Diabetes mellitus (DM) is a major public health problem which can cause serious complications, it’s amongst the five leading causes of death worldwide [1, 2]. This problem is particularly relevant to the elderly. The prevalence of each condition increase with age. But the characteristic of the epidemiology of DM is the variability in the prevalence among different populations, especially in the elderly population. Previous surveys from Mediterranean older populations suggested that DM is present in epidemic proportions throughout the region as in Italy of 22.8% [3], in Crete of 27% [4], in Athens metropolitan region of 25.4% among males compared to 31% among females [5] and in Cyprus of 26% among males compared to 18% among females [6].

In Tunisia, despite an aging population, only a limited and fewer Tunisian studies have focused exclusively on the elderly. Tunisia is a country in transition. The elderly population aged more than 60 years has been rapidly increasing, from 5.5% in 1966 to 9.3% in 2004 of the country’s estimated population of 9910872 inhabitants. This percentage is expected to rise to almost 20% by the year 2040 [7]. Life expectancy at birth was 72.1 years in 2005, a figure that is envisaged to rise to 75.5 years in 2014 and nearly 77 years in 2029. However, the vast social and economic developments in Tunisia since 1956 have led to cultural changes including unhealthier eating habits, decreased physical activity and manifestation of a wide range of no communicable diseases [8]. DM is one of the most prevalent conditions (9% in the year 2005), and has become a health challenge in Tunisia [9]. According to World Health Organization’s, DM is one of the top continuing risk factors for cardiovascular disease in the world [2]. DM is one of the major contributors of metabolic syndrome due to its pathophysiological link to other cardiovascular risks, such as hypertension, dyslipidemia, obesity, unhealthier diet, sedentarity lifestyles and smoking habits [10].

The objective of this study was to investigate the prevalence of DM among elderly aged 65 years and older. We also examined socio-economic factors and life style that are likely to be associated with DM.

The data obtained from this community based study report an overall prevalence of DM of 27.4% (164/598) in Monastir City. Clearly, a substantially higher prevalence than that has been reported by previous study for Tunisia [18, 19]. Compared to other surveys that used WHO diagnostic criteria, prevalence of DM in elderly living in their home in Monastir City is higher than in Thailand [20], Nepal [21], Greece [22], Spain [23], French [24], and Canadian [25], lower than in Egypt [26], in Saudi Arabia [27], United Arab Emirates, Bahrain and Oman [28], India and Singapore [29, 30], and similar to that in US [31], and Mayotte [32]. The observed increase in DM prevalence obtained from our study is likely to be explained by several factors. First, our subjects are selected in older age group (more than 65 years), as it is well known that diabetes prevalence increases with age [2]. Second, another possible reason is the fact that risk factors for developing DM are also increasing in Tunisia, particularly, obesity and sedentary life with lack of physical activity [8]. Third, the diagnosis of DM obtained from our study, was based on the new criteria endorsed by the ADA and adopted by WHO in 1998 [33]. The possible other causes to explain higher prevalence of DM in the centre region is probably urbanization (more than 80% individuals live in urban areas) with less physical activity and higher rates of obesity. The data obtained from our study indicate a rural/urban differences in prevalence with a higher prevalence of DM among Tunisian living in urban areas of 29.2% compared to rural Tunisian’s of 15.9% (p <0.001). Rural populations with more traditional lifestyles exhibit lower rates of DM risk factors and DM, whereas urban populations, and particularly those of a higher socioeconomic status, have a higher rate of both risk factors and DM. It is clear that various environmental and lifestyle factors can increase the likelihood that a genetically susceptible individual will develop diabetes in old age.

Furthermore, apparently, the reported figures from this study is alarming, demonstrating an epidemic of DM striking the Tunisian elderly population. Our study showed a higher prevalence of DM among males of 29.6% compared to 26.5% in females. DM prevalence increased with age, peaking among those less than 70 years of age and then decreasing. The age-and gender- specific prevalence of DM are relatively similar to those of several cohorts [26, 27, 34]. However the present study found that the DM prevalence declined after age 70 years. It is possible that the earlier onset of DM with a high prevalence and a high incidence of cardiovascular disease and myocardial infarction resulted in a greater premature mortality in diabetic individuals, and that this contributed to the decline in the prevalence of diabetes after 70 years of age in Tunisian subjects [11, 25]. It is no clear whether insulin clearance or genetic background played a role. The proportions (5.5%) predicting undiagnosed DM, were relatively lower than those of some developing countries [26, 27]. WHO currently recommends that diabetes be diagnosed by measuring venous fasting blood glucose [33], in this study, in view of its practical application, agility, rapidity and safety we used CG for identifying undiagnosed DM. The CG test is considered to be a convenient screening method in low resource communities. However the discriminatory capacity would like be improved by a second confirmatory venous blood glucose test [15, 35].

The DM prevalence increased in those with higher educational level in both women and men, but the difference was not significant, this is consistent with the findings from other developing countries [20], but is in contrast to the developed countries, where the prevalence was higher in those with a lower educational level [36]. Confirming the literature data, the study revealed that several cardiovascular risk factors such as hypertension, obesity and abdominal obesity are more common in diabetic than non diabetic subjects. Abdominal obesity and hypertension were the main predictors for DM, even after adjustment on potential confounding factors. The present study showed that 48% of male Tunisian with obesity (BMI ≥30 kg/m²), studied in this survey are diabetic demonstrating an association between higher rates of DM with obesity. This association was also evident among female subjects. The positive relationship between obesity and DM was well recognized [37–39]. It is well documented that obesity is a strong risk factor for the development of DM as shown by several studies [40, 41]. There is also an age related increase in obesity, particularly central obesity, and a reduction in physical activity, both of which can be associated with abnormal glucose metabolism. According to Diabetes Prevention Program, for every kilogram of weight loss, there was a 16% reduction in risk, adjusted for changes in diet and activity [42]. In fact, the Diabetes Prevention Program found that modifications of diet and activity were more effective in older people than in younger patients in preventing the development of DM. It is believed that obesity contributes to the development of DM by elevating levels of non esterified free fatty acids, hormones, adipocytokines, and other substances that increase insulin resistance. Obesity-related elevation in proinflammatory molecules, including tumor necrosis factor-α and interleukin-6 are also believed to contribute to the development of both DM and metabolic syndrome [43, 44]. The prevalence of overweight and obesity among patients with DM are both extremely high. Obesity or abdominal obesity is frequently associated with other cardiometabolic factors such as hypertension, lipid disorders. These factors may be clustered as metabolic syndrome, which is well known to seriously increase the cardiovascular risk [45, 46]. In the present study, those with diagnosed DM tended to have a higher prevalence of high blood pressure in both men and women. Individuals with DM had more concomitant cardiovascular risk. The rapid transition and changes of lifestyles involving dietary intake (high fat caloric dense food, low in complex carbohydrates, refined sugar and salt) and decreasing physical activity have take a place in the past 20 years in Tunisia. The urbanization had negative consequences on lifestyle aspects of Tunisians [8]. This suggests that there is a need to improve the awareness of health and use of regular activity and Mediterranean diet to prevent or reduce the cardiovascular risk. For those reasons, the promotion of healthier eating habits may protect elderly and contribute to improved health and quality of life. The Mediterranean diet is a healthy dietary pattern that has already shown its cardioprotective effects [47]. The Mediterranean diet is characterized by high consumption of monounsaturated fatty acids (Olive oil), and encourages daily consumption of fruits, vegetables, whole grain cereals with low animal-fat consumption. Recently, a meta-analysis, performed in 50 studies, with an overall incorporated population of approximately one-half million subjects, revealed the beneficial effect of the Mediterranean diet. The researchers showed that adherence to the Mediterranean diet have a positive effect on human health through the beneficial effect on abdominal obesity, lipids levels, glucose metabolism and blood pressure. Results indicate that adherence to Mediterranean diet may attenuate the prevalence of metabolic syndrome and, consequently the increasing burden of DM and cardiovascular diseases [48]. Pathophysiological mechanisms include antioxidant and anti-inflammatory effects of the functional foods included in the Mediterranean diet [48].

Physical activity is well recognized as cardiometabolic protect factor [6]. However, physical activity was not associated with DM in our study. This surprising finding may be explained by the small number of elderly who practice regular physical activity (less than 4%). Increasing numbers of diseases and drugs are associated with high prevalence of DM. The number of hospital admission in preceding year was also positively associated with DM. Elderly diabetic patients often require multiple medications to adequately and appropriately treat their diabetes and associated comorbidities. It is also, well documented that co-existing illnesses and take multiple drugs can adversely impact glucose metabolism [49].

It is important to acknowledge that estimation of the prevalence of DM in elderly population and formulation of effective treatments strategies is only the first step. It is clear that the magnitude of the problem of DM among the elderly poses a major economic challenge to health care systems. We believe that higher public health organization, health planners, clinicians and public health practitioners in developing countries must formulate a program targeting high risk group to implement a preventive strategy in modifying lifestyle by increasing physical activity, reducing obesity, adopting healthier eating habits and raising diabetic’s awareness of their disease to reduce morbidity and mortality [50].

DM is very common in elderly Tunisian subjects and is frequently associated with other cardiovascular risk factors, mainly obesity and hypertension. An ageing population together with social, economic and lifestyle changes have led to a dramatic increase in DM. These data emphasize the needs to inform the general public and health planner. There is an urgent need for a comprehensive integrated population-based intervention program to ameliorate the growing problem of DM. The above information suggests that lifestyle modifications might be of value in the DM prevention in older people.