Introduction

Within the last couple of decades, non-communicable diseases (NCDs) have gained worldwide attention, especially in low- and middle-income countries (LMIC), where they have been increasingly recognized and prevalent [1, 2]. Among the NCDs, diabetes mellitus has become a global health challenge [1, 3, 4]. Type 2 diabetes mellitus—the most common form of diabetes—due to its rather silent disruption may be a current uninvited companion to over 465 million persons worldwide. In 2019, it was estimated that the number of persons with diabetes in Latin America (LatAm) was 31.6 million [5, 6] and is predicted that by 2030, the number will increase to 40.2 million, and to 49.1 million by 2045 [6].

Because of its multi-organ and multi-system impact, diabetes has been associated with both acute and long-term complications that affect not only health care needs and costs but also wellbeing and productivity [7, 8]. Within the last decade, it has also been recognized as one of the leading causes of death in some LatAm countries [9,10,11,12,13,14,15] and an important risk factor for cardiovascular diseases (CVD), which is the leading cause of death in LatAm [14, 16].

Far from being a monolithic group, the LatAm population is highly heterogeneous, with various populations reflecting diverse genetic ancestry, ethnicity, culture of origin, sociopolitical contexts, environmental exposures, and beliefs and practices [17, 18]. Levels of inequality in LatAm remain among the highest in the world [19,20,21,22]. All these factors—coupled with biological susceptibility, income, education, access health care, cultural influences on nutrition, health, self-image, and self-care—influence the development of diabetes in LatAm.

We conducted a review of the most current publications on the state of prevalence, awareness, treatment, and control of diabetes mellitus across LatAm. By laying out a detailed accounting of what is known, we aim to identify population, clinical, and health care needs, and opportunities for future research studies and potential interventions.

Literature Search and Review

We conducted the search using the PubMed electronic database as the primary scientific literature source. LatAm was defined as the countries in the Western hemisphere which were previously colonized by Spain, Portugal, or France. A combination of keywords was used to define the scope of the searches: diabetes prevalence, awareness, treatment, control, guidelines of care, adherence, retinopathy, nephropathy, neuropathy, foot care, fundoscopic exam, and urine albumin, and searched under LatAm and by each individual country. Hispanics/Latinos living in the USA were not included in the search.

We limited the search to publications since 2000 to reflect the most recent research on the prevalence of diabetes across LatAm countries, assessments of awareness, treatment, and control of diabetes (glycemic control), blood pressure and low-density lipoprotein cholesterol (LDL-C), and adherence to guidelines for care recommended by the American Diabetes Association (ADA) [23,24,25] and the Latin American Diabetes Association (ALAD) [26], and specifically hemoglobin A1c (HbA1c) measurement, fundoscopic exam, foot exam, and urine albumin excretion test. We included literature written in English, Spanish, French, and Portuguese.

In addition to PubMed, when available, we manually searched each country’s Ministry of Health and the Pan American Health Organization (PAHO) websites and accessed published and downloadable national health surveys performed during the selected timeframe. Since most available studies did not distinguish between type 1 and type 2 diabetes mellitus, our review is centered on diabetes mellitus (diabetes, henceforth) in general. Because their specific mechanisms of disease and clinical implications, gestational diabetes mellitus, and type 1 diabetes merit separate reviews.

Prevalence of Diabetes Mellitus in Latin America

The earliest contemporary reports on the prevalence of diabetes mellitus among adults throughout LatAm date from the 1950s and 1960s [27,28,29], when most countries were beginning to experience epidemiologic transitions [30, 31]. In 2001, Barceló reported an incidence of type 1 diabetes in LatAm in the range 0.1 cases/100,000 in Venezuela to 17.4 cases/100,000 in Puerto Rico [32]. However, the authors highlighted a handful of reports on the prevalence of type 2 diabetes and underlined the near absence of surveillance for the disease throughout the LatAm region [32].

From 2005 to 2020, the prevalence of diabetes mellitus across LatAm has been assessed within individual countries and through multinational studies [33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114] and ranged between 3 and 36.3% (Fig. 1, Table 1). In our review, some national surveys assessed the prevalence of diabetes via population representative samples [33, 36, 38, 40, 42,43,44, 47, 49, 55, 60, 61, 65, 66, 68, 72, 85,86,87, 89, 91, 96, 98, 105, 107] and used similar population sampling methods (e.g., multi-stage, clustered, probabilistic sampling), whereas other studies focused on specific geographic regions or communities [34, 35, 37, 45, 46, 48,49,50,51,52,53,54, 56,57,58, 63, 67, 73,74,75, 77, 82,83,84, 92,93,94,95, 102, 110,111,112], recruited participants from clinical settings [51, 59, 62, 69, 95], or focused on specific age groups [37, 42, 56,57,58, 75, 109, 112]. Also, the age range of the population surveyed—and consequently, age-adjustment estimates—varied among surveys.

Fig. 1
figure 1

Prevalence of diabetes mellitus in Latin America Based on national surveys from 2000 to 2020. Prevalence data was extracted from national surveys, when available. Prevalence was estimated either by self-report of diabetes exclusively or in combination with glycemic tests. References next to each country’s name in [brackets]

Table 1 Prevalence of diabetes mellitus across Latin America based on reports published from 2005 to 2020

Most of the studies (especially national surveys) reported the overall prevalence of diabetes without differentiating between type 1 and type 2 diabetes mellitus and many estimated the prevalence of the disease based on self-report (being aware of having diabetes and/or taking antihyperglycemic medications) only. Some national surveys and independent studies estimated the prevalence based on the sum of self-report and identifying individuals without history of diabetes but hyperglycemia within the diabetes range [26, 115]. The latter group was considered to have “suspected,” “undiagnosed,” or “unknown” diabetes. Hyperglycemia within the diabetes range was assessed by measuring fasting blood or plasma glucose (FBG or FPG) only, FBG/FPG and 2-h oral glucose tolerance test (OGTT), FBG/FPG and hemoglobin A1c (HbA1c), HbA1c only, or the combination of FBG/FPG, OGTT, and HbA1c, or glucose levels in urine. Some studies measured capillary blood glucose (CBG), while most studies measured venous blood or plasma glucose. While multiple studies used the ADA/ALAD-recommended glucose/HbA1c cut points for the diagnosis of diabetes [26, 115], some studies used different thresholds (e.g., fasting glucose ≥ 100 mg/dL (per CBG), random blood glucose ≥ 140 mg/dL, or random blood glucose ≥ 200 mg/dL).

Although the differences in the methodology described above limit the ability to perform cross-sectional or trend comparisons among countries, we note several commonalities. During 2005–2020, some countries reported an increase in the prevalence of diabetes [33, 36, 38,39,40, 66, 70,71,72, 79, 85, 86], consistent with previously published reviews [5, 15, 32, 116,117,118,119,120,121,122,123]. Compared with the rest of the region, and as previously reported [5, 15, 32, 124, 125], diabetes prevalence varies across the region, with higher prevalence in Mexico (13.7%), Haiti (14.1% in women and 8.2% in men), and Puerto Rico (12.5–12.7% in the population aged 18 ≥ years and 26.8% in the population aged ≥ 45 years), and lower in Colombia (3.0% in the population aged 18 ≥ years, but 11.2% in age group ≥ 60 years), Dominican Republic (3.5%), Ecuador (2.7%), Peru (3.7%), and Uruguay (5.5–6.0%) (Fig. 1, Table 1). Multiple studies reported a greater prevalence of diabetes among women [36, 38, 40, 42, 44, 47, 49,50,51,52, 57, 60, 62, 63, 65, 70, 72, 75, 78, 79, 83,84,85,86, 90, 95, 96, 110, 113], and with increasing age, especially over age 60 years [33, 36, 44, 47, 50, 55, 69,70,71,72, 78, 80, 81, 86, 91, 93, 110]. Some studies reported an inverse relationship between diabetes and socioeconomic status (SES) [33, 79, 103] or educational attainment [33, 44, 62, 63, 70, 72, 73, 75, 76, 78, 79, 86, 101]. Other studies reported a direct relationship between having health insurance and self-reported diabetes [42, 70, 97, 100], implying that persons who have health insurance—proxy of access to health care services—would be aware of their health issues and report them accordingly. This interaction also poses questions about not only the access to health care but also the timeliness and quality of the care, and health literacy (or the lack of) that persons in the lowest SES—and at the highest risk of diabetes—would experience. Some studies reported a lower prevalence of diabetes among indigenous populations [35, 48, 74], with one study proposing that exposure to urbanicity was associated with an increased prevalence of diabetes among some indigenous communities [83]. Indeed, rural to urban migration (or living in rural compared with urban areas) has been associated with increased prevalence or risk of developing diabetes in Peru [126, 127], and multiple countries reported a lower diabetes prevalence in rural compared with urban settings [33, 39, 47, 60, 65, 89,90,91, 99, 103].

The number of epidemiological studies published since 2005 indicates greater public health awareness about diabetes mellitus across LatAm. Multiple countries have performed at least one national survey on chronic non-communicable diseases in which self-reported diabetes mellitus and/or elevated glycemia has been included (Table 1). Some surveys have also included at least one laboratory test (i.e., fasting or random blood glucose measurement or HbA1c), which could identify individuals at risk of developing diabetes or those who may have it and are not aware of it. Because hyperglycemia may be mediated by at least two mechanisms of disease—increased hepatic glucose output manifested as fasting hyperglycemia and uncoupled postprandial insulin secretion manifested as postprandial hyperglycemia [115, 128]—a single blood test or measurement may not identify all or most of individuals affected by the disease [115]. Therefore, the actual prevalence of diabetes may still be underestimated in many countries, as highlighted in previous reviews [5, 15, 124].

The etiologies of diabetes mellitus are complex. Thus, the increasing prevalence of diabetes experienced across LatAm may reflect the convergence or interaction of multiple factors [18, 125, 129]. For instance, the increasing prevalence of overweight and obesity documented across LatAm has paralleled the increasing prevalence of diabetes in the region [84, 125, 130, 131]. In addition to increased adiposity, type 2 diabetes mellitus and insulin resistance have also been linked to malnutrition (at different life stages) in some LMICs [130, 132,133,134]. Stress associated with chronic poverty, intergenerational poverty, natural disasters, and other adverse events [1, 129, 132, 135] has been linked to chronic systemic inflammation and epigenetic changes, potential common denominators of multiple NCDs [136, 137]. Many LatAm major cities may be epicenters where a fragile built environment and infrastructure and changes in lifestyle and nutrition intersect increasing the cumulative risk of developing diabetes in low-income communities [30, 126, 127, 129, 135, 138, 139]. Increased life expectancy has been associated with increased diabetes prevalence [4, 16, 30, 125, 140], whereas higher educational attainment, increased access to health care, and higher health literacy level are associated with increased awareness of the disease [117]. These are all factors to consider upon designing comprehensive diabetes prevention and treatment strategies across LatAm countries.

In addition, the growing prevalence of diabetes mellitus across LatAm and the complexity of the disease suggest opportunities to create or strengthen collaborations towards its prevention and early detection [141,142,143,144]. For example, multinational and multidisciplinary research–public health–health care policy–clinical care partnerships which already exist in formal or informal platforms may be well-positioned to evaluate the impact of nutrition, health insurance, housing, and other public policies [79, 141, 143, 145,146,147,148,149,150,151,152,153,154] on health outcomes and assess their potential translation into preventive strategies at the public health and clinical care levels. At the same time, the eventual implementation of such strategies will be strengthened by local governments’ commitment to prioritize the prevention and treatment of NCDs, in this case, diabetes, as previously voiced by experts and advocates in the region [79, 141, 155,156,157,158].

Diabetes Awareness, Treatment, and Control

Diabetes Awareness

Although fewer than studies focused on prevalence, a considerable number of reports centered on diabetes awareness, treatment, and control across LatAm were published between 2005 and 2020 (Table 2) [33, 37, 40, 41, 43, 44, 49, 51, 60,61,62,63, 65, 72, 73, 87, 98, 101, 103, 104, 111, 112, 159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189]. A few of the studies evaluated diabetes awareness, treatment, and control altogether [85, 185, 189]. Most studies did not use the term “diabetes awareness,” but equated it (or more appropriately, diabetes unawareness) to “suspected,” “undiagnosed,” “unknown,” or “new” diabetes or “elevated glycemia.”

Table 2 Diabetes awareness, treatment, and control across Latin America based on reports published from 2005 to 2020

“Undiagnosed” diabetes—a proxy for lack of diabetes awareness—ranged widely from 10.3 to 50% across studies and countries (Table 2). The prevalence of undiagnosed diabetes was higher in Guatemala (48.8%), Uruguay (48.7%), Puerto Rico (37.7–50%), Honduras (31.9–53.7% range), Mexico (29.9–50% range), and Nicaragua (43.3%) and lower in Colombia (Bogota) (23.5%), the southernmost countries of South America (20.2%), and Costa Rica (10.3–28.4%). Irazola et al. [189] described that diabetes awareness slightly increased with educational attainment. However, associations between undiagnosed diabetes with age, sex, educational attainment, SES, or geographic location were not published by most studies.

The observed range of undiagnosed diabetes suggests that the actual prevalence of diabetes across LatAm could exceed previous estimates [6, 124] and that a potentially significant proportion of persons with diabetes for whom both macro- and microvascular complications may be present but not assessed and treated. Therefore, current estimates of the prevalence of diabetes across continents may not fully account for the necessary resources to provide adequate health care for Latin Americans with diabetes [7, 8, 190, 191]. Considering the workforce and resources needed to screen the millions of persons across the region who are at risk of diabetes or have the disease and are not aware, experts have proposed diabetes predictive models requiring specific easily obtained clinical data points that could be readily used in primary care settings [192,193,194]. Also, the Finnish Diabetes Risk Score (FINDRISC) has been proposed, tested, or modified to screen and identify individuals at high risk of developing diabetes in Latin America [195,196,197,198,199]. Point-of-care tests for HbA1c and urine microalbumin have also been proposed as alternatives to identify persons with “undiagnosed diabetes” and/or those at risk of chronic kidney disease (CKD) in low-resource and remote settings in LatAm [200,201,202,203]. The standardization, reliability, and repeatability of some of these tests, as well as the clinical and public health benefit derived from their integration into the health care systems, may need to be determined [204]. However, these and other emerging diagnostic technologies [205, 206] are promising alternatives that could be incorporated to assess the prevalence of diabetes and implement timely interventions.

Treatment and Control of Diabetes, Blood Pressure, and LDL-C

The percent of persons with diabetes following any treatment for diabetes ranged from 52.6 to 99% across studies (Table 2). Prescription and/or use of antihyperglycemic medications was mostly assessed via interviews, although a few studies evaluated medical records. Most individuals reported taking oral antihyperglycemic medications either as monotherapy or as a combination of oral medications, while a smaller percent reported using insulin alone or in combination with oral medications. Five (5%) to 12.9% only followed diet/exercise prescription [161, 163, 167, 176, 179, 186], and 3.2 to 10.1% were not taking any medications [41, 104, 168, 169, 175]. Receiving or adhering to pharmacological treatment was positively associated with having health insurance [71], and receiving medical care in private rather than public health care settings [71, 187]. At least one study observed better pharmacologic treatment adherence with female sex [185].

Achievement of ADA/ALAD-recommended glycemic goals [23, 207] was assessed by multiple studies. The percentage of persons attaining HbA1c < 7% ranged from 3.5 to 54%. However, some studies defined glycemic control based on fasting or random blood glucose thresholds and reported attainment of glycemic control in the 31.4 to 61.4% range. Attainment of glycemic control was associated with higher socioeconomic status (SES) [160], having health insurance [160], and better access and services [208]. Not attaining glycemic control was associated with longer duration of diabetes [163, 187, 209], taking insulin (alone or in combination with oral antihyperglycemic medications) [176], forgetfulness (e.g., taking multiple medication for more than one condition) [185], complex therapeutic regimes [209], inadequate access to health care services [22], and availability or health insurance coverage of medications [187], among other factors.

In addition to glycemic control, a smaller number of studies examined the attainment of ADA/ALAD-recommended blood pressure and LDL-C—blood pressure < 130/80 mmHg and LDL-C < 100 mg/dL—for patients with diabetes [24, 207]. The percentage achieving blood pressure goals ranged from 25 to 67%, and the percent achieving LDL-C goals ranged from 12 to 52.6% (Table 2). The percent achieving optimal glycemic, blood pressure, and LDL-C levels altogether was reported by a handful of studies and up to 9.9% (Table 2).

The findings described above denote critical aspects of the state of diabetes care in Latin America. The achievement of glycemic goals reported by the studies included in our review is similar to previously published studies [164, 179, 180, 187, 210]. This implies seriously chronic and inadequate glycemic control at the population level across the region.

The inclusion of questions on treatment for glycemic control, medical, and self-care in some national surveys increases our understanding of health-seeking behaviors, both patients’ and clinicians’ adherence to recommended guidelines of care, and challenges related to the utilization of health care services and availability of medications. The smaller number of studies reporting on the attainment of blood pressure and LDL-C goals and the proportion of patients achieving those goals also poses questions about the prevention of macrovascular complications in persons with diabetes in Latin America, considering the raising prevalence of CVD in the region [16, 211]. Of note, most national surveys report prevalence and treatment and/or control of diabetes, hypertension, and blood cholesterol and the prevalence of tobacco use individually. Since diabetes involves multiple organs and deserves a holistic care approach, reporting on the co-existence of other CV risk factors with diabetes would enhance critical understanding of CV risk and health care needs. Also, some surveys collected biospecimens, but the test results were not included in the reports. It is possible that they are analyzed and published later. Yet including test results in the surveys would offer a more comprehensive picture of the status of diabetes prevention and care needs [180, 212, 213] to plan interventions accordingly.

Following Guidelines of Care for the Prevention of Microvascular Disease

Various studies included in our review reported on participants’ receiving or following ADA/ALAD-recommended guidelines of care [25] for early detection and prevention of microvascular disease—annual fundoscopic exam, examination for peripheral neuropathy and comprehensive foot examination, annual function/urine albumin excretion testing, and HbA1c tested at least 3 times per years [38,39,40, 72, 96, 159, 160, 165, 166, 168, 169, 171, 172, 175, 176, 180, 182, 186, 214] (Table 3). Some studies assessed the completion of several guidelines, whereas most studies focused on a few. The completion of the selected ADA guidelines varied, ranging from 14.7 to 97.5% for the foot exam, from 8.6 to 92% for the fundoscopic exam, and from 1.1 to 51.1% for the urine albumin excretion test. Most studies (especially national surveys) inquired about having HbA1c checked within the previous 12 months. The affirmative response ranged from 3.7 to 90.0%. In addition to inquiring about HbA1c testing, some surveys asked whether the participant’s blood glucose had been tested (by a health care professional). Having private health insurance was associated with a greater number of affirmative responses to the latter [70, 71, 91].

Table 3 Completion of selected ADA-recommended guidelines of care across Latin America on reports published from 2005 to 2020

Despite the smaller number of studies evaluating the completion of the ADA guidelines for foot care and prevention of microvascular disease, and the varied guideline completion rates previously described (Table 3), the prevalence of long-term microvascular complications associated with diabetes has been documented across LatAm. For instance, in the studies included on our review and others published during the same time frame, the rate of foot ulcers ranged from 1.2 to 14.8% [40, 214,215,216], and non-traumatic lower extremity amputations attributable to diabetes ranges from 1.2 to 7.3% [40, 184, 214, 215, 217,218,219,220,221], and the prevalence of diabetic retinopathy ranged from 11.2 to 48% [40, 184, 214, 222, 223]. CKD has become a major public health concern across Central America [224,225,226], and the increasing prevalence of diabetes could exacerbate the incidence of CKD—and eventually end-stage renal disease and its associated health complications—in the region [227,228,229].

Innovative Solutions: Emerging Research and Alternative Models of Care

The findings described above underline not just the urgent need to prevent diabetes but also to prevent complications among those with established disease, and the potentially underestimated burden on patients, societies, and health care systems across LatAm. In this regard, several innovative models of health care for patients with diabetes have been proposed and tested throughout LatAm. Combining care of diabetes and other chronic conditions would be expected to maximize time and resources and improve health outcome. Although combining diabetes and chronic pulmonary disease care did not demonstrate a difference in outcomes [230], this model could be revisited. Also, interventions at the health care system element of the chronic care model might need to be adapted to the local health care system [231] or synchronized with interventions at other levels. Improvement of health care system structure and processes [232] would assure timely access to patient information and enhance clinician decision-making. Integrating social determinants of health into diabetes care demonstrated objective improvements in patient knowledge and cardiometabolic parameters [233]. Enhancing medical continuing education [234], an intervention combining diabetes prevention and self-management [235], co-creating interventions with community stakeholders and other countries [141, 144] are other examples of alternatives to improve diabetes care throughout the region. Another major regional example of efforts to implement better care for patients with diabetes has been led by the Latin American Diabetes Association (ALAD in Spanish) to engage 17 medical associations and wrote a consensus statement on the treatment of type 2 diabetes in LatAm [207].

Kaselitz et al. published a scoping review of policies and interventions for diabetes in LatAm [147], telehealth, mobile clinics, and other non-traditional health care delivery models. In addition, a non-exhaustive list of examples of past or current interventions, policies, and initiatives is provided in Table 4 [184, 186, 234, 236,237,238,239,240,241,242,243,244,245,246,247,248,249,250,251,252]. Interventions in the list include tele-ophthalmology [249, 250, 253, 254], team-based foot self-care education [236], diabetic retinopathy education and screening at a community pharmacy [255], rapid assessment/diagnostic tools to screen for or detect retinopathy, nephropathy, and risk of developing foot ulcers [201, 256,257,258,259,260,261,262] and are examples of clinical research and/or implementation activities designed to strengthen the prevention and early detection of diabetes-associated complications and improve health outcomes throughout LatAm.

Table 4 examples of past and ongoing diabetes care interventions initiated in Latin America from 2000 to 2020

Many interventions on diabetes care have focused on patients and/or clinicians as the primary recipients or enablers of the interventions. Because of the complex nature of the disease and the multiple factors that mediate treatment effectiveness, interventions involving other levels or elements within the health care organization or system [155, 157, 232, 263,264,265] or the health care workforce [158, 263, 266] could be considered. Interventions involving other sectors (e.g., housing, infrastructure, national or local policies) could uncover very valuable and needed strategies to enhance treatment effectiveness and potentially reduce health care costs in the long-term. The feasibility and sustainability of such research efforts—and subsequent policies—would need to be demonstrated and supported locally [143].

Additional Observations

Women

Multiple studies in our review reported a higher prevalence of diabetes among women [36, 38, 40, 42, 44, 47, 49,50,51,52, 57, 60, 62, 63, 65, 70, 72, 75, 78, 79, 83,84,85,86, 90, 95, 96, 110, 113]. While the mediating factors for this sex difference need further study (e.g., history of GDM, which was outside of the scope of this review), the increased prevalence of diabetes among women in some LatAm countries would be expected to have implications for health and health care, and potentially future generations [267,268,269]. Since diabetes may increase women’s risk for CVD, including stroke [270], cognitive decline [271, 272], or some cancers [273, 274], timely and comprehensive preventive care for women of all ages would need to be prioritized.

Older Adults

Due to the epidemiologic transition already experienced by some countries throughout LatAm, the population pyramid is also shifting towards a greater proportion of older adults. Studies included in our review consistently reported an increased prevalence of diabetes with age. Diabetes care challenges specific to this age group include risk of obesity or undernutrition [42, 56], increased risk for disability [57], economic barriers to appropriate access to health care [42], disruption in funding of health insurance [275], disparate completion of diabetes care guidelines based on health insurance coverage [276], inequalities in access to and utilization of health care services [277,278,279], complex medical care needs and frailty [280], cultural beliefs, mental health, and lack of family or social support [281], among others. Prevention of diabetes and its complications and reliable continuity of care and social support [282] need to be especially tailored for this population across the region.

Indigenous and Other Ethnic Underserved Populations

A few studies in our review reported a low prevalence of diabetes among some indigenous populations in LatAm [55, 74, 82], in parallel to some previous reports [283,284,285,286] about other indigenous groups in the region and in contrast with the higher prevalence of diabetes among American Indians in the USA [287] and the First Nations in Canada [288]. However, other studies in our review and in the current literature have documented elevated diabetes prevalence or risk among indigenous and other socioeconomically disadvantaged ethnic groups [48, 50, 73, 76, 77, 83, 90, 91, 166, 289,290,291,292,293]. Some of the diabetes prevalence studies included in our review focused on or mentioned participants from indigenous groups [35, 48, 50, 74, 83] and other underrepresented groups (e.g., Garifuna, Afro-Panamanian, Afro-Peruvian, Afro-Ecuadorian) [55, 76, 90, 91, 166]. However, a few studies have evaluated diabetes care, prevalence, and/or prevention of macro- or microvascular complications, diabetes management interventions, other health care needs and access to health care among indigenous populations [241, 244, 246, 294,295,296,297,298,299,300,301,302], and none on the other groups (that we could identify through our search). Understanding the protective mechanisms (e.g., biochemical, immune, epigenetic) against diabetes experienced by some indigenous populations would be relevant to millions at high risk of developing diabetes. At the same time, the increased prevalence of the metabolic syndrome and diabetes experienced by some indigenous groups and other ethnic groups may increase their risk not only for CVD and other diabetes long-term complications but also for re-emerging infectious diseases, like tuberculosis [303,304,305]. Therefore, disease prevention and health care models that account and reach these populations need to be considered.

Conclusion

Through this review, we have highlighted the most current reports on prevalence, awareness, treatment, control, and adherence to recommended guidelines of care for diabetes mellitus across LatAm published from 2000 to 2020. During that time frame, a considerable number of surveys assessing the prevalence of the disease and an increasing body of reports on the achievement of treatment and care goals were identified. Such reports demonstrate the imperative need to garner a more comprehensive understanding of the extent of diabetes across countries, and both past and ongoing efforts to establish effective and sustainable models of prevention and high-quality care able to reach and serve all peoples across the region.

During the writing of this manuscript, Latin America had been recognized as the new epicenter of the SARS-CoV-2 (COVID-19) pandemic [306]. The effects of the disease in persons with diabetes in the region are beginning to be uncovered [307,308,309], while some solutions are proposed [310, 311]. The magnitude of the impact of the pandemic on the health and health care needs of persons with diabetes mellitus and other NCDs—let alone on the health care systems infrastructures—in the region are yet to be known. The task ahead is substantial and will require multidisciplinary and cross-sectoral strategies and collaborations to reduce diabetes burden and improve health outcomes across Latin America.