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Diabetes Mellitus Among Adults in 
Herat, Afghanistan: A Cross-
Sectional Study 

 
Khwaja Mir Islam Saeed1 
 
1Grant and Service Contract 
Management Unit, Ministry of Public 
Health, Kabul, Afghanistan  

 
 

 
 
 
 

 
Vol. 6, No. 1 (2017)   |   ISSN 2166-7403 (online)  
DOI 10.5195/cajgh.2017.271 |   http://cajgh.pitt.edu 

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Abstract 

Introduction: Diabetes is reaching epidemic levels in Afghanistan. This study identifies the risk factors associated with diabetes 
in Herat City, Afghanistan, and explores the prevalence of previously undiagnosed diabetes. 
Methods: A cross-sectional study was conducted using multistage cluster sampling by adopting the World Health Organization’s 
(WHO) STEPwise approach to Surveillance (STEPS). We enrolled 1129 participants aged 25-70 years between May and June of 
2015 (47.4% males, 52.6% females). A structured questionnaire was used for data collection of demographic, socioeconomic, and 
behavioral factors. Investigators collected anthropometric measurements and blood samples from study participants. A 
multivariable logistic regression model was used to identify factors associated with diabetes prevalence. 
Results: We found that the prevalence of diabetes in Herat City was 9.9% (9.8% in males and 10.1% in females). Of the 1129 
respondents, only 3.3% were previously diagnosed with diabetes or were under treatment, whereas 6.6% of respondents were 
previously undiagnosed. The multivariable analyses showed that age, frequency of rice consumption, type of cooking oil, and 
systolic blood pressure were associated with diabetes.   
Conclusions: This is one of the first studies to discuss the high prevalence of undiagnosed diabetes in Herat, Afghanistan. This 
study found several modifiable factors that were associated with diabetes in Herat, Afghanistan. Future reduction of disease burden 
should focus on these factors in the development of the most optimal diabetes prevention programs.  

Keywords: Risk Factors; Diabetes; Chronic Disease; Afghanistan 

 
Diabetes Mellitus Among Adults in 
Herat, Afghanistan: A Cross-
Sectional Study 

 
Khwaja Mir Islam Saeed1 
 
1Grant and Service Contract Management 
Unit, Ministry of Public Health, Kabul, 
Afghanistan 

 
 
 
 

 

 

Research 

Diabetes mellitus (DM) is a global public health 
problem and is listed as a priority noncommunicable 
disease (NCD) by the World Health Organization 
(WHO).1 The rising prevalence of diabetes is reaching 
epidemic proportions worldwide.2 Genetics, 
environmental factors, and lifestyle choices are 
contributing to the development of this chronic metabolic 
disorder.3 Diabetes was ranked as the sixth leading cause 
of death in 2015, with 1.6 million deaths attributed to this 
disease.4 The global prevalence of diabetes increased 
from 4.7% in 1980 to 8.5% in 2014, resulting in 422 
million people in the world living with diabetes in 2014.5 

  According to a study of diabetes in Kuwait, the 
crude prevalence of total diabetes cases in this country 
was 21.4%, and almost one-fifth of these cases were 
previously undiagnosed.6 In Oman, the overall 

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Figure 1. Location of study setting in western province of Herat, Afghanistan 

prevalence of diabetes appears to be on the rise with risk 
factors such as urban residence, obesity, age, and systolic 
blood pressure being significantly associated with 
diabetes.7 The study from Iran demonstrated that diabetes 
was more prevalent among older age groups, females, 
and urban dwellers.8 In China, the prevalence of diabetes 
in the 35–74 age group was 5.5%, with 5.8% of females 
and 5.2% of males being diagnosed with diabetes.9 A 
study in Pakistan found that central obesity, 
hypertension, and family history of the disease were risk 
factors for diabetes.10 

In Afghanistan, due to years of war and conflict, 
few studies were conducted to estimate the burden of 
diabetes in the country. However, the Afghanistan 
Mortality Survey (AMS) in 2010 reported that one third 
of all deaths were attributed to NCDs.11 The prevalence 

of diabetes in the 20-79 year age group in Afghanistan 
was estimated to be 8.6% in 2010, whereas by 2030 it is 
projected to reach 9.9%.12 Moreover, studies reported 
that the prevalence of diabetes was 13.2% in Kabul (age 
group of ≥40 years), 11.8% in Jalalabad, and 22.4% in 
Kandahar in the early 2010s.13-16 We also previously 
reported an overall diabetes prevalence  of 9.9% in a 
cohort of adults from Herat.15  However, the risk factors 
associated with diabetes in this population have not yet 
been explored. The aim of this study was to determine 
risk factors associated with diabetes among adults living 
in Herat, Afghanistan and to explore the prevalence of 
previously undiagnosed diabetes in this geographic 
region.  

 

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Methods 

The Institutional Review Board of the Ministry of 
Public Health, Afghanistan, provided ethical approval of 
the study protocol. The study design was a cross-
sectional survey of permanent residents of Herat, 
Afghanistan, using the STEPwise approach to 
Surveillance (STEPS) tool,17 which inludes 
demographic, physical, and biochemical measurements. 
Herat is the largest city in the Herat province of 
Afghanistan. The location of the study setting in Herat is 
shown in Figure 1. The urban population of Herat is 
estimated to be 491,967, (242,102 females and 249,865 
males.18) Permanent residents of Herat between the ages 
of 25 and 70 were enrolled in this study. Participants 
signed informed consents prior to face-to-face 
interviews. For illiterate participants, the informed 
consent was read by the interviewer and the fingerprint 
of the respondent was taken to confirm agreement to 
participate. 
 

Sampling Strategy 

The statistical software program Epi Info v. 7 was 
used to calculate the sample size for this study. Although 
the national burden of diabetes is not well known in 
Afghanistan, a WHO report estimated the prevalence of 
diabetes at 8.6%.12 Although information on diabetes risk 
factors is scarce for Afghanistan, epidemiological 
research from other developing countries has reported 
that physical activity, blood pressure, dietary factors, 
obesity, age, level of education, smoking status, and other 
factors were associated with diabetes. The sample size 
was calculated to be 1200 based on the proportion of 
these risk factors and the cluster sampling technique. 
Inclusion criteria were as follows: adult population aged 
25-70 (as outlined in WHO survey tool), must be Herat 
residents during the study period, and must consent to 
participate. Exclusion criteria included: temporary 
residents (less than six months in the city) and those 
living in the institutionalized settings or unsafe areas. 

Study Variables and Data Collection 

The primary outcome variable was the presence of 
diabetes (yes/no). Participants with a fasting blood sugar 
(FBS) of ≥126mg/dl or undergoing diabetes treatment 
during the data collection appointment were considered 
as diabetic.19 Main factors such as age, sex, ethnicity, 
educational status, income, job type, proxy for physical 
activity (vigorous or moderate physical activity), dietary 
factors, tobacco use, obesity, hypertension, and blood 
lipid levels were assessed and analyzed.  

A structured (standardized) STEPS questionnaire 
was adopted and translated into the Dari language, the 
official language of Afghanistan. The answer options in 
the questionnaire were previously coded to facilitate the 
data entry and data analysis. Training and field testing 
was conducted ahead of time, and the questionnaire was 
adjusted accordingly before the actual data collection 
period of May-June 2015.  

A household was defined as a group of people who 
are cooking together in same kitchen, sharing the same 
food pot but no necessarily the same roof. In each 
household, the interviewer counted all persons eligible 
for the study based on the inclusion and exclusion 
criteria. In the households with more than one eligible 
person, a lottery system was used to select the respondent 
for the survey. If that individual refused to participate, the 
interviewers approached the next household on the list. 
Anthropometric measurements (height and weight) were 
used to calculate body mass index (BMI). A BMI of >30 
kg/m2 was considered as obese, 25–30 kg/m2 as 
overweight, and 18.5–25 kg/m2 as normal weight.20 A 
waist circumference of 94 cm for men and 80 cm for 
women was considered as central obesity.21 Systolic 
blood pressure of 140 mmHg and diastolic blood pressure 
of 90 mmHg were considered as hypertensive.22 Blood 
samples were collected and processed by lab technicians 
under supervision of the lab coordinator. After samples 
were shipped to the Central Public Health Laboratory 
(CPHL) in Kabul, they were stored at -80°C until glucose  

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 
 

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Figure 2. Prevalence of diagnosed and undiagnosed diabetes by age group 

measurements were completed. To enhance the quality of 
the data, close monitoring of all procedures was carried 
out throughout the study.  

Statistical Analysis  

Data entry was done using Epi Info v. 7 and data 
analysis was done using SPSS version 20. Participants 
with missing data and specimens were excluded from the 
final analysis. Our final sample size for statistical 
analysis was 1,129 participants. Central tendencies, 
proportions, and frequencies were calculated and 
tabulated. The prevalence of diabetes was calculated in 
all subgroups, and different tables were developed 
including tables of demographic, socio-economic, and 
behavioral data using descriptive analyses. Statistical 
analyses were conducted using student t-test, chi-square, 
univariate, and multivariable logistic regression. In the 
univariate model, the relationship between the variables 
and the outcome was analyzed individually.  Then, based 
on the level of significance and biological plausibility, a 
multivariable analysis was conducted to address 

confounding and to find independent associations of 
factors with the outcome. Statistical significance was 
based on an α level of <0.05 and 95% confidence interval. 

 
Results 

Table 1 summarizes all of the participant 
characteristics. Out of 1129 participants included in this 
analysis, 594 (52.6%) were females and 535 (47.4%) 
were males. The participants had a mean age of 
41.7±13.1 years, and 60% were aged less than 45 years. 
About 48% of study respondents were overweight or 
obese and 52.3% had central obesity. High blood 
pressure was recorded in 35.6% of the participants. 
Approximately 28.4% had high cholesterol and 45% had 
high triglycerides. Furthermore, high levels of low 
density lipoprotein (LDL) and high levels of high density 
lipoprotein (HDL) were observed in 47% of the study 
participants. More than half of the respondents (54%) 
were illiterate, and 82.7% of the participants had a 
monthly income lower than 10,000 Afghanis (USD 146). 

3.50%
6.90% 7.70%

10.80%

6.60%
0.80%

1.80%

5.00%

8.10%

3.30%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

25-35 35-45 45-55 55+ Total

Undiagnosed Diagnosed

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Variables Categories 

No diabetes Diabetes Odds 
Ratio 

CI 95% 
Lower Limit 

CI 95%   
Upper Limit N % N % 

Age in years 

  25 - 34 382 37.6 17 15.2 1.00 Reference 

  35 - 44 263 25.9 25 22.3 2.14 1.13 4.03 

  45 - 54 192 18.9 28 25.0 3.28 1.75 6.14 

  55 + 180 17.7 42 37.5 5.24 2.91 9.46 

Gender 

  Female 536 52.7 58 51.8 1.00 Reference 

  Male 481 47.3 54 48.2 1.84 1.15 2.95 

Fruit serving days per week 

  ≤3 days 793 84.0 77 74.0 1.00 Reference 

  > 3 days 151 16.0 27 26.0 0.96 0.72 1.27 

Vegetable serving days per week 

  ≤ 3 days 692 71.9 70 66.7 1.00 Reference 

  >3 days 270 28.1 35 33.3 1.28 0.83 1.97 

Cooking Oil in Kitchen 

  Liquid 491 60.1 37 40.7 1.00 Reference 

  Solid 326 39.9 54 59.3 2.20 1.41 3.42 

Obesity based on BMI 

  No 858 84.6 90 81.1 1.00 Reference 

  Yes 156 15.4 21 18.9 1.28 0.78 2.13 

High Blood Pressure 

  No 687 67.6 40 35.7 1.00 Reference 

  Yes 330 32.4 72 64.3 3.75 2.49 5.64 

Triglycerides 

  
<150 

mg/dL 574 56.4 47 42.0 1.00 Reference 

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≥150 

mg/dL 443 43.6 65 58.0 1.79 1.21 2.66 

Rice consumption in days per week 

  ≤3 days 290 29.1 53 48.2 1.00 Reference 

  > 3 days 708 70.9 57 51.8 0.44 0.30 0.66 

Vigorous Physical Activity 

  No 903 89.5 101 91.0 1.00 Reference 

  Yes 106 10.5 10 9.0 0.84 0.43 1.67 

Moderate Physical Activity   

  No 781 77.6 96 85.7 1.00 Reference 

  Yes 225 22.4 16 14.3 0.58 0.33 1.00 

Table 1. Univariate analysis of demographic, socio-economic and behavioral factors associated with diabetes 
among study participants in Herat, Afghanistan 

As previously reported, the overall prevalence of diabetes 
was 9.9%.15 When stratified by sex, we found that 9.8% 
of males and 10.1% of females had diabetes. We found 
that 6.6% of the participants were previously 
undiagnosed with diabetes, while 3.3% had been 
previously diagnosed and were undergoing treatment 
(Figure 2). The mean level of fasting blood sugar was 
96.20 mg/dl, with a range of 22-388 mg/dl. The main 
diabetes management modalities reported by the 
participant were insulin (28%), oral drugs (74%), dietary 
restriction (68%), and weight loss recommendation 
(38%). Identification of diabetes type (Type I vs. Type 
II) was not the objective of the study and is not reported.  

Table 1 shows the results of univariate analysis 
of risk factors and diabetes among study participants. 
Odds of having diabetes were 2.14 (95% CI: 1.13 – 4.03) 
times higher in the 35-45 year age group, 3.28 (95% CI: 
1.75 – 6.14) times higher in the 45-55 year age group, and 
5.24 (95% CI: 2.91 – 9.46) times higher in the ≥55 year 
age group as compared to 25-35 age category. Gender, 
level of education, marital status, income, and other 

socioeconomic factors were not significantly associated 
with diabetes in this study. There was a statistically 
significant association between type of cooking oil used 
(liquid that was assumed to be unsaturated oil and solid 
that was assumed to be saturated oil) and diabetes with 
an OR=2.20 (95% CI: 1.41 – 3.42) (Table 1). Greater 
frequency of rice consumption was significantly 
associated with reduced odds of diabetes with an OR = 
0.44 (95% CI: 0.30-0.66). Other dietary habits such as 
frequency of consuming vegetables, fruits, chicken, red 
meat, and table salt were not significantly associated with 
diabetes. High blood pressure and high levels of 
triglycerides were associated with diabetes with 
OR=3.75 (95% CI: 2.49 – 5.64) and OR=1.79 (95% CI: 
1.21 – 2.66) respectively. Furthermore, blood lipids 
(except triglycerides) and proxies for physical activity as 
defined by WHO STEPwise approach to Surveillance 
were not associated with diabetes (Table 1).  

In the multivariable analysis, only the variables 
of biological and statistical significance (Table 1) were 
included in the model. Table 2 summarizes the variables  

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Variables Categories B Odds Ratio CI 95% Lower Limit CI 95% Upper Limit P Value 

Age Groups 

  25-35 
 

1          Reference 

  35-45 0.90 2.45 1.17 5.15 0.02 

  45-55 0.94 2.56 1.20 5.48 0.02 

  55+ 1.43 4.17 2.02 8.61 <0.01 

High Blood Pressure 

  No 
 

1          Reference 

  Yes -0.88 0.42 0.26 0.67 <0.01 

Triglyceride 

  <150 mg/dL 
 

1          Reference 

  ≥150 mg/dL -0.57 0.56 0.36 0.90 0.02 

Cooking oil 

  Liquid 
 

1          Reference 

  Solid -0.75 0.47 0.30 0.75 <0.01 

Consuming rice three times per week 

  ≤3 per week 
 

1          Reference 

  >3 per week 0.63 1.53 1.03 2.26 0.01 

Table 2. Multivariable analysis of risk factors and diabetes among study participants in Herat, Afghanistan 

that were significantly associated with diabetes, 
including age group, blood pressure, triglyceride, type of 
cooking oil, and rice consumption. The multivariate 
model was run with all variables in one model to identify 
the independent associations in logistic regression. 
Increasing age group was associated with greater odds of 
having diabetes, with the 55+ age group having the 
greatest odds (OR = 4.17, 95% CI: 2.02-8.61). Greater 
rice consumption was significantly associated with 
increased odds of having diabetes with an OR = 1.53 
(95% CI: 1.03-2.26). High blood pressure, high 

triglycerides, and solid cooking oil were all associated 
with lower odds of having diabetes (all p < 0.05). 

Discussion 

The prevalence of diabetes in Herat City was 
found to be 9.9%, which was lower than reported in 
similar studies from Kabul13 and Jalalabad14; and it is less 
than half of the rate recorded in Kandahar, in southern 
Afghanistan.16  This may be due to age differences and/or 
cultural variations. Although blood samples were 
collected after fasting for 10-12 hours, outliers could be 
present due to non-fasting status of some of the 

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participants (noncompliance to fasting requirement) or 
higher level of diabetes. However, our findings are 
consistent with similar reports from India, Pakistan, and 
China.10,23-25 Global studies reported that low- and 
middle-income countries have a greater burden of 
diabetes.5 Countries from the Eastern Mediterranean 
region including the UAE, Saudi Arabia, Bahrain, 
Kuwait, and Oman have reported a higher prevalence of 
diabetes ranging from 13.4-18.7% among wider age 
ranges.11 

In a multivariatable analysis, age was a 
significant non-modifiable risk factor for diabetes, 
similar to results reported by other studies.12 Our findings 
show a higher prevalence of diabetes in women (10.1%) 
as compared to men (9.8%); however, gender was not 
statistically significant in both the univariate and 
multivariable analyses. Other studies have supported the 
statistical significance of gender at the national level in 
Kabul13 and in other countries.25 Significant increases in 
the global age-standardized prevalence of diabetes was 
observed in both men and women, with the greatest 
increase and highest prevalence reported in men. This 
increase could be due to the factors such as global 
population aging and sex differences in prevalence of risk 
factors, such as smoking and BMI.5  

Analysis of dietary habits showed that 
consuming rice more frequently is associated with higher 
levels of diabetes. Systolic blood pressure was 
significantly associated with diabetes. Hypertension, 
frequency of vegetable consumption, and obesity was 
associated with diabetes in other studies conducted in 
Jalalabad, Kabul, and Kandahar cities.13,14,16,26 
Triglycerides were found to be significant risk factors for 
diabetes, which may be due to their association with 
obesity as supported by published research.14,27  

There were several limitations to our study. The 
main limitation was the inability to do follow-up visits. 
In addition, offering blood tests and blood pressure 
checks could have encouraged those with pre-existing 
diabetes or hypertension to be over enrolled. Physical 

activity levels were not significantly associated with 
diabetes; however, this association has been supported by 
other studies.8,14,28,29 Our future studies may need to 
assess physical activity using standardized data 
collection tools.   

Afghanistan is traditionally viewed as a conflict 
zone, with health issues receiving inadequate attention. 
The design, implementation, and reporting of scientific 
studies, particularly epidemiological research in health, 
is an essential step in improving healthcare and the public 
health system of Afghanistan. To our knowledge, the 
current study was the first epidemiological cross-
sectional investigation with the objective to identify the 
risk factors associated with diabetes among Herat 
residents in Afghanistan.  

The high prevalence of diabetes among the adult 
population and the presence of modifiable risk factors are 
of importance for planning and implementing effective 
public health interventions. The findings of this study 
could be used as a baseline or starting point to design and 
implement nationwide studies to reflect the national 
burden of diseases and risk factors in Afghanistan.  

  

References  

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Health Organization; 2016. 

2. IDF Atlas. Brussels, Belgium: International 
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3. American Diabetes Association. Clinical 
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4. WHO Mortality Database.  
http://www.who.int/mediacentre/factsheets/fs3
10/en/. Accessed 29 July 2017. 

5. NCD Risk Factor Collaboration (NCD-RisC). 
Worldwide trends in diabetes since 1980: a 
pooled analysis of 751 population-based studies 
with 4.4 million participants. Lancet (London, 
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6. Al Khalaf MM, Eid MM, Najjar HA, Alhajry 
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8. Esteghamati A, Gouya MM, Abbasi M, et al. 
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diabetes. 2010;4(2):79-83. 

11. Afghan Public Health Institute at the Ministry of 
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12. Shaw JE, Sicree RA, Zimmet PZ. Global 
estimates of the prevalence of diabetes for 2010 

and 2030. Diabetes research and clinical 
practice. 2010;87(1):4-14. 

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Prevalence and risk factors associated with 
diabetes mellitus among Kabul citizens—
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2015;35(3):297-303. 

14. Mir Islam SK. Prevalence and Predictors of 
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	Diabetes Mellitus Among Adults in Herat, Afghanistan: A Cross-Sectional Study
	Abstract
	Keywords: Risk Factors; Diabetes; Chronic Disease; Afghanistan
	Diabetes Mellitus Among Adults in Herat, Afghanistan: A Cross-Sectional Study
	Research

