Vulnerabilities to Mitigate the Newly Recognized Type-5 Diabetes in Low-resource Settings: A Review on Bangladesh Perspective and a Call for Global Action

Abstract

Type-5 diabetes (T5D), a recently identified malnutrition-related diabetes subtype, is a serious public health concern for both world health and Bangladesh, where high rates of undernutrition coexist with a rapidly increasing diabetes epidemic. T5D disproportionately impacts low- and middle-income nations. Bangladesh is a hotspot due to the dual burden of undernutrition and diabetes, with high rates of childhood stunting (24%), wasting (11%), and adult diabetes prevalence (13.2%). This review attempts to identify T5D mitigation vulnerabilities in Bangladesh, a representative sample of low-resource nations, including resource limitations, socioeconomic inequalities, dietary attitudes and practices, awareness gaps, cultural obstacles, and natural disaster concerns. Key constraints include widespread economic hardship, which restricts access to healthy food and healthcare; dietary shifts toward processed foods, which intensify micronutrient deficiencies; and suboptimal child feeding practices. Weaknesses in the healthcare system, such as insufficient resources, diagnostic restrictions, rural-urban inequities, and a scarcity of skilled professionals, impede early identification and treatment. Gender disparities and domestic violence increase the hazards, since starving women have intergenerational metabolic effects on their children. Furthermore, frequent natural catastrophes interrupt food security, exacerbating malnutrition-diabetes relationships. Multisectoral initiatives are required for effective mitigation of T5D, including scaling up nutrition interventions, enhancing basic healthcare, and establishing social protection programs. Policy changes must include T5D in national diabetic standards, and community-based awareness initiatives must remove cultural stigmas. Without measures, T5D will worsen health disparities in low-income countries such as Bangladesh, highlighting the need for global attention and customized public health initiatives to prevent the malnutrition-based T5D.

Background

Diabetes mellitus is a chronic metabolic disease characterized by elevated levels of blood glucose. It is a complicated condition which can take many different forms. ¹ It has long been categorized into Type 1, Type 2, and gestational diabetes, with emerging discussions on Type 3 (linked to Alzheimer’s disease) and Type 4 (age-related). ² The other types of diabetes include maturity-onset diabetes of the young, neonatal diabetes, latent autoimmune diabetes in adults and cystic fibrosis diabetes. ³ About 2% of people have these other types of diabetes. Recently, the International Diabetes Foundation and World Health Organization have identified a novel subtype, termed Type-5 diabetes (T5D). ³ The condition was first described as J-type diabetes in Jamaica in 1950. ⁴ Later, this type was termed “malnutrition-related diabetes mellitus” by the WHO in 1985, but the classification in 1999 was due to insufficient evidence linking malnutrition to the disease’s development. ⁴ In 2022, researchers from Christian Medical College Vellore (CMC, Vellore), India, and Albert Einstein College of Medicine, New York, USA, helped to re-establish it. ⁴ Finally, the International Diabetes Federation (IDF) recognized this new type of diabetes in April 2025. ⁵ This formal recognition and integration of Type 5 Diabetes Mellitus (T5DM) into global diabetes classifications will advance health equity by prioritizing populations affected by poverty and chronic undernutrition, thereby enabling improved diagnostic accuracy, tailored therapeutic interventions, and focused global research initiatives. ⁴

Compared to T2DM, which is driven by insulin resistance and often linked to obesity, or Type 3c Diabetes (T3cDM), which results from pancreatic damage due to disease or surgery, T5DM stems from impaired pancreatic growth without autoimmune involvement.^6,7 Patients typically present with low BMI, reduced but preserved C-peptide levels, and a notable resistance to ketosis despite significant hyperglycemia. Its management requires both insulin therapy and nutritional rehabilitation, and misclassification can lead to inadequate care, especially in resource-limited settings.^6,8 Studies from India have found that malnutrition causes comparable types of diabetes, such as fibrocalculus pancreatic diabetes and protein-deficient pancreatic diabetes.^6,9 Recent specialists and medical groups have also stated that this ailment has distinct origins and health consequences in the region. ⁹

Malnutrition during pregnancy, infancy, or early childhood may lead to metabolic problems in the future. ¹⁰ Low protein diet during pregnancy may lead to increased oxidative stress, fibrosis, defective mitochondriogenesis and β-cell dysfunction, which may increase the risk of insulin resistance. ¹⁰ Studies of large-scale “natural experiments” such as the famines in the Netherlands, China, and Ukraine, have shown that people who experience famine before the age of nine are about twice as likely to develop diabetes as adults. ¹¹ T5D is estimated to affect between 20 and 25 million people worldwide. ⁴ A rising trend is observed in low- and middle-income countries (LMICs), where malnutrition persists alongside rapid dietary transitions.^4,12 Regions with high food insecurity, such as South Asia and sub-Saharan Africa, have reported increasing cases of diabetes in non-obese individuals, suggesting a possible overlap with T5D. ¹³ It is also reported that diabetes among low and normal BMI was found in India, Sri Lanka, Uganda, Ethiopia, Rwanda, and Korea, mostly in the Global South.^5,13

Countries with high rates of childhood stunting and wasting, like Bangladesh is at heightened risk of T5D. ¹⁴ Though malnutrition-associated diabetes has been an emerging health issue, still historically overlooked and under-researched, leading to potential misdiagnosis and lack of tailored care. ¹⁴ The recognition of T5D highlights the importance of addressing nutritional deficiencies and their impact on diabetes development, particularly in vulnerable populations. ⁵ Therefore, this review explores the emergence of the T5D in Bangladesh and vulnerabilities in mitigating this growing public health aspect.

Dual Burden: Undernutrition and Rising Diabetes Prevalence

Role of Various Endocrine Disruptors for Developing T5D in South Asia

Emerging data show that endocrine-disrupting chemicals (EDCs) may play an important role in the development of T5D in South Asia, particularly among poor people.^15,16 Persistent organic pollutants (POPs), including organochlorine pesticides such as dichloro-diphenyl-trichloro-ethane (DDT) and dichloro-diphenyl-dichloro-ethylene (DDE), heavy metals, and industrial chemicals such as per- and polyfluoroalkyl substances (PFAS), have been associated with pancreatic β-cell dysfunction and decreased insulin production.^15,17 Research from India focuses on the diabetogenic consequences of persistent pesticide residues in agricultural areas, where the uncontrolled use of pesticides such as endosulfan and chlorpyrifos affects pancreatic endocrine function.^15,17

Undernutrition and Rising Diabetes Prevalence in Bangladesh

Despite significant progress in reducing extreme poverty, undernutrition remains a serious public health problem in Bangladesh. ¹⁸ A significant portion of children under five experience undernutrition. ¹⁸ Nearly 24% of children under five years old are stunted, meaning they are too short for their age, 11% are wasted, meaning that they are too thin for their height, and 21% are underweight, indicating chronic undernutrition. ¹⁸ Stunting is most prevalent among children 18–23 months. ¹⁸ Additionally, 11.9% of the adult population is undernourished, highlighting the coexistence of nutritional challenges alongside chronic diseases. At the same time, the prevalence of diabetes among adults in Bangladesh is 13.2%, affecting approximately 13 million people. ¹⁹ It is also reported that 1 in 7 adults has diabetes, among them, about 40%–60% of patients are undiagnosed. ¹⁹ Another study revealed that the prevalence of diabetes has tripled in the past two decades, affecting over 16 million adults in Bangladesh. ²⁰

A significant number of individuals with diabetes are lean or of normal weight, highlighting a shift in the demographics of the disease in Bangladesh. ²⁰ One study focusing on a lean urban middle-class population in Bangladesh found a diabetes prevalence of 8.5%. ²¹ The coexistence of undernutrition and diabetes suggests that a substantial proportion of these cases may be associated with T5D. ²¹ Thus, Bangladesh faces the dual burden of undernutrition and diabetes, risking a surge in T5D cases and straining an already overburdened healthcare system.

Vulnerabilities of Bangladesh for Mitigating Newly Recognize T5D

Mitigating malnutrition-related T5D in Bangladesh is complex because of the paradoxical coexistence of undernutrition and metabolic disorders. ²² Bangladesh is mitigating several key vulnerabilities related to T5D, including socioeconomic, nutritional attitude and practice, resource limitations, lack of education and awareness, cultural barriers, gender inequalities in a patriarchal society, domestic violence, and effects of natural disasters. Some of the key vulnerabilities are:

Socioeconomic Status

T5DM develops not only by chronic malnutrition, but also by a variety of socioeconomic factors. Persistent poverty, restricted access to healthcare, low educational attainment, and food insecurity all lead to poor development and consequences.^23,24 Individuals in deprived regions frequently experience early-life trauma, psychological stress, and insufficient living circumstances, all of which decrease pancreas function and metabolic resistance. These systemic imbalances distinguish T5DM as a separate, socially driven kind of diabetes that needs both medical and policy-level solutions. ²⁵

In LMICs like Bangladesh, socioeconomic factors like poverty and economic difficulty can all contribute to the undernutrition from pregnancy and infancy on to the later stages of child development.^4,22 A low socioeconomic profile significantly limits access to nutritious food, healthcare, and quality education. The rate of child undernutrition is consistently high among people of low socioeconomic status that leads to malnutrition-related diabetes. ²² Study has confirmed that there is a strong link between poverty and undernutrition, such as households experiencing poverty are strongly associated with higher rates of child undernutrition, and can affect nutrition throughout the entire lifespan. ²⁶ Furthermore, poverty restricts access to timely diagnosis and management of diabetes. ²⁶ The economic conditions of the household can be considered the most important factor in undernutrition. ²⁷ Individuals with lower earnings may struggle to afford a balanced diet, relying on cheaper, calorie-dense, but nutrient-poor foods. ²⁷ This can lead to undernutrition and increase the risk of developing T5D. ²⁷ Children in the poorest 20% of households were three times as likely to suffer from an adverse growth rate. ²⁷ Thus, poverty and economic hardship can lead to undernutrition and increase the risk of developing T5D.

Nutrition-related Attitude and Practice

Food Insecurity

Food insecurity is still a pivotal issue in Bangladesh and has major impacts on hunger and undernutrition. ²⁸ In 2025, approximately 16 million (17%) people in Bangladesh are experiencing high levels of acute food insecurity. ²⁹ According to the Global Report on Food Crises 2025, Bangladesh is the fourth most severely food-insecure country in the world. ²⁹

Dietary Transition

Rapid dietary transition also has a significant role in developing undernutrition. ³⁰ Processed food and refined carbohydrate along with low protein and micronutrient deficiencies, lead to chronic undernutrition and worsen metabolic dysfunction in undernourished individuals, which can contribute to developing T5D. ³⁰

Poor Feeding Practice

In the context of Bangladesh, poor feeding practice also contribute to childhood undernutrition that may later lead to the development of T5D. ³¹ Children who receive supplemental (post-EBF) feedings have low micronutrient intake because the content of these feedings is frequently insufficient or incorrect, and they are started either too early or too late. ³¹ Inadequate infant and young child feeding (IYCF) practices also contribute to the high prevalence of undernutrition. ³¹

Hygiene and Sanitation

In Bangladesh, frequent diarrhea and intestinal worms (soil-transmitted helminths) are two major public health problems that are closely related to undernutrition in children. ³² Recurrent diarrhea reduces nutrient absorption, leading to micronutrient deficiencies such as zinc, vitamin D, B12, and iron, which impair metabolic function and are linked to diabetes.^30,32 However, these deficiencies in vitamin D, Iron, zinc, B12 and folate are a matter of concern because they play a role in developing diabetes. ³⁰

Tobacco Use

Tobacco consumption in Bangladesh is indeed a barrier to mitigating malnutrition-related diabetes. ³³ Tobacco use, both smoking and smokeless forms, negatively impacts dietary intake, exacerbating the challenges of undernutrition and diabetes. ³³ The study depicted that tobacco expenditure in low-income households can exacerbate the effects of poverty and divert household income away from food, housing, health, and education. ³⁴ This can lead to inadequate nutrient intake, contributing to undernutrition. ³⁴ A study has revealed that fathers’ smoking is significantly associated with an increased risk of underweight status and stunting. ³⁵ Smoking is a well-established risk factor for diabetes, with smokers having a 30%–40% higher chance of developing the disease compared to non-smokers. ³⁵ Additionally, tobacco costs often limit funds for nutrition and healthcare, and secondhand smoke weakens children’s immune systems, increasing their susceptibility to infections that impair nutrient absorption and growth. ³⁵

Resource Limitations

Limited Systematic Resources

Limited health resources significantly hinder efforts to mitigate undernutrition-related diabetes by restricting access to essential services, including diagnosis, treatment, and nutritional support. ³⁶ Limited resources can obstruct the establishment of community-based programs that provide nutritional support, education, and monitoring for individuals with diabetes. ³⁶

Diagnostic Barrier

The identification of T5D may be delayed by inadequate screening and diagnostic resources, which could result in lost chances for early intervention and management, which could exacerbate complications and impeding efforts to mitigate the condition.^4,37 Current diabetes classifications do not account for malnutrition-related variants, leading to misclassifications and suboptimal treatments. ⁴ Traditional markers commonly utilized in Bangladesh, such as HbA1c, fasting blood glucose, and oral glucose tolerance tests, may be less reliable in undernourished populations due to altered erythrocyte turnover. ⁴ Emerging research suggests that pancreatic polypeptide levels, C-peptide assays, and metabolic profiling can help differentiate T5D from other subtypes. ⁴

Lack of Services

A lack of adequate hospital services significantly hinders efforts to mitigate malnutrition-related diabetes by limiting access to insufficient specialist services, necessary diagnostic, treatment, and preventative care, which includes limited access to medication and essential nutritional supplements. ³⁸

Lack of Trained Personnel

A lack of trained personnel and expertise in diabetes can result in limited capacity for effective diagnosis, treatment, and management of the condition. ³⁹ T5D often goes undiagnosed due to a shortage of doctors, nurses, and other healthcare providers with expertise in diabetes management and nutritional deficiencies. ³⁹ Without trained professionals, it is difficult to implement comprehensive diabetes prevention and management programs and provide self-management education and effective nutritional support. ³⁹

Rurality

Regional disparities are another crucial barrier in mitigating T5D. ⁴⁰ In rural areas of Bangladesh, malnutrition is more prevalent. ⁴⁰ According to a previous study, children are more likely to be stunted in rural communities (38%) as compared to children from urban communities (31%). ⁴⁰ Not only rural population but also urban slum dwellers have limited access to nutritious diets and healthcare services. ⁴⁰ The availability and quality of healthcare providers in underserved areas are often inadequate. ⁴⁰ There is a shortage of primary care physicians, endocrinologists, and diabetes specialists in many low-income and rural communities. ⁴⁰ Furthermore, healthcare facilities in rural areas may lack the necessary resources and equipment to provide comprehensive diabetes care. ⁴⁰

Lack of Policies

The lack of effective health policies to address undernutrition and its link to diabetes is a significant challenge, particularly in LMICs. ⁴¹ While some policies exist, gaps in implementation, funding, and a comprehensive life-course approach hinder progress. ⁴¹ Feasible health policies play a crucial role in mitigating the risk of undernutrition-related diabetes by promoting healthy diets, improving access to healthcare, and addressing the root causes of malnutrition. ⁴¹ These policies can focus on integrated public health strategies, improved access to healthcare, nutrition-focused diabetes management, strengthening food security, and public awareness campaigns. ⁴¹

Lack of Education and Awareness

Lack of quality education can contribute to both undernutrition and diabetes, often through interconnected pathways. ⁴² Individuals with limited education may have reduced access to information about healthy eating and disease prevention, leading to poor dietary choices and increased risk of both undernutrition and diabetes. ⁴² Lower education levels are often linked to lower income and limited access to resources, leading to reliance on cheaper, less nutritious foods and increasing the risk of undernutrition and related health issues such as diabetes. ⁴² In Bangladesh, maternal education plays a pivotal role in child nutrition. Children of mothers with no schooling face a stunting rate of 47.5%, compared to just 18.4% among children whose mothers have completed secondary school. ²⁷

Lack of education results in unawareness among many Bangladeshi people about the connection between diabetes and malnutrition. ⁴³ Lack of public awareness about malnutrition-related diabetes makes them detached from recognizing the risk, seeking appropriate care, and adopting preventative measures. ⁴³ This leads to delayed diagnosis, poor management and increased risk of complications of T5D. ⁴³ Insufficient health literacy severely restricts initiatives to treat diabetes linked to malnutrition by restricting people’s capacity to comprehend and regulate their health, which leads to inadequate disease management and poorer results. ⁴³

Patriarchy and Gender Inequality

In Bangladesh, patriarchal traditions hinder women’s access to healthcare, education, and employment, which leads to poor maternal nutrition, gender-biased food distribution, and intergenerational health hazards, including an increased susceptibility to diabetes. ⁴⁴ Women often eat last and least, contributing to chronic undernutrition, which predisposes them and their offspring to metabolic disorders. ⁴⁴ In Bangladesh, the prevalence of undernutrition among female children is higher than the prevalence among male children in terms of household allocation of food. ⁴⁴ Gender dynamics can lead to sustained maternal undernutrition, and multiple pregnancies contribute to low birth weight in offspring. Consequently, the risk of malnutrition-related diabetes later in life is increasing due to the high prevalence of low birth weight (16.3%). ⁴⁴

Domestic Violence

In Bangladesh, Domestic violence exposes women to psychological stress and food instability, which can result in undernutrition.^45,46 According to research, undernutrition in infancy, which is associated with maternal violence, puts infants at risk for insulin resistance and diabetes in later life.^45,46 Children born to undernourished moms are more likely to suffer from stunted growth and poor metabolic development. ⁴⁷ According to research, undernutrition in infancy, which is associated with maternal violence, puts infants at risk for insulin resistance and diabetes in later life.^45,46 In Bangladesh, maternal exposure to Intimate Partner Violence (IPV) is significantly linked to child undernutrition. ⁴⁷ Children under five whose mothers experienced IPV—whether physical, sexual, or both—had greater odds of being stunted or underweight compared to those in nonviolent households. ⁴⁷ IPV also harms maternal mental health and caregiving capacity, indirectly reducing children’s food security and immunization rates. ⁴⁷ These early-life nutritional deficits can lay the groundwork for metabolic disorders, including Type2 diabetes, later in life. ⁴⁷

Cultural Barrier

Cultural norms and stigma significantly hinder efforts to mitigate undernutrition-related diabetes by creating barriers to healthcare access, promoting unhealthy dietary practices, and discouraging individuals from seeking help. ⁴⁸ In Bangladesh, cultural beliefs and eating habits might make it more difficult to maintain enough nutrition and manage diabetes. They can cause misconceptions about “healthy” foods and prioritize high-energy meals like white rice, which exacerbates nutritional deficiencies and makes it more difficult to control blood sugar. ⁴⁸ Culturally motivated feeding habits and resistance to dietary modifications raise the risk of diabetes complications and chronic undernutrition. ⁴⁸ According to a previous study, more than 80% of pregnant diabetic women avoided foods like pineapple and duck, and many skipped meals around eclipses or prayer times, which resulted in poor glucose control and insufficient nutrient intake. ⁴⁸

Natural Disaster

Natural catastrophes such as floods, cyclones, and droughts are common in Bangladesh and interrupt food production, increasing the risk of diabetes and malnutrition. ⁴⁹ Due to interrupted meals, diarrhea, and low immunization rates, children who experience frequent floods are 1.74 times more likely to experience chronic undernutrition. ⁴⁹ According to climate-health evaluations, hunger brought on by disasters impairs metabolic health pathways, raising the risk of insulin resistance and diabetes in impacted communities. ⁵⁰

Natural disasters are producing severe food security and public health issues in the disaster-prone areas of Bangladesh, leading to underweight, stunting, and malnutrition in women and children, especially those who were exposed to these events. ⁵¹ The previous study highlights increased vulnerability to diabetes in the disaster-prone area in Bangladesh caused by limited healthcare access and food insecurity, which worsens disease management and leads to greater health complications. ⁵²

Way Forward

Malnutrition-related T5D is exacerbated by structural vulnerabilities beyond the health sector, including poverty, undernutrition, limited care access, gender inequality, and disaster vulnerability, creating a self-reinforcing cycle that exacerbates the disease burden in countries with low-resource settings like Bangladesh.^21,53 Inadequate public health knowledge, cultural obstacles, and fragmented healthcare delivery frequently impede efforts to minimize T5D. ⁴ Addressing the escalating prevalence of T5D in Bangladesh requires a comprehensive, multisectoral strategy that aligns with both national priorities and global health frameworks. This approach must integrate socioeconomic, gender, and geographic determinants within evidence-based public health interventions to achieve equitable outcomes.^4,39,53

To mitigate T5D in Bangladesh, as well as in other low-resource settings, strengthening economic and social security through targeted social protection programs, such as conditional cash transfers, food vouchers, and expanded benefits for marginalized groups, should be prioritized to mitigate economic vulnerability and enhance access to essential nutrition and healthcare.^27,36 Expanding nutritional support via maternal and child micronutrient supplementation, community-based therapeutic nutrition programs, and integrated diabetes screening and counseling at the primary care level is vital to reducing the dual burden of malnutrition and T5D.^28,30,31 Strengthening healthcare resource capacity through healthcare worker training, investment in rural and climate-vulnerable infrastructure, and the development of malnutrition-diabetes surveillance systems will further enhance system resilience and responsiveness.^4,38

At the research and policy level, countries should align with global initiatives such as the WHO Global Diabetes Compact and the United Nations Sustainable Development Goals (SDGs), particularly SDG 2 (Zero Hunger) and SDG 3 (Good Health and Well-being). This includes funding longitudinal and cross-country comparative studies on malnutrition-diabetes interactions, formulating national clinical guidelines for T5D, and advancing interdisciplinary research into gut microbiome dynamics, epigenetic mechanisms, and disease pathogenesis.^36,38,39,54 Regionally, collaboration with South Asian countries through knowledge-sharing platforms, standardized surveillance systems, and coordinated public health campaigns could enhance collective capacity to combat the growing T5D burden.

Finally, given the urgency of intervention, countries with low-resource and climate vulnerabilities like Bangladesh and its regional neighbors, must prioritize the establishment of climate-resilient health and nutrition systems, to develop emergency nutrition protocols, and to implement culturally sensitive communication strategies that engage religious and community leaders. These efforts should aim to reduce stigma surrounding women’s nutrition and illness while leveraging regional and community media to raise awareness of the malnutrition-diabetes nexus, particularly among women and rural populations.^27,48

Conclusion

T5D represents a paradigm shift in understanding the etiology of diabetes, highlighting the critical role of malnutrition in metabolic diseases. Bangladesh, like many other developing nations with its high malnutrition rates and escalating diabetes burden, is at the forefront of this crisis. Without urgent action, the T5D could exacerbate health disparities and economic losses in vulnerable populations of countries with limited resources. Addressing this challenge requires innovative diagnostics, tailored treatment, and robust public health policies that bridge nutrition and diabetes care. By prioritizing T5D in global health agendas, Bangladesh and other developing countries can mitigate this silent epidemic and safeguard future generations from its devastating consequences.