Gaps in Guidelines for Diabetes Management in Low- and Middle-Income Countries

Investigators examined gaps in guidelines for type 2 diabetes in low- and middle-income vs high-income countries.

Most guidelines for diabetes management in low- and middle-income countries address a narrow spectrum of clinical care and are insufficient in terms of clarity, applicability, ethical-legal and socioeconomic contextualization, and dissemination plan, compared with those in high-income countries. Furthermore, guidelines from low- and middle-income countries comply with less than half of the Institute of Medicine standards and primarily target health care providers as their audience, with very few also including policy makers, payers, and patients. These findings were described in a study recently published in Diabetes Care.

Country-specific recommendations on type 2 diabetes management published between 2006 and 2016 were included in this review. In the case of duplicates, the most current guideline was included. Numerous electronic medical databases were used for searches, as well as Google and national ministries of health and diabetes associations. Study investigators also contacted the Global Alliance for Chronic Diseases Research Network as a source of relevant guidelines. These efforts produced 2695 guidelines total, which were assessed and reduced to 56 eligible, non-duplicate guidelines from 55 countries.  

After a systematic review, it was determined that the quantity and quality of diabetes management guidelines from low- and middle-income countries were inadequately compared with those from high-income countries. Guidelines often did not identify or were vague about the source of contained recommendations, and the information was not contextualized to target the unique environmental factors of each country such as technology, policies, culture, philosophy of care, available resources, or special situations such as surgery or hospitalizations; nor were guidelines for recommended actions and medication issues made explicit. Detailed and contextualized information is particularly important in low- and middle-income countries where health care services are more likely to be carried out by non-clinicians such as community health workers. Guidelines also rarely addressed patient education, which is crucial for the management of diabetes.

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Study investigators conclude that “A new approach to the contextualization, content, and delivery of [low- and middle-income countries] guidelines is therefore recommended. Guideline(s) should… recommend clear up-to-date clinical interventions carefully contextualized with respect to specific sociocultural and economic barriers and facilitators. This should go a long way in reducing the burden of [diabetes] generally and in [low- and middle-income countries] particularly.”


Owolabi MO, Yaria JO, Daivadanam M, et al; for the COUNCIL Initiative. Gaps in guidelines for the management of diabetes in low- and middle-income versus high-income countries—a systematic review. Diabetes Care. 2018; 41(5):1097-1105.