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Current Issues International Health and Diabetes
Diabetes and Tuberculosis – Old Associates
Posing a Renewed Public Health Challenge
Anil Kapur,
1
Anthony D Harries,
2
Knut Lönnroth,
3
Ib C Bygbjerg
4
and Pierre Lefèbvre
5
1. Managing Director, World Diabetes Foundation; 2. Senior Advisor, International Union Against Tuberculosis and Lung Diseases;
3. Medical Officer, Stop TB Department, World Health Organization; 4. Professor, Department of International Health, Medical Microbiology and Immunology,
University of Copenhagen; 5. Emeritus Professor of Medicine, University of Liège
Abstract
Diabetes and tuberculosis (TB) have existed for thousands of years. Today, the global burden of disease from diabetes and TB is huge and,
in the case of diabetes, rapidly increasing. Recent systematic reviews show that diabetes is associated with an increased risk of TB, yet the
potential public health and clinical importance of the association seems to be largely ignored. Irrespective of whether the association is
causal or a result of co-morbid factors, in low-resource societies with a dual disease burden, can a common health system approach for
diabetes and TB be adapted to address prevention and care? How and to what extent can this be done? Good-quality implementation
research is urgently needed to create robust action plans to address this double burden.
Keywords
Diabetes, tuberculosis (TB), co-morbidity, public health, clinical implications, millennium development goals (MDGs)
Disclosure: The authors have no conflicts of interest to declare.
Received: 23 April 2009 Accepted: 15 July 2009
Correspondence: Anil Kapur, World Diabetes Foundation, Lottenborgvej 24, 2800 Kgs Lyngby, Denmark. E: akap@worlddiabetesfoundation.org
Intersecting Epidemics it was estimated that there were 14.4 million people living with TB,
Diabetes and tuberculosis (TB) have existed for thousands of years. 9.2 million new cases and 1.7 million deaths.
7
While it is widely
Great physicians in the ancient civilisations of Egypt, India, Greece appreciated that 95% of TB patients live in the developing world, it is
and Rome described an illness that we now understand as diabetes. not so well known that 70% of diabetes patients also live in
Similarly, the earliest evidence of TB has been found in the skeleton of developing countries, especially in South-East Asia and the Western
a 30-year-old woman in Italy, dated to 5,800BCE.
1
The term ‘phthisis’, Pacific region.
8
The number of adults with diabetes globally is likely to
or consumption, first appeared in Greek literature, and around 460BCE grow to an estimated 380 million by 2025, and the majority of this
Hippocrates identified phthisis as the most widespread and invariably increase will occur in low- and middle-income countries. Populous
fatal disease of the times. The co-morbidity of diabetes and TB was developing countries such as India, China, Brazil, the Russian
also well known in those times. Richard Morton’s Phthisiologia: or a Federation, Indonesia, Pakistan and Bangladesh rank quite highly in
treatise on consumption, written in 1694, stated that an association both the number of people with diabetes and the number of those
between the two conditions was suggested even in Roman times.
2
with TB. Notable exceptions seem to be Mexico and Egypt, with a
The great Indian physician Susruta in about 600CE was aware of the larger number of people with diabetes but a relatively lower ranking
association, and Avicenna in about 800CE commented that phthisis in terms of the number of people with TB, and Nigeria and South
frequently complicated diabetes.
3
Root, in reviewing the history of the Africa, with a high ranking for the number of people with TB but a
association of diabetes and TB, noted that ‘’in the latter half of the relatively lower ranking for the number of people with diabetes.
19th century the diabetic patient appeared doomed to die of
pulmonary TB if he succeeded in escaping coma’’.
4
In 1883, The incidence of TB is declining very slowly globally, at less than 1%
Bouchardat stated ‘’at autopsy every case of diabetes had tubercles annually.
7
Speeding up the decline in incidence will require both
in the lungs’.’
5
Indeed, half a century ago expert clinics were scaling up of diagnostic and curative services (hopefully with the help
established for ‘tuberculous diabetics’ and appeared to be successful of new tools that are now in the pipeline) and additional preventative
in reducing the otherwise high mortality rate.
6
actions, including addressing diabetes and other risk factors that
increase the individual’s susceptibility for TB.
9
On the other hand, an
In the modern time, the global burden of disease from diabetes and increasing prevalence of diabetes may counteract the positive effects
TB is huge. According to the Diabetes Atlas published by the of improved curative services for TB.
International Diabetes Federation (IDF), in 2007 there were an
estimated 246 million people living with diabetes, amounting to 6% of In the face of this unprecedented health challenge, it is troubling that
the global adult population, and 308 million people with impaired the potential public health and clinical importance of this relationship
glucose tolerance (IGT), amounting to 7.3% of the global adult seems to be largely ignored and no significant initiative has been
population. There are 6–7 million new cases of diabetes and 3.5 undertaken to jointly address this double burden. This neglect may
million deaths ascribed to diabetes each year. In the same year (2007), have disastrous consequences.
10 © TOUCH BRIEFINGS 2009