R
Diabetes in the Caribbean: results of a population
survey from Spanish Town, Jamaica
R. Wilks*, C. Rotimi², F. Bennett*, N. McFarlane-Anderson*, J. S. Kaufman²,
S. G. Anderson*, R. S. Cooper², J. K. Cruickshank³ and T. Forrester*
*Tropical Metabolism Research Unit, University of
the West Indies, Mona, Jamaica
²Department of Preventive Medicine and
Epidemiology, Loyola University Stritch School of
Medicine, Maywood IL, USA
³Clinical Epidemiology Unit, School of
Epidemiology and Health Sciences, University of
Manchester, Manchester, UK
Supported in part by grants from the US National
Institutes of Health, the European Commission
and the Wellcome Trust
Received 20 October 1998; revised 9 March 1999;
accepted 7 June 1999
Correspondence to: Dr Terrence Forrester, Tropical Metabolism Research Unit,
University of the West Indies, Mona, Kingston 7, Jamaica 4, West Indies.
E-mail: tmru@infochan.com
ã 1999 British Diabetic Association. Diabetic Medicine, 16, 875±883
Abstract
Aims To characterize the prevalence of diabetes and associated risk attributes
in the Jamaican population.
Methods A random population sample was recruited by door-to-door
canvassing (n = 1303). A ®nal participation of 60% was achieved. Oral glucose
tolerance testing was conducted after an overnight fast and standard
anthropometric and demographic data were collected.
Results The prevalence of Type 2 diabetes mellitus was 9.8% (95%
con®dence interval (CI) 7.2±12.4) among men and 15.7% (95% CI 13.1±18.3)
among women with an overall prevalence of 13.4% (95% CI 11.5±15.2).
Impaired glucose tolerance was found among 12.3% of men and 14.7% of
women. The sex patterns were consistent with a fourfold excess of obesity in
women compared to men. The odds ratios for diabetes, fourth vs. ®rst
quartiles were 5.42 (95% CI 2.02±16.88) in men and 3.32 (95% CI 1.73±
6.63) in women for body mass index (BMI) and 17.39 (95% CI 3.86±78.27) in
men and 5.48 (95% CI 2.84±11.00) in women for WHR in a logistic model
controlling for age. The population attributes risk percentage, for diabetes, of
being overweight and having waist-to-hip ratio (WHR) greater than the
median (0.80) were 66% and 80%, respectively. The contribution of central
obesity, as characterized by WHR, was also signi®cant in sex-speci®c
multivariate models that included age and BMI. Prevalent hypertension and
family history of diabetes were likewise associated with increased odds of
having the disease.
Conclusions The prevalence of diabetes in Jamaica now exceeds that observed
among European-origin populations and re¯ects the emerging epidemic of
obesity. The excess risk for this population could not be attributed entirely to
relative weight. The pronounced sexual dimorphism in diabetes prevalence
most likely re¯ects the substantial excess of obesity among women compared
to men. Like many other island nations, Caribbean societies now appear to be
at substantial risk of diabetes.
Diabet. Med. 16, 875±883 (1999)
Keywords Caribbean, Jamaica, obesity, Type 2 diabetes mellitus
Abbreviations BMI, body mass index; FPG, fasting plasma glucose; IGT, im-
paired glucose tolerance; NGT, normal glucose tolerance; OGTT, oral glucose
tolerance test; OR, odds ratio; PAR%, population attributable risk percentage;
WHO, World Health Organization; WHR, waist-to-hip ratio
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876 Diabetes in Jamaica · R. Wilks et al.
Introduction
Recent evidence from epidemiological studies in the
Caribbean show that the burden of chronic noncommunic-
able diseases, especially diabetes and hypertension, is
increasing rapidly [1±8]. The rise in the prevalence of
chronic conditions has resulted in the change in the pattern
of mortality over the last several decades and the leading
causes of death in the English-speaking Caribbean
countries now mirror those found in industrialized
societies [3]. Heart disease, cancer, cerebrovascular
diseases, diabetes and other diseases of the circulatory
system represent the ®ve leading causes of death in most
Caribbean countries [3]. Some reasons advanced for the
observed increase in chronic diseases include economic
development and improved health status leading to
increased longevity [9]. Improved living conditions have
been accompanied by rural to urban migration and
increased pressure to adopt a consumer life-style. The diet
typical of Westernized societies, which is high in fat and
sugar and low in ®bre, leads to increased caloric density
thereby increasing the likelihood of excess intake. In
combination with increasing access to labour-saving
devices and a sedentary lifestyle, the problem of chronic
positive calorie balance is manifested in metabolic dis-
orders of epidemic proportions.
The systematic documentation of changes in the
prevalence of obesity and related risk factors in the
Caribbean has been inadequate. Few population surveys
have been conducted to estimate the magnitude of the
problem of diabetes, hypertension and related risk factors,
making the development of public health policy dif®cult.
The present study was undertaken to begin to provide
additional information on the prevalence of diabetes in the
Caribbean at the population level and to evaluate the
association with two primary indices of fatness ± body
mass index (BMI) and waist-to-hip ratio (WHR).
Patients and methods
Participant recruitment
A cluster sampling technique known as probability propor-
tionate to size [10±12] was used to enrol equal proportions of
men and women in ®ve age strata (25±34, 35±44, 45±54, 55±64,
65±74 years) from Spanish Town, Jamaica. Spanish Town, the
former capital of Jamaica, lies 15 miles west of Kingston (the
present capital) and has a population of 110 000 of which
45 000 individuals were in the age range of interest. This
community was selected on the advice of the Statistical Institute
of Jamaica (STATIN) as being most representative of the
demographic pro®le of urban Jamaica and is known to be stable
with little external migration. STATIN has an enviable record
for producing reliable population data. Enumeration districts
derived from the most recent census (1991) represented
appropriate clusters in Spanish Town. The island's most recent
census was used to ascertain the number of persons residing
within each cluster. A random sample of clusters was then
selected giving larger clusters a higher probability of being
selected. After selection, all individuals residing within the
selected clusters were approached to participate in the study.
Households were visited numerous times to increase the chance
of ®nding individuals at home. Eighty-three of 219 clusters were
selected and the aim was to enrol equal numbers in the ten age/
sex categories. Among the 2171 persons contacted, 1303
persons were enrolled and examined, for an overall participa-
tion rate of 60%. The lowest response rate was in the 35±49 year
age group, men worse than women. The protocol was reviewed
and approved by the Institutional Review Board of the
University of the West Indies, Mona.
Measurements
Subjects completed an interviewer-administered questionnaire
covering personal, medical and social history and family history.
Smoking status de®ned as `ever smoked' identi®ed the number of
persons who had ever smoked 100 or more cigarettes. Current
smokers were also identi®ed. Alcohol drinkers were de®ned as
those individuals who had consumed at least 12 drinks in the last
12 months. A drink was de®ned as 340 ml beer, 113 ml wine or
28 ml spirit (e.g. rum).
Blood pressure (BP), height, weight, and arm, waist and hip
circumference were measured using a standardized protocol
[13,14]. All blood pressures were measured to the nearest
2 mmHg as the ®rst and the ®fth Korotkoff phases by using a
standard mercury sphygmomanometer. Three BP measure-
ments were taken 1 min apart after 5 min in the sitting position.
BMI was calculated as the measured weight in kilograms divided
by height in metres squared (kg/m2). Waist and hip circumfer-
ence were measured twice for each participant to the nearest
0.1 cm using a hand-held steel retractable tape. WHR was
calculated as waist divided by hip circumference measured in
centimetres.
Participants were invited to a centrally located clinic in the
Spanish Town Community Hospital after an overnight fast of
12±14 h. Fasting venous blood samples were obtained from each
participant by trained ®eld staff into heparinized and ¯uoridated
tubes. Subsequently, each participant consumed 75 g oral
glucose load (over 2±3 min). Another blood sample was taken
after 120 min for the oral glucose tolerance test (OGTT). Plasma
glucose was estimated using the glucose oxidase method.
Glucose tolerance was de®ned on the basis of WHO recom-
mendations [15] as follows: a participant was classi®ed as
diabetic if fasting plasma glucose (FPG) was > 7.8 mmol/l or if
the 2-h post-load plasma glucose concentration was > 11.1 m-
mol/l. Individuals with a veri®ed history of diabetes (i.e. on
insulin or oral hypoglycaemic agent or diet) were classi®ed as
known diabetic. The prevalence of impaired glucose tolerance
(IGT) was estimated among participants with FPG < 7.8 mmol/l
and a 2-h post-load plasma glucose concentration between 7.8
and 11.0 mmol/l. Participants with both fasting and 2-h plasma
glucose < 7.8 mmol/l were classi®ed as normal glucose tolerance
(NGT). Although WHO does not have a NGT category, we use
the term here, as have others [16], to mean the absence of IGT
and diabetes. Diabetes was also de®ned by the new diagnostic
ã 1999 British Diabetic Association. Diabetic Medicine, 16, 875±883
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Epidemiology 877

criteria as follows: FPG > 7.0 mmol/l (126 mg/dl) or 2-h post-
load plasma glucose concentration > 11.1 mmol/l (200 mg/dl)
or on treatment for diabetes (i.e. insulin or oral hypoglycaemic
agent or diet) [17]. Hypertension was de®ned as systolic
BP > 140 or diastolic BP > 90 or current use of anti-hyperten-
sive medication,
association is one of cause and effect [22]. Therefore, PAR%
represents that proportion of disease in the total population that
could be eliminated by removal of the harmful exposure [22].
For example, the PAR% for BMI could be interpreted as the
proportion of diabetes that could be eliminated if individuals
were encouraged and succeeded in reducing their BMI to below
25 kg/m2.

Statistical analyses

Statistical analyses were performed using programs available in Results

SAS [18] and Intercooled Stata 5.0 (College Station, TX). The
Student's t-test and ANOVA were used to assess differences in
continuous variables while the chi-square test was used for
categorical variables. Prevalence estimates were age-standar-
dized to the total Spanish Town population and also to the
standard world population of Segi [19,20]. Multivariate logistic
regression analyses were used to model the relationship between
diabetes status and known risk factors. Population attributable
risk percentage (PAR%) was determined from a maximum
likelihood estimation of the attributable fraction (AF) from
logistic models (age and sex included) where the exposed
proportion was de®ned as having a BMI > 25 kg/m2. Standard
errors and con®dence intervals are based on asymptotic
approximations calculated on log(1-AF) scale after Greenland
and Drescher [21]. The OR is the odds ratio comparing persons
with BMI > 25 kg/m2 and persons with BMI < 25 kg/m2, adjust-
ing for age and sex [22]. Similar analyses were performed for
WHR, where the exposed proportion was de®ned as those
subjects above the median (WHR > 0.8) and the OR is the odds
ratio comparing persons with WHR > 0.8 and persons with
WHR < 0.8 in a logistic model including age and sex. The
attributable risk provides a measure of the public health impact
of an exposure (in this case BMI and WHR), assuming that the
A total of 1303 persons (520 men, 783 women) partici-
pated in the study (Table 1). Men were slightly older than
women (47.2 vs. 46.2 years; P = 0.2). Female participants,
both shorter and weighing more, were signi®cantly more
obese than their male counterparts (BMI = 23.8 vs. 28.0 kg/
m2; P < 0.001; for men and women, respectively) and had
larger waist and hip circumferences. Females also had
consistently higher BMI and lower WHR than men across
the categories of glycaemic status (Table 2). Over 60% of
the men reported ever smoking cigarettes and using
alcoholic beverages compared to 20% of the women.
Current smoking was reported among 36% and 11% men
and women, respectively (21% total). Current smokers
among those with diabetics was 27% and 8% among men
and women, respectively, compared to 37% and 13%
among normoglycaemic subjects. These differences were
not statistically signi®cant. The prevalence of hypertension
was 21% among men and 28% among women and
increased with increasing age in both men and women.
Hypertension prevalence rose to 52% and 35% in women

Table 1 Basic characteristics of study participants

Men Women Total

Variables Mean (95% CI) Mean (95% CI) Mean (95% CI)

Age (years) 47.2 (46.0±48.4) 46.2 (45.2±47.1) 46.6 (45.8±47.3)

Height (cm) 171.9 (171.3±172.4) 160.8*** (160.3±161.2) 165.2 (164.7±165.6)
Weight (kg) 70.2 (69.0±71.5) 72.4* (71.3±74.0) 71.7 (70.7±72.6)
BMI (kg/m2) 23.8 (23.2±24.2) 28.0*** (27.6±28.4) 26.3 (26.0±26.7)
Waist (cm) 80.8 (79.8±81.9) 83.4*** (82.5±84.2) 82.4 (81.7±83.0)
Hip (cm) 95.7 (94.7±96.6) 104.4*** (103.6±105.2) 100.9 (100.3±101.6)
Waist/hip ratio 0.84 (0.84±0.85) 0.80*** (0.79±0.80) 0.82 (0.81±0.82)
Arm circumference 29.3 (28.9±29.7) 31.1*** (30.8±31.4) 30.4 (30.1±30.6)
Pulse (30 s) 34.0 (33.6±34.1) 36.7*** (36.4±37.1) 35.6 (35.4±35.9)
Frequencies>
Hypertension1 0.21 (0.17±0.24) 0.28*** (0.25±0.32) 0.25 (0.23±0.28)
Hypertension2 0.16 (0.12±0.19) 0.21* (0.18±0.24) 0.19 (0.17±0.21)
Ever smoked 0.61 (0.57±0.65) 0.20*** (0.17±0.22) 0.36 (0.34±0.39)
Current smoker 0.36 (0.32±0.40) 0.11*** (0.09±0.14) 0.21 (0.19±0.23)
Ever drank 0.64 (0.60±0.68) 0.21*** (0.18±0.23) 0.38 (0.35±0.41)
Overweight² 0.33 (0.28±0.37) 0.67*** (0.64±0.71) 0.54 (0.51±0.56)
Obese³ 0.086 (0.06±0.11) 0.34*** (0.31±0.37) 0.24 (0.22±0.26)

BMI, body mass index. Hypertension1: systolic BP > 140 or diastolic BP > 90 mmHg or anti-hypertension medication. Hypertension2: systolic BP
> 160 or diastolic BP > 95 or anti-hypertension medication.
²BMI > 25 kg/m2. ³BMI > 30 kg/m2.
***P-value < 0.0001 and *P-value < 0.05 for difference between two means or proportions (men vs. women).

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878 Diabetes in Jamaica · R. Wilks et al.

Table 2 Mean (95% con®dence intervals) of selected variables strati®ed by glycaemic status and sex

Normoglycaemic Impaired glucose tolerance Type 2 diabetes P-value for differences

(n = 950) (n = 179) (n = 174) between means*

n (male/female) M/F 405/545 64/115 51/123

Age (years) M 44.6 (43.3±45.9) 57.9 (54.7±61.1) 54.1 (50.7±57.7) P < 0.0001
F 43.2 (42.1±44.3) 50.8 (148.4±53.2) 54.9 (52.6±57.0) P < 0.0001
Body mass index (kg/m2) M 23.5 (22.9±24.0) 24.4 (23.0±25.8) 25.4 (23.8±27.0) P = 0.004
F 27.5 (27.0±28.0) 29.1 (28.1±30.1) 29.3 (28.3±30.3) P = 0.003
Systolic BP (mmHg) M 119 (117±121) 134 (129±139) 131 (125±137) P < 0.0001
F 117 (116±119) 129 (125±132) 135 (130±137) P < 0.0001
Diastolic BP (mmHg) M 68 (67±70) 75 (71±79) 72 (68±76) P = 0.003
F 68 (67±69) 73 (70±76) 71 (68±73) P = 0.003
Waist-to-hip ratio M 0.83 (0.82±0.84) 0.87 (0.86±0.89) 0.90 (0.88±0.91) P < 0.0001
F 0.79 (0.78±0.79) 0.80 (0.79±0.82) 0.84 (0.82±0.85) P < 0.0001
Fasting glucose (mmol/l) M 4.8 (4.7±5.0) 5.5 (5.1±5.9) 10.3 (9.8±10.7) P < 0.0001
F 4.8 (4.7±4.9) 5.5 (5.2±5.8) 9.0 (8.7±9.3) P < 0.0001
2 h glucose (mmol/l) M 5.2 (5.0±5.5) 8.9 (8.4±9.5) 14.8 (14.2±15.5) P < 0.0001
F 5.8 (5.6±6.0) 8.4 (8.4±9.3) 14.1 (13.7±14.5) P < 0.0001
Prevalence of hypertension1 (%) M 16.1 (12.5±19.6) 40.6 (28.3±53.0) 35(21.7±48.9) P < 0.0001
F 20.9 (17.5±24.3) 38.6 (29.5±47.7) 52.0 (43.1±61.0) P < 0.0001
Prevalence of overweight²(%) M 29.8 (25.3±34.3) 36.5 (24.2±48.7) 53.1 (38.6±67.5) P = 0.004
F 62.5 (58.4±66.5) 77.4 (69.6±85.2) 80.5 (73.4±87.6) P < 0.0001
Prevalence of obesity³(%) M 6.4 (4.1±8.8) 15.9 (6.6±25.2) 16.3 (5.6±21.1) P = 0.006
F 31.2 (27.3±35.2) 40.0 (31.0±49.1) 41.5 (32.6±50.3) P = 0.035
Prevalence of current smokers (%) M 36.8 (32.1±41.5) 37.5 (25.3±49.7) 27.4 (14.8±40.1) NS
F 13.0 (10.2±15.8) 7.0 (12.2±11.7) 8.1 (3.2±13.0) NS
Prevalence of ever smokers (%) M 61.1 (56.3±65.9) 68.7 (57.0±80.4) 52.9 (38.7±67.1) NS
F 21.1 (17.7±24.6) 17.4 (10.3±24.4) 15.4 (8.9±21.9) NS
Prevalence of alcohol drinkers (%) M 61.1 (61.7±71.0) 68.7 (47.0±71.1) 50.9 (36.8±65.2) NS
F 22.6 (19.1±26.1) 20.0 (12.6±27.4) 12.3 (6.4±18.2) P = 0.039

Hypertension1: systolic BP > 140 or diastolic BP > 90 or anti-hypertension medication. *Differences between three means were assessed using
2
ANOVA and the c -test for categorical variables.
NS, not signi®cant. ²BMI > 25 kg/m2 and ³BMI > 30 kg/m2.

Table 3 Prevalence of impaired glucose tolerance (IGT) and diabetes (DIAB) by age and sex

Men Women Total

Ages n IGT(%) DIAB(%) n IGT(%) DIAB(%) n IGT(%) DIAB(%)

25±34 134 3.0 2.2 197 8.6 2.5 331 6.3 2.4
35±44 113 4.4 6.2 192 13.0 10.4 305 9.8 8.8
45±54 105 17.1 13.3 182 17.6 18.7 287 17.4 16.7
55±64 87 14.9 21.8 126 15.1 30.2 213 15.0 26.8
65 + 81 29.6 9.9 86 25.6 30.2 167 27.5 20.4
Total 520 12.3 9.8 783 14.7 15.7 1303 13.7 13.4

and men with diabetes compared to their normoglycaemic
counterparts (21% vs. 16%, respectively; Table 2).
Although mean FPG was the same for men and women
(5.5 6 2.3 mmol/l), women had signi®cantly higher 2-h
post-glucose values (7.5 6 3.9 vs. 6.6 6 3.7 mmol/l;
P < 0.001). When persons on insulin or oral hypoglycaemic
agents were excluded from the analysis (14 out of 78 people
on insulin or oral agent), the 2-h post-load glucose level
dropped to 6.2 6 2.8 mmol/l for men and 6.9 6 3.0 mmol/l
for women. Mean FPG and 2-h post-load concentration
increased with age with a slight downward trend for the
last age group (65±74 years). The increase in the mean 2-h
level with age was much steeper than was FPG for both men
and women.
Based on the WHO criteria [15] the prevalence of
diabetes was 9.8% (95% con®dence interval (CI) 7.2±
12.4) for men and 15.7% (95% CI 13.1±18.3) for women
(Table 3), with an overall prevalence of 13.4% (95% CI
11.5±15.2). When age-standardized against the overall
population of Spanish Town the rates were 7.6% (95% CI

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Epidemiology 879

Figure 1 Prevalence of diabetes mellitus by quartiles of body mass index (BMI) among Jamaicans, by sex, c2 for trend P < 0.001. Inter-quartile
ranges for men (1st to 4th, respectively): 14.1±20.7; 20.8±22.8; 22.9±26.5; 26.6±48. Inter-quartile ranges for women (1st to 4th, respectively):
14.3±23.5; 23.6±27.5; 27.6±31.6; 31.7±56.2.

Table 4 Age-adjusted odds ratios and 95% con®dence intervals for diabetes by sex-speci®c body mass index (BMI) quartiles

Men (n = 514) Women (n = 782)

BMI² OR³ 95% CI P-value§ BMI² OR³ 95% CI P-value§

14.1±20.7 1.00 ± ± 14.3±23.5 1.00 ± ±

20.7±22.8 2.55 (0.82±8.65) 0.114 23.6±27.5 1.93 (1.00±3.71) 0.049
22.9±26.5 3.17 (1.21±9.40) 0.026 27.6±31.6 2.81 (1.46±5.41) 0.002
26.6±48.0 5.42 (2.02±16.88) 0.002 31.7±59.2 3.32 (1.73±6.63) 0.000

²Sex-speci®c empirical quartiles.

³Age-adjusted odds ratios from sex-speci®c logistic regression models.
§P-value for null hypothesis that adjusted OR = 1.

Figure 2 Prevalence of diabetes mellitus by quartiles of waist-to-hip Ratio (WHR) among Jamaicans, by sex, c2 for trend P < 0.001. Inter-quartile
ranges for men (1st to 4th, respectively): 0.68±0.79; 0.80±0.83; 0.84±0.88; 0.89±1.07. Inter-quartile ranges for women (1st to 4th, respectively):
0.64±0.76; 0.77±0.79; 0.80±0.84; 0.85±1.35.

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880 Diabetes in Jamaica · R. Wilks et al.

5.5±9.7), 12.0% (95% CI 10.0±14.0) and 10.2 (95% CI
8.7±11.6) for men, women and the total population,
respectively. When age-standardized against the standard
world population of Segi, the rates were similar at 9.5%
(95% CI 7.1±12.0), 15.2% (95% CI 12.8±17.5) and
12.8% (95% CI 11.1±14.5) for men, women and the total
population, respectively. Seventeen individuals who re-
ported a history of diabetes and were not on any form of
treatment (i.e. oral, insulin or diet) were classi®ed
according to their FPG and OGTT values. Fifteen of the
17 had normal blood glucose levels (i.e. both FPG and
OGTT values below 7.8 mmol/l) and the remaining two
demonstrated impaired glucose tolerance. Prevalence of
diabetes increased to 11.5%, 17.0% and 14.8%, respec-
tively, for men, women and all persons combined based on
the new American Diabetic Association (ADA) diagnostic
criteria [17]. The mean FPG and 2-h post-load glucose
concentration for the additional 19 persons classi®ed as
diabetic using the new ADA criteria were 7.2 6 0.2 (range
7.0±7.7 mmol/l) and 8.7 6 1.8 (4.6±10.8 mmol/l) respec-
tively. The prevalence of impaired fasting glucose (IFG)
using the new ADA diagnostic criteria was 5.1%. From this
point on, all discussion refers to prevalence estimates based
on the earlier WHO criteria.
As expected, the prevalence of diabetes increased with
age for both men and women, with the highest prevalence
occurring in the 55±64 years age group. This is maintained
in the 65+ age group among women but falls sharply
among this oldest group of men. With the exception of the
youngest age group (25±34 years), women had a higher
prevalence of diabetes in all age groups. The distribution of
IGT followed similar patterns of increasing prevalence
with age. The sex-speci®c prevalence of IGT was 12.3% for
men and 14.7% for women, with a combined prevalence of
13.7%. The IGT : DM ratio was greater among men at 1.3
compared to 0.94 in women.
Based on the sex-speci®c empirical quartiles, there was a
consistent trend of increasing risk with increasing BMI for
both men and women (Fig. 1; Table 4). Comparing all
other quartiles to the lowest quartile, there was a two to
®vefold increased risk of developing diabetes as estimated
from age-adjusted odds ratios obtained from sex-speci®c
logistic regression models. The absolute contribution of
BMI (>25 kg/m2) to the prevalence of diabetes as measured
by the PAR% was 66% (95% CI 52±76).
Similar analyses were performed using WHR for men
and women (Fig. 2, Table 5). As with BMI, the risk of
diabetes increased monotonically with WHR for both men

Table 5 Age-adjusted odds ratios and 95% con®dence intervals for diabetes by sex-speci®c waist-to-hip quartiles.

Men (n = 519) Women (n = 782)

Waist/Hip² OR³ 95% CI p-val§ Waist/Hip² OR³ 95% CI p-val§

0.68±0.79 1.00 ± ± 0.64±0.76 1.00 ± ±

0.80±0.83 2.45 (0.52±17.36) 0.290 0.77±0.79 1.22 (0.54±2.78) 0.635
0.84±0.88 7.47 (1.89±50.15) 0.012 0.80±0.84 2.71 (1.43±5.35) 0.003
0.89±1.07 17.39 (3.86±78.27) 0.000 0.85±1.35 5.48 (2.84±11.00) 0.000

²Sex-speci®c empirical quartiles.

³Age-adjusted odds ratios from sex-speci®c logistic regression models.
§P-value for null hypothesis that adjusted OR = 1.

Table 6 Age adjusted Mantel±Haenszel odds ratio and 95% con®dence intervals by hypertension status and family history

Men Women

Normal vs. IGT or diabetic

Hypertension
(140/90/Meds) 1.93 (1.18±3.17) P = 0.009 1.73 (1.19±2.51) P = 0.004
Hypertension
(160/95/Meds) 1.88 (1.10±3.22) P = 0.021 2.04 (1.38±3.01) P = 0.000
Family history 2.59 (1.54±4.35) P = 0.000 1.66 (1.18±2.34) P = 0.000
Normal. vs. diabetic
Hypertension
(140/90/Meds) 1.83 (0.93±3.59) P = 0.079 2.00 (1.25±3.18) P = 0.004
Hypertension
(160/95/Meds) 1.43 (0.67±3.05) P = 0.351 2.47 (1.54±3.96) P = 0.000
Family history 4.40 (2.18±8.87) P = 0.000 2.38 (1.52±3.73) P = 0.000

IGT, impaired glucose tolerance.

ã 1999 British Diabetic Association. Diabetic Medicine, 16, 875±883


and women. In contrast, however, the increase in risk was
much greater for each subsequent quartile, with a 17-fold
and ®vefold excess for men and women, respectively, for
the highest compared to the lowest quartile of WHR. The
absolute contribution of WHR (> 0.8) to the prevalence of
diabetes as measured by the PAR% was 80% (95% CI 69±
88).
The contributions of family history (i.e. any grand-
parent, parent or sibling) and of concurrent hypertension
are displayed in Table 6. A logistic analysis comparing
people with diabetes to people with normal tolerance
indicated that family history of diabetes was associated
with approximately a fourfold increased risk among men
and a twofold increased risk among women.
Approximately half (82/174) of the diabetic people were
also hypertensive. The OR from the logistic models
evaluating the association between hypertension and
diabetes status were 1.8 for men and 2.0 for women. The
corresponding risk values were 1.4 and 2.5 for men and
women when hypertension was de®ned as systolic BP
> 160 or diastolic BP > 95 or currently taking anti-
hypertension medication. The association of diabetes and
hypertension is signi®cant at both levels of de®nition in
women and in both comparisons, that is, diabetes vs.
normal and diabetes and IGT vs. normal. Among men the
association is not signi®cant in the diabetes vs. normal
comparison where the sample size is smaller.
Discussion
Knowledge of the prevalence of diabetes and associated risk
factors at the population level is essential for proper
planning and implementation of public health policy aimed
at prevention and control. Knowing the magnitude of the
problem will also facilitate rational planning of research
activities directed at understanding the aetiology of diabetes
and implementation of programmes to promote health. The
present study used WHO standardized criteria [15] to de®ne
diabetes and IGT status of a representative sample of men
and women in Spanish Town, Jamaica. The prevalence of
diabetes for these participants with a mean age of 47 years
was 9.8% and 15.7% for men and women, with an overall
prevalence of 13.4%. These estimates are similar to
previously reported rates from Caribbean countries [2±
8,23±25]. The adjustment using the standard world
population of Segi made little difference to the prevalence
estimates and this may be reassuring. There is however, a 2±
4% fall in prevalence when adjusted for the overall
population of Spanish Town. As diabetes prevalence
increases with age this suggests that our sample was older
than the general population of Spanish Town. Among
persons classi®ed as diabetic in this study, 32% were newly
diagnosed cases, which is lower than the estimate of 48%
from an earlier population survey conducted in Jamaica [8].
The observed lower rate of newly diagnosed cases may
ã 1999 British Diabetic Association. Diabetic Medicine, 16, 875±883
R
Epidemiology 881
indicate greater awareness of diabetes resulting in early
screening and diagnoses in the general population.
However, the proportion of newly diagnosed cases is still
very high, an indication of a large reservoir of undetected
cases similar to that reported in the United States [26] and
elsewhere [19]. Furthermore, among the 78 known cases
receiving pharmacological treatment (i.e. insulin and/or
oral hypoglycaemic agents) only 14 (18%) had values for
FPG below 7.8 mmol/l or 2-h post glucose load below
11.1 mmol/l.
The participation rate in this population survey was 60%.
While it is recognized that this relatively low rate may reduce
the generalizability of the study ®ndings, it is however,
higher thanthe estimate of57.9% fromprevious population
survey in Jamaica [8]. Given that each participant was
expected to undergo an OGTT, the participation rate of
60% at the population level will be considered a success by
most investigators in this line of scienti®c endeavour.
Furthermore, studies that require venepuncture will gen-
erally become less attractive in Jamaica because of the
unfounded but widely held belief that one is at risk of
acquired immune de®ciency syndrome (AIDS).
The pathophysiological signi®cance of the high rate of
IGT observed in this population (12.3% for men and 14.7%
for women) is not clear. Some investigators have suggested
that it may indicate an increase in the public health impact of
diabetes in the future [16,19,26,27]. It has also been
suggested that the ratio of IGT to Type 2 diabetes mellitus
may indicate the stage of an epidemic of glucose intolerance
within a population [28]. The ratio in this study is similar to
that observed in industrialized societies, an indication that
diabetes is not an emerging disease in Jamaica. Thus, by all
criteria, the problem of diabetes has reached epidemic
proportions in this and other communities in the Caribbean.
A caveat is, however, in order. Given the relative leanness
(meanBMI = 23.8 kg/m2)ofthemeninthiscommunity,IGT
may not necessarily mean deterioration of carbohydrate
metabolism since on repeat testing IGT often reverts to
normal tolerance in lean and physically active populations
[29±32]. It may be that the impact of obesity on diabetes
prevalence has reached a plateau among women while it is
still increasing among men. This question was not examined
directly in the present study.
There is limited evidence on the secular trends in the
prevalence of diabetes in Jamaica. Florey et al. [33] reported
aprevalenceof8.1%inbothmenandwomeninthesameage
group using criteria suggested by FitzGerald and Keen [34].
Diabetes was de®ned as a 2-h post-prandial glucose in
venous blood of greater than 6.7 mmol/l or greater than
8.9 mmol/l at some other time point during a glucose
tolerance test. These criteria would include as diabetic some
of the subjects classi®ed in our study as having IGT. The
prevalence of diabetes mellitus in this study at 9.8% and
15.7% among men and women, respectively, is by
comparison an underestimate. Using similar criteria the
L
882 Diabetes in Jamaica · R. Wilks et al.
increase in prevalence of diabetes over the last 25 years
would have been more marked than the 9.8% vs. 8.1%
among men and the 15.7% vs. 8.1% among women
suggested by this comparison.
Similar to results from other Caribbean countries and the
USA, there was a signi®cant rise in FPG with age. The oldest
age group (65±74 years) showed a lower rate of rise relative
to those who are younger. The prevalence of diabetes among
men in this age group was also signi®cantly lower. Some of
the reasons that have been advanced for these observations
include differential exposure by age group and decreased
availability of susceptible persons in the non-diabetic
population with age. Selective mortality prior to this age
group may have accounted for this. A clear example of a
cohort effect may be an increased energy intake and
declining physical activity for more recent generations
[16]. Cohort effects may also have a signi®cant impact on
known risk factors, including relative weight, as measured
byBMIandfatdistribution,measuredbyWHR.Therewasa
clear and consistent gradient between diabetes prevalence,
BMI and WHR for both men and women. Independent of
BMI, the OR for WHR was 1.6 (95% CI 1.4±1.8), lending
supporttothenotionthatapartfromtheriskassociatedwith
overall heaviness, fat distribution, especially around the
waist, adds to the risk of diabetes [35±37]. The PAR% was
66% and 80%, respectively, for BMI and WHR, suggesting
the need for vigorous prevention efforts among even those in
the normal range of relative weight.
The epidemic of obesity in the Caribbean, especially
amongwomen,isbeginning toreceivedeservedattention,as
evidence by the recent conference on the origins and
consequences of obesity [38]. Using the National Institutes
of Health consensus values (BMI > 27.8 kg/m2 for men and
27.3 kg/m2 women), Forrester et al. reported that females
have twice the rate of being overweight as males in Jamaica,
Barbados and St Lucia [9]. For women the rate of obesity,
de®ned as a BMI > 31.1 kg/m2 for men and 32.3 kg/m2
women, was four times that of men in Jamaica (3.9 vs.
15.6%). In Barbados, the rate of obesity for women was
three times that of men, with over 30% of the women
classi®ed as obese [9]. Similar high rates of overweight and
obesity has been observed in the island of Trinidad [2]. The
WHO classi®cation for obesity suggests that a BMI < 25 kg/
m2 is normal, however, two recent studies have shown that
BMI within the so called safe range are associated with
diabetes [39,40]. In our data analysed by BMI quartiles
(Table 4), there is an increased risk of diabetes beginning
with the second quartile (a lower limit of 20.8 kg/m2 for men
and 23.6 kg/m2 for women). Although statistically signi®-
cant for women, the failure to achieve signi®cance for men
probably re¯ects the small sample size involved in the
comparison between the second and ®rst quartile. When the
data was dichotomised at a BMI of 23 kg/m2, individuals
above this cut off were at an increased risk of diabetes in both
men (OR = 2.84 (95% CI 1.47±5.47); P = 0.002) and
women (OR = 3.24 (95% CI 1.76±5.97); P < 0.0001),
supporting the data of Perry et al. [39] and Colditz et al.
[40]. As has been suggested [41], increases in the prevalence
of obesity within a population often precede a rise in the
incidence of chronic diseases, most notably diabetes and
hypertension.
While obesity, which undoubtedly has environmental as
well as genetic causes, contributes signi®cantly to the
incidence of diabetes, it accounts for only a small proportion
of the variance in glucose tolerance. The signi®cant
independent contribution of family history of diabetes
observed here and in other studies [16,42,43] suggests the
presence of genes that may increase susceptibility to
diabetes. Another important risk factor that was not
measured in the present study is the level of physical activity
[44,45]. Our research group is in the process of testing the
hypothesis that the difference in diabetes rate observed
between Jamaican and Nigerian men, who have similar
levels of obesity, is a result of, in part, differences in physical
activity and different body composition [46]. Preliminary
®ndings of a on-going study indicate that for a given BMI,
Nigerian men have 50% lower levels of body fat. Parallel
studies measuring resting metabolic rate and total energy
expenditure using double-labelled water in Nigeria,
Jamaica and the US suggest group differences in physical
activity.
In summary, evidence presented here con®rms previous
reports that the prevalence of diabetes and associated risk
factors, especially obesity, has reached epidemic propor-
tionsin theCaribbean. Rates,atleast amongwomen,exceed
those for most European-origin populations [19]. While it is
imperative to re®ne our understanding of the epidemiology
and genetics of diabetes, the implementation of coherent
public health policy advocating preventive practices ±
including reduction in the level of obesity through nutri-
tional education and increased physical activity, an under-
standing of family history and early detection programs for
high risk groups ± has become an urgent challenge.
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