Influence of Nutritional Factors on
Prevalence of Diabetes
Kelly M. West, M.D., and John M. Kalbfleisch, M.D., Oklahoma City
SUMMARY
Twelve age-matched populations of eleven countries were
tested by standardized methods to determine associations
between prevalence of hyperglycemia and certain epidemio-
logic variables, including several nutritional factors. There
were great differences among some of these populations in
socioeconomic status, diet, adiposity, and race. Environ-
mental and demographic circumstances varied widely and
prevalence of diabetes differed as much as ten-fold. There
was in general a positive association between prevalence of
diabetes and dietary intake of fat and of sugar, and a
negative association between prevalence of diabetes and
total carbohydrate consumption; but some inconsistencies
in these~Threc"as5ociaii6ns suggested that they may have
been partly or completely coincidental. Prevalence of dia-
betes correlated well with serum cholesterol levels, both
among and within populations. Thejnost impressive and
consistent association in these studies was between pre-
valence of "diabetes and fatness (as estimated by weight
in relation to lieTghT)7 Both within and among countries
and races, this association was observed to a high degree.
Interracial differences in prevalence of diabetes were small
when racial groups were matched for adiposity.
In a group of 1,645 subjects from the general population
of Central America, those with abnormal glucose tolerance
had a substantially higher prevalence of electrocardio-
graphic abnormalities than those with normal tolerance.
DIABETES 20:99-108, February, 1971.
The purpose of this report is to present further
data on the relationships between the prevalence of
diabetes and certain epidemiologic variables, particu-
larly nutritional factors. Results of studies in four of
the countries were published in 1966.1 More recently,
it has been possible to compare the former results with
data from six additional countries.2 It has not been
possible to compare directly the results in these ten
countries of Asia, South America, and Central America
with the general population of the United States, but
From the Department of Medicine, University of Oklahoma
School of Medicine, Oklahoma City, Oklahoma.
FEBRUARY, 1 9 7 1
some of the same methods were used in testing two
communities in the United States.1'3 The epidemiologic
studies previously reported in these twelve populations
of three continents included observations on preval-
ence of hyperglycemia in relation to several factors in-
cluding age, sex, parity, birth weights of children, race,
and socioeconomic and rural-urban status.1-2 Nutri-
tional data were also reported. In this paper, additional
information will be given concerning the diet in six of
the countries; and the prevalence of hyperglycemia in
the various populations will be related to serum choles-
terol levels, electrocardiographic status, and the dietary
intake of carbohydrate, protein, fat, and sugar. Popula-
tions were tested in Uruguay, Venezuela, Malaya (now
Malaysia), East Pakistan, Costa Rica, El Salvador, Gua-
temala, Honduras, Nicaragua, and Panama.
Although an association between adiposity and preva-
lence of diabetes has been observed repeatedly, the ex-
tent to which, and the circumstances under which,
nutritional factors influence prevalence of diabetes have
not been determined precisely. Indeed, O'Sullivan et
al. followed for seventeen years a group of obese peo-
ple whose blood glucose levels were initially normal,,
and found no significant increase in the incidence of
diabetes as compared to the nonobese in the same popu-
lation.4 Moreover, the hypothesis that diabetes causes
obesity is still under consideration.5 It has also been
suggested that specific dietary components such as
sugar6 and fat7 may increase susceptibility to diabetes.
Among the problems which have made it difficult to
evaluate the associations between prevalence of diabetes
and nutritional factors have been the paucity of syste-
matically collected data on nutrition in populations
where prevalence of diabetes has been established (and
vice versa), the lack of uniformity in methods and
definitions, and difficulties in obtaining representative
samples of age-matched populations. Our methods did
not overcome all of these difficulties, and in several
respects our data are less than ideal; but we were able
9S>
 INFLUENCE OF NUTRITIONAL FACTORS ON PREVALENCE OF DIABETES
to test ten population samples which were at least
crudely representative, and use of standard procedures
and criteria permitted some comparisons which were
not possible heretofore.
METHODS
In ten countries, the diabetes-related studies were
part of detailed nutrition surveys. The methods em-
ployed have beeen described in detail.1'2-8'14 The stud-
ies in the six Central American countries included the
selection and testing of representative population sam-
ples, clinical examinations, extensive biochemical de-
terminations in representative subgroups, dietary cal-
culations based on interviews with representative fami-
lies using standard methods, and food measurements
and analyses.
Similar studies had been conducted previously in
Uruguay, Malaya, East Pakistan, and Venezuela.1 How-
ever, in the latter four countries, methods of popula-
tion sampling were less systematic and refined. For ex-
ample, in Venezuela, a total of 480 subjects from the
general population were tested for diabetes in fifteen
arbitrarily selected sites in six different regions of the
country. Although an attempt was made to test repre-
sentative subjects of representative communities, the
unsystematic methods used and other sources of poten-
tial bias were such that this could not be considered a
truly representative national sample of the kind ob-
tained in the Central American countries.
The number of testing sites ranged from thirteen in
Uruguay to forty in Guatemala. In Uruguay, 484 sub-
jects were tested for diabetes; in East Pakistan, 513
were tested; and in Malaya, 566 participated. Details
published previously concerning the Central American
studies include population characteristics, methods, sam-
pling procedures, and the numbers tested in the various
countries.2
Diets varied somewhat from region to region within
countries, and there were of course differences among
individuals in the quality and quantity of diet. The
average figures given below for each population repre-
sent only the mean consumption per capita, but, in
general, the qualitative interindividual variations in
diet were small. Figures are not presented here for
caloric intake because of the complexity of these cal-
culations and the lack of precision of these methods,8
but these data have been reported.1'9"14 Under the field
conditions which prevailed, the best available index of
caloric intake (in relation to energy expenditure) was
weight in relation to height. This is not of course a
precise measure of body adiposity, but in general it is
well correlated with fatness.8-15 We therefore deter-
mined the weight of each subject in relation to a stand-
ard for his height in order to calculate a per cent of
standard weight.8 This standard is age-independent. It is
based on data published by the Society of Actuaries in
1959 for a group of Americans from twenty to twenty-
nine years of age.8 Although this arbitrary standard was
adopted by the Interdepartmental Committee on Nutri-
tion as a means for expressing weight in relation to
height, it was not assumed that 100 per cent of stand-
ard necessarily represented ideal weight either for young
or older aduits.
The results reported here are confined to the seg-
ments of the population over thirty years of age. In
most countries, only subjects over thirty-four years of
age were included in the diabetes-related studies, but
the nutrition studies included all ages. Details con-
cerning the frequency distributions of ages for each of
these populations have been published.1-2 The fre-
quency distribution of the ages was very similar for
each of these populations; the mean age varied only
from forty-eight years in East Pakistan to fifty-two
years in Venezuela. In contrast to the other methods,
which were standardized, the method for measuring
plasma cholesterol varied among the countries. Cho-
lesterol determinations were not performed in the same
laboratories, but all values for the six countries of Cen-
tral America were measured in the same laboratory by
the AutoAnalyzer technic based on modifications of the
Zak method.16 In Venezuela and East Pakistan, the
method used was that described by Searcy, Bergquist,
and Jung.17 In Uruguay and Malaya, the method used
was that of Carpenter, Gotsis, and Hegsted.18 Details
have been reported previously concerning the glucose
tolerance tests.1-2 Each subject received one gram of
glucose per kilogram of body weight. Subjects whose
two-hour venous blood glucose levels exceeded 149
mg./ioo ml. were classified as diabetic, but because
frequency distribution data have been published, rates
of "diabetes" can be calculated for all countries using
diagnostic standards that are either higher or lower than
the arbitrary criterion we employed.
Twelve-lead electrocardiograms were performed. In-
terpretation of the electrocardiographic data is compli-
cated in some respects by the fact that in every coun-
try electrocardiography was with rare exceptions per-
formed thirty to 180 minutes after glucose loading.
Because glucose loading sometimes produces certain
kinds of electrocardiographic changes,19"24 the implica-
DIABETES, VOL. 2O, NO. 2
 KELLY M. WEST, M.D., AND J O H N M. KALBFLEISCH, M.D.

TABLE 1
Relationship in Central America between adiposity and prevalence of abnormal or borderline glucose tolerance

Weight as per cent of standard Two-hour blood glucose

>149 mg,/100 ml. 120 to 149 mg./lOO ml.
Mean
Age
<80% 57 3% 5%
Very lean 80-89% 53 3% 7%
Lean 90-99% 50 3% 6%
Medium 100-109% 50 3% 6%
Thick >109% 50 10% 12%

tions of this phenomenon are reviewed in the Discus-
sion.
RESULTS
Relationship between adiposity and prevalence of
diabetes: In studying the relationship between preval-
ence of diabetes and many factors in the different coun-
tries, the most impressive correlation has been with fat-
ness.1*2 Table i shows the relationship of adiposity
(per cent of standard weight) and prevalence of "dia-
betes" in the Central American subjects (data for all
countries lumped). Impairment of glucose tolerance was
more than three times as common in the subjects whose
weights exceeded 109 per cent of standard as in the
remainder of the population.
Table 2 shows the frequency distribution of per cent
of standard weight by sex for the Central Americans,
all of whom were over thirty-four years of age. The
mean per cent of standard weight for males was 95 per
cent. The mean adiposity of the females was signifi-
cantly greater, 103 per cent of standard. We analyzed
data from the U.S. National Health Survey25 with re-
spect to mean per cent of standard weight for ages
matching those of our Central American subjects. The
mean per cent of standard weight of U.S. males was
i n per cent and for females 113 per cent. Diabetes
was about four times as common in Bangor, Penn-
sylvania1 as in Central America, but rates of diabetes
were not significantly different when the two popula-
tions were matched for adiposity.
Figure 1 shows the marked contrast in the fatness
(per cent of standard weight) of the populations of
East Pakistan, Uruguay, and Central America (data for
all six countries lumped). The rates of "diabetes" for
age-matched segments of these populations (East Pak-
istan, 2.5 per cent, Central America 4.1 per cent, and
Uruguay, 6.9 per cent) reflect closely these differences
in fatness. While the correlation between overnutri-
tion and prevalence of diabetes has been quite consis-
tent in the groups we have studied, a protective effect
of undernutrition (marked leanness) has been observed
less consistently. In Asia, diabetes was definitely more
common in those whose weights were "normal" (90-
109 per cent of standard) than in very lean persons
(weight less than 90 per cent of standard). The rate of
diabetes in the very lean subjects was 1.7 per cent, while
the rate for those of normal weight was 4.9 per cent
[difference statistically significant (p < . o i ) ] . But in
the eight countries of Latin America, diabetes was only
slightly less common in the very lean subjects than in
those with normal weights, and the difference was not
statistically significant. In all these countries, however,
the mean age of the very lean subjects was greater than

TABLE 2
Frequency distribution of per cents of standard weight in Central America by sex

Frequency distribution (by per cent) of weight

(expressed as per cent of standard weight)
Per cent of standard weight <70 70 to 79 80 to 89 90 to 99 100 to 109 110 to 119 120 to 129 >129 Total
Males 1.2 10.8 32.0 26.1 16.6 7.5 3.7 2.2 100.1
Females 1.8 8.4 20.5 21.8 16.5 11.9 7.9 11.3 100.1
Total 1.5 9.4 24.9 23.5 16.5 10.2 6.3 7.7 100.0
Total (Corrected*) 1.5 9.6 26.3 24.0 16.6 9.7 5.7 6.8 100.2
* Based on anticipated results if an equal number of males and females were tested. The observed results were influenced
slightly by the fact that more females than males were tested.

FEBRUARY, 1 9 7 1
 INFLUENCE OF NUTRITIONAL FACTORS ON PREVALENCE OF DIABETES
• - • EAST PAKISTAN
40-
O - - O CENTRAL AMERICA
—A URUGUAY
a.
Z)
O
O
<70 70-79 90-99 110-119 > 129
% OF STANDARD WT.
FIG. I. Frequency distribution of per cents of standard weights
for three populations.
the mean age of those of average weight (see below).
Although rates of diabetes differed markedly in Uru-
guay, East Pakistan, and Central America, rates were
not significantly different for these three populations
when matched for per cent of standard weight. In Cen-
tral America the relatively high rates of diabetes in fe-
males, and for both sexes in Nicaragua and Costa
Rica,2 were entirely "corrected" when adjustments were
made for the greater fatness of these three subgroups
of the general population. There were some differ-
ences among groups and subgroups that were not en-
tirely corrected by matching for adiposity, but these
differences associated with other factors (such as race,
sex, etc.) were modest.1'2 In all of these countries,
some of the diabetics had lost significant amounts of
weight because of diabetes. Thus, the association be-
tween adiposity and risk of diabetes is even stronger
than suggested by these data.
Figure 2 shows for ten populations the relationship
between diabetes prevalence and per cent of standard
weight. The correlation coefficient for this association is
very impressive (r of 0.89).
Data have been reported previously on the relation-
ships between age and glucose tolerance in these popu-
90 100 110 120 130
% STANDARD WEIGHT (MEAN)
FIG. 2. Association of diabetes prevalence and mean per cent
of standard weight. EP stands for East Pakistan, M
for Malaya, E for El Salvador, P for Panama, G for
Guatemala, H for Honduras, N for Nicaragua, C for
Costa Rica, V for Venezuela, and U for Uruguay.
Data for diabetes prevalence apply only to older
segments of these populations (over thirty-four years}.
lations.1-2 Although older subjects had poorer glucose
tolerance in all countries, associations between preval-
ence of diabetes and adiposity were not attributable to
a greater adiposity of older subjects. Comparable data
concerning-the relationship between age and weight
were available for eight countries (Venezuela, East
Pakistan, and the six Central American nations). In
our subjects over thirty-four years of age, there was no
increase in weight (expressed as per cent of standard
weight) with age in any country. In most countries,
weight increased between age twenty and age thirty-
ica between "sociocultural status"9"14 and cholesterol
before declining in old age. In all of the eight coun-
tries, a significant decline in weight was observed be-
ginning between age fifty-five and sixty-five. In each of
the Central American countries, the relationship be-
tween age and weight was quite similar; when data
were lumped for all of our subjects in six countries,
it was found that weight was 100 per cent of standard
for subjects from thirty-five to forty-four years of age,
100 per cent for those from forty-five to fifty-four years,
98 per cent for those from fifty-five to sixty-four years,
and 94 per cent for those over sixty-four years of age.
Table 1 shows the mean age for each of five subgroups
in Central America with different degrees of adiposity.
Diet: Table 3 summarizes the diets in each of eleven
populations. The twelfth age-matched population tested
DIABETES, VOL. 2O, NO. 2
 KELLY M. WEST, M.D., AND J O H N M. KALBFLEISCH, M.D.

TABLE 3 and other characteristics of the diet, including levels of

Diets and prevalence of diabetes* in eleven populations fat, animal fat, and protein. There was also a negative
association between total carbohydrate consumption
Diabetes Per cent of calories
prevalence Carbo- and the prevalence of diabetes, as shown in table 3. For
(per cent)* hydrate Sugar Protein Fat reasons described in the Discussion, these associations
East Pakistan 2.0 83 2 10 7
were not thought to have a cause and effect relation-
Malaya 3.3 68 8 11 21
Costa Rica 5.4 69 17 11 21 ship.
El Salvador 3.2 70 7 12 17
Guatemala 4.2 73 10 12 15 Cholesterol: Levels of dietary cholesterol in the vari-
Honduras 4.1 66 8 13 22 ous populations of Central America are not yet avail-
Nicaragua 5.0 66 12 13 21
Panama 2.5 67 9 11 22 able to us, but cholesterol intake is probably much
Uruguay 6.9 53 12 14 33
7.0 62 7 14 24
lower than in the United States because fat intake is
Venezuela
Bangor, Pa.f 17.2 47 13 40 substantially less than in North America, as shown in
* Venous blood glucose >149 mg./lOO ml. in subjects table 3. Also, the portion of fat which is of animal
over thirty years of age. These prevalence rates differ slightly origin (roughly half) is lower in Central America than
from observed rates because they have been adjusted to the
predicted rate if an equal number of males and females had in the United States.9"14 Plasma cholesterol levels for
been tested. 2,034 subjects (803 males and 1,231 females) in Cen-
t Crude estimates.1
Some totals do not add to 100 per cent because of tral America and the relationship of these levels to age
rounding.
are shown in table 4. Cholesterol levels did not rise
with age in either sex. On the contrary, in old age
for diabetes by these methods was the Cherokee Indians there was some decline in these values. This does not
of North Carolina, in whom the prevalence of dia- necessarily mean, of course, that old age was associated
betes was approximately 25 per cent.3 The diet of these with a decline in the cholesterol levels of individual
Indians was high in calories but qualitative dietary subjects. This phenomenon could be attributable in part
studies were not adequate to warrant presentation in or entirely to a higher rate of survival of those with
table 3. Table 3 also shows the relationship between low cholesterol levels, or to other factors.
several dietary factors and the prevalence of diabetes The relationship between glucose tolerance and
in these age-matched populations. In the twelve age- cholesterol level is shown in table 5. Cholesterol levels
matched populations we have tested, the prevalence of were substantially greater in those with impairment of
impaired glucose tolerance ranged from 2 per cent in glucose tolerance. In males, a statistically significant in-
the very lean Pakistanis to 25 per cent in the very crease in cholesterol values was observed even in those
fat Cherokees. with minimal impairment of tolerances (two-hour glu-
Sugar consumption: It is difficult to precisely deter- cose levels between 150 and 199 mg./ioo m l ) . In
mine levels of sugar intake in large populations. Table females, no significant change in cholesterol values was
3 gives the levels of dietary sugar in ten countries. We observed until two-hour glucose values reached 200
regard these figures as only rough estimates. Calcula- mg./ioo ml. This association between cholesterol and
tions based on data of the International Sugar Council26 glucose levels could reflect some direct relationship be-
suggest that sugar consumption in the United States is
roughly twice as high as in the Central American
TABLE 4
countries and many times higher than in Pakistan.
Relationship of age and plasma cholesterol in
Table 3 shows that there was a positive correlation be- Central America (2,034 subjects)
tween prevalence rate and sugar consumption (r =
.53). Although this association was not statistically Age Mean cholesterol (mg./lOO ml.)
Males Females
significant, the failure to demonstrate statistical signi- 35 to 44 142 141
ficance may be attributable to the relatively small num- 45 to 54 137 154
55 to 64 136 151
ber of populations (ten) for which data were avail- 65 to 74 139 149
able (see Discussion). 75 to 84 129 142
84* 119* 123*
Other dietary factors: There were also some rather
* Only ten males and eleven females were more than
consistent associations between prevalence of diabetes eighty-four years of age.

FEBRUARY, 1 9 7 1 103
 INFLUENCE OF NUTRITIONAL FACTORS ON PREVALENCE OF DIABETES

TABLE 5
Relationship of plasma cholesterol to glucose tolerance in Central America*

Cholesterol (mg./lOOml.)
All subjects Males Females
Clearly normal tolerance 142 137 147
(2-hr, venous blood glucose <120mg./100 ml.)
High normal or borderline tolerance 142 139 145
(2-hr, value 120 to 149 mg./lOO ml.)
Slightly abnormal tolerance 152 166 140
(2-hr, value 150 to 199 mg./lOO ml.)
Grossly abnormal tolerance 173 179 168
(2-hr, value > 199 mg./lOO ml.)
* 2,034 subjects over thirty-four years of age.

tween these two factors; on the other hand, it may
reflect only a relationship of both factors to some other
factor or factors. Table 6 shows that there was some
association between mean per cent of standard weight
and cholesterol level. The difference between the cho-
lesterol levels of those above and below 109 per cent
of standard weight is statistically significant. There
was no difference in cholesterol levels of those with
normal weight (90-109 per cent of standard weight)
and those who were lean (less than 90 per cent of
standard). The positive association between adiposity
and cholesterol values could mean that subjects with
higher caloric intake (in relationship to energy expen-
diture) tend to have both higher cholesterol levels and
lower glucose tolerance.
There was a positive relationship in Central Amer-
ica between "sociocultural" status9"14 and cholesterol
levels. In 271 males in whom sociocultural status was
graded as "low," "medium" or "high," mean cholesterol
levels were 123, 138, and 147 m g . / i o o ml., respec-
tively.
In Central America, there were no instances of
marked hypercholesterolemia among 2,034 subjects; the
highest value was 360 m g . / i o o ml. Six females
(0.5 per cent) had values over 300 m g . / i o o m l , and
only one male of the 803 tested had a plasma choles-
terol level exceeding 300 m g . / i o o ml. Very low
cholesterol concentrations were common in both sexes.
Values of less than 100 m g . / i o o ml. were observed in
18.8 per cent of males and 14.1 per cent of females. In
contrast to most other procedures which were standard-
ized, three different methods were used in the ten
countries in determining serum cholesterol levels. How-
ever, a common method was used in all Central Amer-
ican countries. W e have not adequately defined the
comparability of these different methods, so compari-
sons among those countries where methods differed
must be interpreted with this in mind. (The section
on Methods indicates which procedures were used in
each of the countries.) Mean levels of cholesterol were
in East Pakistan, 133 m g . / i o o ml. (134 in males and
133 in females); in Malaya, 185 m g . / i o o ml. (182 in
males and 188 in females); in Uruguay, 189 m g . / i o o
ml. (188 in males and 189 in females); and in Vene-
zuela, 211 m g . / i o o ml. (212 in males and 210 in
females). It is evident that there was a general asso-
ciation between these levels of cholesterol and both
the prevalence of diabetes (table 3) and fatness
(figures 1 and 2 ) . There was also an association be-
tween cholesterol levels and several dietary factors, in-
cluding fat intake and animal fat consumption (table
3 ) . The correlation between prevalence of diabetes and
mean cholesterol is significant statistically but it should
be kept in mind that the degree of association might
have been greater or lesser if the same laboratory meth-
od had been used in all countries to measure choles-
terol.
Electrocardiographic findings: Table 7 shows the rela-
tionship between glucose tolerance and electrocardio-
graphic status in Central America. Although 1,645 indi-
viduals had both a glucose tolerance test and an electro-
TABLE 6
Relationship of plasma cholesterol and adiposity
(per cent of standard weight) in Central America
Weight as peri cent of Mean cholesterol (mg./lOOml.)
standard Male Females
<80 138 146
80 to 89 127 142
90 to 99 142 140
100 to 109 144 156
>109 150 152

104 DIABETES, VOL. 2O, NO. 2

 KELLY M. WEST, M.D., AND J O H N M. KALBFLEISCH, M.D.

cardiogram, the low prevalence of diabetes and the
infrequency of some electrocardiographic abnormalities
made it impossible to determine their relationship to
abnormal glucose tolerance. The prevalence of abnormal
electrocardiograms was substantially greater in those
with abnormal glucose tolerance. Table 7 also shows
the impressive relationship between abnormal glucose
tolerance and the prevalence of nonspecific T-wave
changes. The number of older subjects was greater in
the group with abnormal tolerance. This accounts to
some extent for the higher rate of electrocardiographic
abnormalities in hyperglycemic subjects. But table 7
also indicates that the rate of electrocardiographic ab-
normalities was much greater in those with hyper-
glycemia even when the data were age-adjusted. There
was little difference between the sexes in the rate of
electrocardiographic abnormalities. Tejada and his as-
sociates had found previously that the difference be-
tween the sexes in coronary atherosclerosis was much
less in Central America than in whites from New
Orleans.27
DISCUSSION
The relatively high rate of electrocardiographic ab-
normality (36 per cent in men and 39 per cent in
women) was attributable to several factors including
the age distribution of the populations tested and the
glucose loading prior to electrocardiography. It should
also be kept in mind that the presence of any one of
many major or minor electrocardiographic changes such
as left ventricular hypertrophy, ventricular extrasystoles,
bundle branch block, T-wave changes, etc., resulted in
classifying the electrocardiogram as abnormal. Detailed
results will be published subsequently concerning these
electrocardiographic findings. We have considered the
possibility that the higher rate of electrocardiographic
abnormality in those with impaired glucose tolerance
might have been attributable to a greater electrocardio-
graphic response to glucose loading in the hypergly-
cemic subjects. We cannot exclude this possibility, but
it seems unlikely. Data were not systematically col-
lected concerning the temporal relationship between
the load and electrocardiography, but the experimental
conditions were the same for diabetics and nondia-
betics. It seems unlikely that the electrocardiographic
changes which result from glucose loading are at-
tributable to hyperglycemia itself.26"27 We believe that
the most likely explanation for the higher rate of elec-
trocardiographic abnormality in our diabetic subjects
was an increased amount of coronary disease. Table 5
shows that cholesterol levels were higher in the dia-
betics, and Robertson and Strong have recently demon-
strated that coronary atherosclerosis (gross pathology) is
much greater in diabetics than nondiabetics in Costa
Rica and Guatemala.28
Campbell and Cleve have assembled an impressive
array of evidence linking prevalence of diabetes and
dietary sugar levels.6 Although the association between
sugar consumption and prevalence of diabetes is not
statistically significant in the ten countries to which our
data apply, it would be statistically significant if this
same degree of association were demonstrated in a
somewhat larger series. When our experience is added
to that of Campbell and his associates,6 and when one
considers the general association between sugar con-

TABLE 7
Rates of electrocardiographic abnormalities in Central America
and their relationship to glucose tolerance

Abnormal Nonspecific
ECG T-wave changes
Males Females Males Females
Subjects with clearly normal glucose 34% 37% 9% 14%
tolerance* (203 of 602) (312 of 837) (52 of 602) (114of 837)
Subjects with "borderline" glucose 60% 44% 20% 17%
tolerance* (18 of 30) (43 of 98) (6 of 30) (17 of 98)
85% 57% 39% 22%
Subjects with abnormal glucose tolerance* ( l l o f 13) (37 of 65) (5 to 13) (14of65)
36% 39% 10% 15%
All subjects (232 of 645) (392 of 1000) (63 of 695) (145 of 1000)
43% 43% 12% 16%
All subjects (age-adjusted)t
* This classification assumes that 2-hour glucose values more than 149 mg./lOO ml. are abnormal, those less than 120
mg./lOO ml. clearly normal, and those from 120 to 149 borderline,
t Adjusted to match age distribution of subjects with abnormal tolerance.

FEBRUARY, 197 I IO5

 INFLUENCE OF NUTRITIONAL FACTORS ON PREVALENCE OF DIABETES
sumption and affluence, it seems highly probable that
there is a significant association between sugar con-
sumption and the prevalence of diabetes. But the estab-
lishment of a statistically significant correlation would
not of course prove a cause and effect relationship.
Among our data are some impressive inconsistencies in
this association. For instance, sugar consumption was
about the same in Malaya and Venezuela, but diabetes
was much more common in Venezuela (7.0 per cent)
than in Malaya (3.3 per cent). Diabetes was equally
common in El Salvador and Malaya, but sugar con-
sumption was much higher in Malaya. Some of the
data of Poon-King, Henry, and Rampersad29 are also
inconsistent with the hypothesis that the risk of dia-
betes increases in relation to sugar intake. Campbell and
Cleave6 have suggested the imperfect relationship be-
tween risk of diabetes and "sugar" intake may be at
least in part the result of failing to take into account
the consumption of other refined carbohydrates (e.g.,
in beer) which are often not identified as "sugar" in
dietary surveys. They point out that refined carbohy-
drates may cause obesity because the satiety produced by
these highly concentrated foods may be less than with
the more bulky "natural" foods.
The negative association between the total amount of
carbohydrate consumed and the prevalence of diabetes
is compatible with the hypothesis that the ingestion
of carbohydrate protects a population from developing
diabetes. Yet certain findings argue against this. The
well-fed subjects in Venezuela who consumed high
levels of carbohydrate had a high prevalence of dia-
betes. The people of Central America have a relatively
low rate of diabetes and high consumption of carbo-
hydrates; but the small minority in Central America
who are overweight also consume high levels of carbo-
hydrates, and they have a relatively high rate of dia-
betes. Our data do clearly confirm that very high carbo-
hydrate diets are not necessarily associated with a pro-
pensity to diabetes.
There was also a general association between the rate
of diabetes and levels of dietary fat and protein. Hims-
worth proposed that diabetes might be caused by high
levels of fat intake.7 Certain of our findings, however,
appear to contradict this hypothesis. For instance, the
lean subjects we tested in the ranching country of rural
Uruguay have excellent glucose tolerance even though
they consume high levels of fat and protein. This sug-
gests that neither protein nor fat in themselves pro-
duce diabetes. That the low prevalence of diabetes in
106
rural Uruguay is not due to a low prevalence of the
genetic trait or traits for diabetes, is suggested by the
fact that the relatives of these rural Uruguayans who
live in Montevideo have relatively high rates of dia-
betes. Obesity is common in urban Uruguay.
Many other measurements were positively or nega-
tively associated with the prevalence of diabetes. Some
of these associations are clearly coincidental and have
no direct cause and effect relationship. There was, for
example, in the countries we studied, a good correlation
between the gross national product per capita and the
prevalence of diabetes. However, in examining these
data and the results of others, it is apparent that this
correlation is inconsistent after a level of income is
reached which permits a high caloric intake. For in-
stance, the Indians of Cherokee, North Carolina have
incomes that are low by U.S. standards, but they con-
sume more calories and have more diabetes than the
rest of the nation.3 In New York City, certain poorer
elements of the population are fatter than their more
affluent counterparts.30 But these "poor" New Yorkers
and Cherokees are "rich" by standards of Asia or Cen-
tral America. Thus, the positive association between
diabetes and income which generally prevails over the
low spectrum of income levels is probably attributable
mainly to the effect of varying degrees of poverty on
the availability of calories.
Our epidemiologic studies and those of others, which
indicate the very strong relationship between adiposity
and rate of diabetes, have been recently reviewed.1
The data in this paper extend and confirm our previous
observations in this regard. In contrast to the general
trend of this evidence, Jackson et al. found that a group
of fat African women had less diabetes than African
men and Indian women, both of whom were leaner.31
It was pointed out that the environment of the Afri-
cans has been changing rapidly. Perhaps overnutrition
had not existed long enough to reflect the full risk of
long term obesity. Also, the obese subjects of Jackson
et al. had glucose loads which were slightly smaller in
relation to their extracellular spaces than the lean sub-
jects. The size of the load was constant irrespective of
the size of the subject. Nevertheless, the data of Jack-
son and his associates and other findings indicate that
environment and adiposity are by no means the sole
determinants of prevalence. A study of glucose toler-
ance was made in a small population of Alaskan Eski-
mos by Mouratoff, Caroll, and Scott.32 They found that
impairment of glucose tolerance was exceptionally rare
in Eskimos even though their weights in relation to
DIABETES, VOL. 2O, NO. 2
 KELLY M. WEST, M.D., AND J O H N M. KALBFLEISCH, M.D.
heights exceeded those of a control population of
whites. It was pointed out, however, that the Eskimos
engaged in heavy physical exercise and were probably
more muscular than the control group. Tulloch33 and
Pyke34 have recently published good review articles con-
cerning the epidemiology of diabetes.
Our studies reported here and elsewhere1'3 included
many races (Hindu and Moslem Indians, North Amer-
ican Indians, Central American Indians, Malays, Chi-
nese, and "whites" from widely differing ethnic
groups). Among these races, the prevalence of dia-
betes varied substantially but these differences were
small when races were matched for fatness.1'- To
the extent that dietary sugar adds to, rather than re-
places, other sources of calories, it would increase adi-
posity. Our data do not exclude the possibility that
high levels of sugar consumption increase susceptibility
to diabetes by a mechanism independent of their effect
on caloric intake. Although the epidemiologic evidence
is by no means conclusive in this regard, we believe
that fatness (irrespective of its cause) is probably
more deleterious than high levels of dietary sugar.
Certain recent observations from the laboratory support
this view. For example, it is now evident that adiposity
causes hyperinsulinism35'36 which declines with weight
reduction.37-38 Another pertinent recent finding is that
certain protein-carbohydrate mixtures produce a much
greater beta cell response than carbohydrate alone.39
Finally, we note the very low rates of diabetes in Asian
populations where carbohydrate (mainly rice) con-
sumption is quite high.
ACKNOWLEDGMENT
A detailed list of participants in the studies in Cen-
tral America is part of the publications relating to the
specific countries.9"14 Lists of the principal participants
in the diabetes-related studies have been published
elsewhere.1'2 The nutrition surveys in Central America
were sponsored by the Institute of Nutrition of Cen-
tral America and Panama, the Nutrition Program of
the U.S. Public Health Service (formerly Office of
International Research), and the governments of the
six republics. We are especially indebted to Edwin
Bridgforth, M.S., William McGanity, M.D., Guillermo
Arroyave, Ph.D., Werner Ascoli, M.D., and Arnold
Schaefer, Ph.D., for advice and assistance in planning
and conducting those aspects of the nutrition studies
relating to diabetes.
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