main Outcomes and Measures:Self-reported use of aspirin for secondary prevention of CVD. Results:The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries. Conclusion and Relevance:Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

BACKGROUND:Testing for the risk factors of cardiovascular disease, which include hypertension, diabetes, and hypercholesterolaemia, is important for timely and effective risk management. Yet few studies have quantified and analysed testing of cardiovascular risk factors in low-income and middle-income countries (LMICs) with respect to sociodemographic inequalities. We aimed to address this knowledge gap.METHODS:In this cross-sectional analysis, we pooled individual-level data for non-pregnant adults aged 18 years or older from nationally representative surveys done between Jan 1, 2010, and Dec 31, 2019 in LMICs that included a question about whether respondents had ever had their blood pressure, glucose, or cholesterol measured. We analysed diagnostic testing performance by quantifying the overall proportion of people who had ever been tested for these cardiovascular risk factors and the proportion of individuals who met the diagnostic testing criteria in the WHO package of essential noncommunicable disease interventions for primary care (PEN) guidelines (ie, a BMI >30 kg/m2 or a BMI >25 kg/m2 among people aged 40 years or older). We disaggregated and compared diagnostic testing performance by sex, wealth quintile, and education using two-sided t tests and multivariable logistic regression models.FINDINGS:Our sample included data for 994 185 people from 57 surveys. 19·1% (95% CI 18·5-19·8) of the 943 259 people in the hypertension sample met the WHO PEN criteria for diagnostic testing, of whom 78·6% (77·8-79·2) were tested. 23·8% (23·4-24·3) of the 225 707 people in the diabetes sample met the WHO PEN criteria for diagnostic testing, of whom 44·9% (43·7-46·2) were tested. Finally, 27·4% (26·3-28·6) of the 250 573 people in the hypercholesterolaemia sample met the WHO PEN criteria for diagnostic testing, of whom 39·7% (37·1-2·4) were tested. Women were more likely than men to be tested for hypertension and diabetes, and people in higher wealth quintiles compared with those in the lowest wealth quintile were more likely to be tested for all three risk factors, as were people with at least secondary education compared with those with less than primary education.INTERPRETATION:Our study shows opportunities for health systems in LMICs to improve the targeting of diagnostic testing for cardiovascular risk factors and adherence to diagnostic testing guidelines. Risk-factor-based testing recommendations rather than sociodemographic characteristics should determine which individuals are tested.FUNDING:Harvard McLennan Family Fund, the Alexander von Humboldt Foundation, and the National Heart, Lung, and Blood Institute of the US National Institutes of Health.

Background: The relationship between depression, diabetes, and access to diabetes care is established in high-income countries (HICs) but not in middle-income countries (MICs), where contexts and health-systems differ and may impact this relationship. In this study we investigate access to diabetes care for individuals with and without depressive symptoms in MICs.Methods: We analyzed pooled, nationally representative household survey data for 18,301 individuals aged 50 and above in Brazil, Chile, China, Indonesia, and Mexico. Results from validated survey tools were harmonized and used to identify people with depressive symptoms. Diabetes was defined as self-reported use of medications and biochemical data per WHO PEN guidelines. Our primary outcome was the progression of individuals with diabetes through the stages of the diabetes care continuum as an indication of access to care for diabetes. Descriptive and multivariable logistic regression analyses were conducted to examine diabetes prevalence and diabetes-care continuum progression (stages of (1) received diagnosis, (2) received treatment, and (3) achieved control) in individuals with and without depressive symptoms, controlling for the known confounders of sex, age, educational attainment, and BMI.Findings: Our final pooled sample included 18,301 individuals, with 3,309 (18.1%, CI: 17.5-18.6) having diabetes and 3,934 (21.5%, 95%-CI: 20.9-22.1) having depressive symptoms. Diabetes prevalence was non-significantly higher among participants with depressive symptoms (28.9%, 95%-CI: 27.4-30.3) compared to those without (23.8%, 95%-CI: 23.1-24.6, p for difference =0.071). In multivariable regression analysis, co-occurrence of diabetes and depression was associated with increased odds of diabetes detection (OR 1.398, p<0.001) and treatment (OR 1.344, p<0.001), but not with higher odds of achieving glycemic control (OR 0.913, p=0.377).Interpretation: Among individuals aged 50 years and older living in MICs, the comorbidity of diabetes and depression is associated with a greater probability of identifying and treating diabetes, in contrast to what is seem in HICs.Funding: None to declare. Declaration of Interest: We declare no competing interests.

BACKGROUND:The global burden of diabetes is rising rapidly, yet there is little evidence on individual-level diabetes prevention activities undertaken by health systems in low-income and middle-income countries (LMICs). Here we describe the population at high risk of developing diabetes, estimate diabetes prevention activities, and explore sociodemographic variation in these activities across LMICs. METHODS:We performed a pooled, cross-sectional analysis of individual-level data from nationally representative, population-based surveys conducted in 44 LMICs between October, 2009, and May, 2019. Our sample included all participants older than 25 years who did not have diabetes and were not pregnant. We defined the population at high risk of diabetes on the basis of either the presence of impaired fasting glucose (or prediabetes in countries with a haemoglobin A1c available) or overweight or obesity, consistent with the WHO Package of Essential Noncommunicable Disease Guidelines for type 2 diabetes management. We estimated the proportion of survey participants that were at high risk of developing diabetes based on this definition. We also estimated the proportion of the population at high risk that reported each of four fundamental diabetes prevention activities: physical activity counselling, weight loss counselling, dietary counselling, and blood glucose screening, overall and stratified by World Bank income group. Finally, we used multivariable Poisson regression models to evaluate associations between sociodemographic characteristics and these activities. FINDINGS:The final pooled sample included 145 739 adults (86 269 [59·2%] of whom were female and 59 468 [40·4%] of whom were male) across 44 LMICs, of whom 59 308 (40·6% [95% CI 38·5-42·8]) were considered at high risk of diabetes (20·6% [19·8-21·5] in low-income countries, 38·0% [37·2-38·9] in lower-middle-income countries, and 57·5% [54·3-60·6] in upper-middle-income countries). Overall, the reach of diabetes prevention activities was low at 40·0% (38·6-41·4) for physical activity counselling, 37·1% (35·9-38·4) for weight loss counselling, 42·7% (41·6-43·7) for dietary counselling, and 37·1% (34·7-39·6) for blood glucose screening. Diabetes prevention varied widely by national-level wealth: 68·1% (64·6-71·4) of people at high risk of diabetes in low-income countries reported none of these activities, whereas 49·0% (47·4-50·7) at high risk in upper-middle-income countries reported at least three activities. Educational attainment was associated with diabetes prevention, with estimated increases in the predicted probability of receipt ranging between 6·5 (3·6-9·4) percentage points for dietary fruit and vegetable counselling and 21·3 (19·5-23·2) percentage points for blood glucose screening, among people with some secondary schooling compared with people with no formal education. INTERPRETATION:A large proportion of individuals across LMICs are at high risk of diabetes but less than half reported receiving fundamental prevention activities overall, with the lowest receipt of these activities among people in low-income countries and with no formal education. These findings offer foundational evidence to inform future global targets for diabetes prevention and to strengthen policies and programmes to prevent continued increases in diabetes worldwide. FUNDING:Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program and the EU's Research and Innovation programme Horizon 2020.

Background Testing for the risk factors of cardiovascular disease, which include hypertension, diabetes, and hypercholesterolaemia, is important for timely and effective risk management. Yet few studies have quantified and analysed testing of cardiovascular risk factors in low-income and middle-income countries (LMICs) with respect to sociodemographic inequalities. We aimed to address this knowledge gap. Methods In this cross-sectional analysis, we pooled individual-level data for non-pregnant adults aged 18 years or older from nationally representative surveys done between Jan 1, 2010, and Dec 31, 2019 in LMICs that included a question about whether respondents had ever had their blood pressure, glucose, or cholesterol measured. We analysed diagnostic testing performance by quantifying the overall proportion of people who had ever been tested for these cardiovascular risk factors and the proportion of individuals who met the diagnostic testing criteria in the WHO package of essential noncommunicable disease interventions for primary care (PEN) guidelines (ie, a BMI >30 kg/m(2) or a BMI >25 kg/m(2) among people aged 40 years or older). We disaggregated and compared diagnostic testing performance by sex, wealth quintile, and education using two-sided t tests and multivariable logistic regression models. Findings Our sample included data for 994 185 people from 57 surveys. 19 center dot 1% (95% CI 18 center dot 5-19 center dot 8) of the 943 259 people in the hypertension sample met the WHO PEN criteria for diagnostic testing, of whom 78 center dot 6% (77 center dot 8-79 center dot 2) were tested. 23 center dot 8% (23 center dot 4-24 center dot 3) of the 225 707 people in the diabetes sample met the WHO PEN criteria for diagnostic testing, of whom 44 center dot 9% (43 center dot 7-46 center dot 2) were tested. Finally, 27 center dot 4% (26 center dot 3-28 center dot 6) of the 250 573 people in the hypercholesterolaemia sample met the WHO PEN criteria for diagnostic testing, of whom 39 center dot 7% (37 center dot 1-2 center dot 4) were tested. Women were more likely than men to be tested for hypertension and diabetes, and people in higher wealth quintiles compared with those in the lowest wealth quintile were more likely to be tested for all three risk factors, as were people with at least secondary education compared with those with less than primary education. Interpretation Our study shows opportunities for health systems in LMICs to improve the targeting of diagnostic testing for cardiovascular risk factors and adherence to diagnostic testing guidelines. Risk-factor-based testing recommendations rather than sociodemographic characteristics should determine which individuals are tested. Copyright (c) 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.