Background: Diabetes prevalence and body mass index reflect the nutritional profile of populations but have opposing\r\neffects on tuberculosis risk. Interactions between diabetes and BMI could help or hinder TB control in growing, aging,\r\nurbanizing populations.\r\nMethods and Findings: We compiled data describing temporal changes in BMI, diabetes prevalence and population age\r\nstructure in rural and urban areas for men and women in countries with high (India) and low (Rep. Korea) TB burdens. Using\r\npublished data on the risks of TB associated with these factors, we calculated expected changes in TB incidence between\r\n1998 and 2008. In India, TB incidence cases would have increased (28% from 1.7 m to 2.1 m) faster than population size\r\n(22%) because of adverse effects of aging, urbanization, changing BMI and rising diabetes prevalence, generating an\r\nincrease in TB incidence per capita of 5.5% in 10 years. In India, general nutritional improvements were offset by a fall in BMI\r\namong the majority of men who live in rural areas. The growing prevalence of diabetes in India increased the annual\r\nnumber of TB cases in people with diabetes by 46% between 1998 and 2008. In Korea, by contrast, the number of TB cases\r\nincreased more slowly (6.1% from 40,200 to 42,800) than population size (14%) because of positive effects of urbanization,\r\nincreasing BMI and falling diabetes prevalence. Consequently, TB incidence per capita fell by 7.8% in 10 years. Rapid\r\npopulation aging was the most significant adverse effect in Korea.\r\nConclusions: Nutritional and demographic changes had stronger adverse effects on TB in high-incidence India than in\r\nlower-incidence Korea. The unfavourable effects in both countries can be overcome by early drug treatment but, if left\r\nunchecked, could lead to an accelerating rise in TB incidence. The prevention and management of risk factors for TB would\r\nreinforce TB control by chemotherapy.
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