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T
he number of people with diabetes peared, further epidemiological data have
is increasing due to population become available for several countries in 2 h after a 75-g glucose tolerance test).
growth, aging, urbanization, and in- Africa and the Middle East and for India. The exceptions to the latter criterion were
creasing prevalence of obesity and physi- The sources of these data are identified in the study in China, for which a test meal
cal inactivity. Quantifying the prevalence Table 1. was used (4), and the study in Tanzania
of diabetes and the number of people af- This report provides estimates of the (5), in which fasting glucose alone gave a
fected by diabetes, now and in the future, global prevalence of diabetes in the year higher prevalence of diabetes than a pre-
is important to allow rational planning 2000 (as used in the World Health Orga- vious study that used the optimal WHO
and allocation of resources. nization [WHO] Global Burden of Dis- criteria.
Estimates of current and future dia- ease Study) and projections for 2030. It Prevalence estimates for type 1 diabe-
betes prevalence have been published provides a sequel to the report describing tes for people ⬍20 years of age for indi-
previously (1–3). Since these reports ap- estimates of the global burden of diabetes vidual countries were estimated from
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
available incidence data using methods
described in the International Diabetes
From the 1Public Health Sciences, University of Edinburgh, Edinburgh, Scotland; the 2Department of
Non-Communicable Diseases, World Health Organization, Geneva, Switzerland; the 3Department of Epi- Federation (IDF) Diabetes Atlas 2000 (6).
demiology and Social Medicine, University of Aarhus, Aarhus, Denmark; and the 4International Diabetes Population-based data are not available
Institute, Caulfield, Victoria, Australia. for type 2 diabetes in people ⬍20 years of
Address correspondence and reprint requests to Dr. Sarah Wild, Public Health Sciences, University of age, and this group has been excluded
Edinburgh, Teviot Place, Edinburgh, EH8 9AG, Scotland. E-mail: sarah.wild@ed.ac.uk.
Received for publication 18 October 2003 and accepted in revised form 26 January 2004.
from these estimates.
S.W. received honoraria for speaking engagements from Bayer Corporation. A.G. is a paid consultant of Age- and sex-specific estimates for di-
Novo Nordisk. abetes prevalence were extrapolated to
Additional information for this article can be found in an online appendix at http://care.diabetesjournals. other countries using a combination of
org. criteria including geographical proximity,
Abbreviations: IDF, International Diabetes Federation; WHO, World Health Organization.
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion ethnic, and socioeconomic similarities
factors for many substances. applied by the authors with the advice
© 2004 by the American Diabetes Association. of the WHO regional officer and other
Table 1 —List of diabetes prevalence studies by country of study giving sample size, age-group, and the countries to which the data were
extrapolated
Table 2 —Estimated numbers of people with diabetes by region for 2000 and 2030 and summary of population changes
experts. Table 1 shows the studies used umentation (11). Mortality data were de- ual countries for 2000 and 2030, which
and the countries to which data were rived from developed countries (U.K., were produced by the United Nations
extrapolated. Sweden, and U.S.). As no information was Population Division (12). Conventional,
Surveys were generally performed on available for developing countries, the albeit simplistic, definitions of developed
middle-aged populations, and data are same relative risks were assumed to ap- countries (Europe including former so-
more limited at younger and older ages. ply. Data are required to test the validity cialist economies, North America, Japan,
Data on diabetes prevalence are usually of this assumption. Survival is unlikely to Australia, and New Zealand) and less de-
presented in broad age bands, which sug- be better in developing countries than de- veloped countries (all other countries)
gest a biologically implausible step-like veloped countries, and any bias in the ap- were used. In keeping with previous esti-
increase in diabetes prevalence with in- proach we have taken would lead to mates, prevalence of diabetes was as-
creasing age. DISMOD II software (avail- conservative estimates of incidence of di- sumed to be similar in urban and rural
able from http://www3.who.int/whosis) abetes in developing countries but would areas of developed countries (2). For de-
was used to produce smoothed, age- not affect estimates of prevalence. Esti- veloping countries, urbanization was
specific estimates of diabetes prevalence mates of incidence and mortality are used as a proxy measure of the increased
from the available data from each study. not presented in this report but are risk of diabetes associated with altered
Further details on DISMOD II have been available from the authors and from the diet, obesity, decreased physical activity,
published elsewhere (7). In summary, draft Global Burden of Disease 2000 and other factors such as stress, which are
age- and sex-specific diabetes prevalence documentation (11). assumed to differ between urban and ru-
(derived from the studies listed in Table The prevalence estimates were ap- ral populations. For most developing
1), remission (assumed to be zero), and plied to population estimates for individ- countries, the prevalence of diabetes in
estimates of relative risk of mortality
among people with diabetes (see below)
were entered into models. The model out-
put provides estimates of prevalence, in-
cidence, and mortality that are consistent
with one another (7).
Estimates of relative risk of all-cause
mortality among people with diabetes, by
age and sex, were derived from the lim-
ited number of cohort studies that pro-
vide this information (8 –10). Estimated
relative risks for all-cause mortality
ranged between 1 (for the oldest age-
group, ⱖ80 years of age) and 4.1 (for
20 –39 years of age) for men and between
1 (for ⱖ80 years of age) and 6.7 (for
20 –39 years of age) for women. Further
information on the estimation of age-
specific relative risks is available in the
draft Global Burden of Disease 2000 doc- Figure 1—Global diabetes prevalence by age and sex for 2000.
Table 3 —List of countries with the highest numbers of estimated cases of diabetes for 2000 new approach to estimating age-specific
and 2030 prevalence of diabetes was used for the
present estimates. For the estimates pre-
2000 2030 pared for the Global Burden of Disease
Study 1990, logistic regression models
People with People with with a linear factor for age were used
Ranking Country diabetes (millions) Country diabetes (millions) when data for all age-groups were not
1 India 31.7 India 79.4 available (2). The IDF estimates for 2000
2 China 20.8 China 42.3 included a quadratic regression model
3 U.S. 17.7 U.S. 30.3 for diabetes with age (6), which can result
4 Indonesia 8.4 Indonesia 21.3 in a marked reduction in diabetes preva-
5 Japan 6.8 Pakistan 13.9 lence at the oldest ages. DISMOD II mod-
6 Pakistan 5.2 Brazil 11.3 els showed a flattening or modest reduc-
7 Russian Federation 4.6 Bangladesh 11.1 tion of diabetes prevalence in the oldest
8 Brazil 4.6 Japan 8.9 ages, which appears to be more consistent
9 Italy 4.3 Philippines 7.8 with the pattern observed in the limited
10 Bangladesh 3.2 Egypt 6.7 number of studies giving information on
diabetes prevalence in the oldest age-
groups.
and developing countries is illustrated in diabetes in this subpopulation in 2000. A conservative approach to calculat-
Fig. 2. Despite methodological differences, this ing estimates was taken throughout this
The 10 countries estimated to have was similar to the present estimate for a study. Given that several of the surveys
the highest numbers of people with dia- comparable population of 147 million. were performed more than a decade ago,
betes in 2000 and 2030 are listed in Table The IDF has subsequently released esti- it is probable that this has generated un-
3. The “top three” countries are the same mates of the numbers of people with dia- derestimates of diabetes prevalence. Until
as those identified for 1995 (2) (India, betes for 2003 and forecasts for 2025 of more modern and nationally representa-
China, and U.S.). Bangladesh, Brazil, In- 194 million and 334 million, respec- tive data are available, this approach pro-
donesia, Japan, and Pakistan also appear tively (16). vides a guide to the lower limits of the
in the lists for both 2000 and 2030. The Even if the prevalence of obesity re- extent of the diabetes epidemic. It is an-
Russian Federation and Italy appear in the mains stable until 2030, which seems un- ticipated that estimates will be updated
list for 2000 but are replaced by the Phil- likely, it is anticipated that the number of periodically as new information becomes
ippines and Egypt for 2030, reflecting an- people with diabetes will more than dou- available.
ticipated changes in the population size ble as a consequence of population aging In summary, these data provide an
and structure in these countries between and urbanization. In the light of the ob- updated quantification of the growing
the two time periods. served increase in prevalence of obesity in public health burden of diabetes across
many countries of the world and the im- the world. The human and economic
CONCLUSIONS — The number of portance of obesity as a risk factor for di- costs of this epidemic are enormous. Mor-
cases of diabetes worldwide in 2000 abetes, the number of cases of diabetes in tality from communicable diseases and
among adults ⱖ20 years of age is esti- 2030 may be considerably higher than infant and maternal mortality in less-
mated to be ⬃171 million. This figure is stated here. Increasing evidence of effec- developed countries are declining. In as-
11% higher than the previous estimate of tive interventions, including changes in sociation with increasing diabetes
154 million (2). Estimates of total popu- diet and physical activity or pharmacolog- prevalence, this will inevitably result in
lation size and proportion of people ⬎64 ical treatment to reduce prevalence of di- increasing proportions of deaths from
years of age in 2000 used in the previous abetes, provides an impetus for wider cardiovascular disease in these countries,
report were higher than those used in this introduction of preventive approaches as well as increased prevalence and asso-
report, and therefore demographic (17–19). Furthermore, improved survival ciated consequences of other complica-
changes cannot account for the discrep- may contribute to increasing prevalence tions of diabetes. A concerted, global
ancy. The higher prevalence is more likely of diabetes in the future especially in de- initiative is required to address the diabe-
to be explained by a combination of the veloped countries (20). tes epidemic.
inclusion of surveys reporting higher As with previous similar studies,
prevalence of diabetes than was assumed these estimates are limited by a paucity of
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