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