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Global burden of Diabetes:

Prevalence and projections


Peter H. Bennett, M.B., F.R.C.P.
National Institute of Diabetes and Digestive and
Kidney Diseases,
Phoenix, Arizona, U.S.A.

Belllagio, March 16th 2004

Outline

Prevalence of Diabetes
Estimates of future prevalence (projections)
Mortality attributable to diabetes
Effect of the epidemic on rates of complications
Projections for ESRD

Newsweek,
Newsweek,September
September4,4,
2000
2000

Time,
Time,September
September4,4,2000
2000

Diabetes in 2000 & 2025


in USA and the World
300 million

151million
USA

15

22

King,H, Aubert,RE, Herman,WH: Global burden of diabetes, 1995-2025:


Diabetes Care 21:1414 - 1431, 1998

Diabetes in 2000 & 2030


in USA and the World
366 million

171million
USA

17.7

30.3

Wild, S et al.: Global prevalence of diabetes:


Estimates for 2000 and projections for 2030. Diabetes Care 2004 In press

Global Projections for the Diabetes Epidemic:


2000-2030 (in millions)
EU
17.8
25.1
41%

NA
19.7
33.9
72%
LAC
13.3
33.0
248%

Wild, S et al.: Global prevalence of diabetes:


Estimates for 2000 and projections for 2030
Diabetes Care 2004 In press

SSA
7.1
18.6
261%

MEC
20.1
52.8
263%

China
20.8
42.3
204%
India
31.7
79.4
251%

World
2000 = 171 million
2030 = 366 million
Increase 213%

A+NZ
1.2
2.0
65%

Estimated Number of People with Diabetes


in 2000 and 2030 (and % change)

+176%
+26%

-13%

Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030
Diabetes Care 2004. In press

Estimated Number of People with Diabetes in


2000 and 2030 (and % change)

+247%

+308%
+189%

Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and


projections for 2030 Diabetes Care 2004 In press

Estimated Number of People with Diabetes in


2000 and 2030
+212%
+242%

+75%

Wild, S et al.: Global prevalence of diabetes: Estimates for 2000


and projections for 2030 Diabetes Care 2004 In press

Are these projections realistic?


Based on:
1990s estimates of diabetes prevalence
Demographic projections
Assume constant (current) age-sex specific
prevalence of diabetes

Changing Prevalence of Type 2


Diabetes

No of persons with Physician-diagnosed


Diabetes in USA by year

Data from the US National Health Interview Survey:


http://www.cdc.gov/diabetes/statistics/prev/national/fig1.htm

Diabetes in the United States


1958-1993
Prevalence (%)
> 65 years
55-65 years

45-54 years
< 45 years

Data from the US National Health Interview Survey

Diabetes in the United States


1980-2000
Prevalence (%)
65-74years
75+years

45-64years

< 45 years

Data from the US National Health Interview Survey:


http://www.cdc.gov/diabetes/statistics/prev/national/fig3.htm

Diabetes Epidemic in the United States, 1991-1999


Percent with Diagnosis of Diabetes
(Aged 18 years and over)

1991

1999

%
Increase

Men

4.1%

6.0%

46%

Women

5.6%

7.6%

36%

Mokdad A. H et al. Diabetes Care 23: 1278-1283


Mokdad A. H et al. Diabetes Care 24: 412

increase = 5%/ year

Obesity Epidemic in the United States, 1991-1998


Percent with BMI > 30 kg/m2

1991

1998

%
Increase

Men

11.7%

17.7%

51.5%

Women

12.2%

18.1%

47.4%

Mokdad A.H. et al. JAMA 1999; 282:1519 - 1522

Why were former projections


inaccurate?
They were based on demographic changes
(which are very predictable)
The epidemic of diabetes is driven by other
factors (some or perhaps most of which may
be reflected in occurrence of IGT and IFG)

Importance of IGT and IFG

Impaired Glucose Homeostasis


IGT
'Impaired Glucose Tolerance (IGT)
2h post-load Plasma Glucose of 140-199mg/dl [7.8-11.0mmol/l]
and FPG <126mg/dl [<7.0mmol/l]

IFG
'Impaired Fasting Glucose' (IFG)
FPG of 100-125mg/dl [5.6 -<7.0mmol/l]

Incidence of Diabetes in people with


Impaired Glucose Homeostasis

Prevalence and Incidence of Diabetes (%)


in Impaired Glucose Homeostasis
Prevalence of Impaired
Glucose Homeostasis

Hoorn

5-year Cumulative
Incidence of DM

19.4

29.7

19.3

24.5

15.1

24.8

19.3

? 25% ?

50-75y

Mauritius
25-74y

Pima Indians
15+y

Nhanes III
40-74y

Projections of Numbers with Diabetes* among


persons aged 40-74years in USA (Millions)

Based on diabetes incidence (5% / year) in the 20% of persons with impaired glucose
homeostasis; 300,000 diabetes deaths / year; Net increase = c.700,000 cases of diabetes / year

Proportion of new cases of Diabetes (%) in persons


with NGT and Impaired Glucose Homeostasis
Proportion from
persons with NGT

Hoorn

Proportion from
those with IGT or
IFG

38%

62%

40%

60%

44%

56%

50-75y

Mauritius
25-74y

Pima Indians
15+y

Nhanes III
40-74y

? 40% ?

? 60% ?

Projections of Numbers with Diabetes* among


persons aged 40-74years in USA (Millions)

Based on diabetes incidence (5% / year) in the 20% of persons with impaired glucose
homeostasis; 40% of new cases from persons with NGT; 450,000 diabetes deaths / year

Diabetes in 2000 & 2030

171million
USA

17 19.4

30.3 48.9

366 million
530 million?

Mortality attributable to diabetes

Number of Deaths with Diabetes as Underlying Cause of Death,


United States, 1980-1996.

CDC, Diabetes surveillance, 1999

Excess Deaths attributable to Diabetes


Excess mortality =No of deaths in DMs Expected no. if
not DM
No of DM deaths = (RR of death in DM x No. with DM)
Expected No. = Mortality rate in non DMs*No. with DM
Mortality rate; RR of death in DM; No. with diabetes

Hazard Ratios for death in Normal (NGT), Impaired


glucose tolerance (IGT) and diabetes
(DECODE Study, 25364 subjects aged 25+, mean follow-up 7.3 years)
3

Men

2.5

Women

1.99
1.49 1.54

1.5
1

2.6

0.5
0

NGT

IGT

DECODE study group, Lancet 1999; 354, 617-621

DM

Age-standardized Mortality (22 year follow-up)


in Diabetic and Non-diabetic adults
(NHANES I, aged 25 or older)
50

2.03 x

40

2.22 x

All causes

30
20
10
0

Diabetic
Men

Non-diabetic
men

Gu,K et al. Diabetes Care 21, 1138-1145, 1998

Diabetic
Women

Non-diabetic
women

Global Projections of Excess Deaths


attributable to Diabetes (in 000s)
and percent of all deaths in year 2000
EUR
609.0
6.4%

AMRA
251.1
9.75%
AMRD
32.2
6.1%
AMRB
194.0
7.6%

Roglic et al.: Burden of mortality


attributable to diabetes:
Estimates for the year 2000. In preparation

AFR
319.2
2.6%

EMR
125.3
7.2%

SEAR
1154.1
6.9%

World
In 2000 = 3.164 million
(5.4% of all deaths)

WPR
469.3
4.1%

Consequences of the Epidemic

Consequences of Epidemic
Increase in number with diabetes
Disproportionate increase in
duration-related complications

Effect of Epidemic of Diabetes on Duration-related complications


Cumulative No. of DM cases
% with DM>15y duration
Prevalence of complications (%) among those with DM

50
40

300

30
20

150

Percent with
complications

No. of Cases

450

10
0

0
0

10

15

20

25

30

Time (years)

35

40

45

50

16 new cases/yr. Death occurs after 30y DM; Complication incidence 50% after 15y DM
After 30 years No. of new cases equals no. of deaths.

Incidence of Type 2 Diabetes in Pima Indians


in two time periods
Time Period
1965-75

1975-85
60% increase
0

10

20

30

40

Incidence per 1000 person-years


Age-sex adjusted rates

50

Age-standardized mortality from Ischemic Heart


Disease in diabetic and non-diabetic
Pima Indians aged 35+ years, (30 year follow-up)
Mortality
/1000 person-years

6
5
4
3
2
1
0

1965-74 1975-84 1985-94


Non-diabetic

1965-74 1975-84 1985-94


Diabetic

Renal disease

Frequency of Renal Failure among Pima Indians


25

Cases

20

Deaths
Dialysis

15
10
5
0
1965

1970

1975

1980

Year

1985

1990 1994

Cases per 1000/year

Incidence of Renal Failure


12
8
4
0

1965-74

1975-84
Time Period

1985-94

Number of persons beginning treatment for


ESRD attributable to diabetes in USA by year

http://www.cdc.gov/diabetes/statistics/esrd/Fig1Detl.htm

DIABETES IN END-STAGE RENAL FAILURE: AUSTRALIA


1980 - 2000
Number of Diabetics

Number of New Patients

Year of Entry

Crude and Age-adjusted incidence of ESRD


related to diabetes in the United States
1984-2001
Incidence/100,000
Diabetic persons
Crude rate
Age-adjusted
rate

Data from the US Renal Data System:


http://www.cdc.gov/diabetes/statistics/esrd/fig7.htm

Projections for number of patients with


diabetes initiating ESRD treatment in USA*
2000

2030
(using WHO
estimate)

2030
Revised
projections

Number
with
Diabetes

18 million 31 million

39-48
million

No with
new ESDR

40,000

86-105,000

68,000

* Assuming current incidence rates for initiating ESRD treatment remain constant

Summary
Based on demographic changes alone:
The
numbers of persons with diabetes in the world will
more than double in the next 30 years

In developed countries they will increase by 3070% (mostly in older persons)

In developing countries they will increase by c.


250% (mostly in 45-64y age group)
These projections do not take into account any
increase that is attributable to future increases in
obesity

Summary
c.3.2 million (excess) deaths were
attributable to diabetes in year 2000.

In the USA this is 9% of all deaths


e.g. In USA c.200,000 excess deaths vs. 14,500
for AIDs

The numbers of deaths attributable to


diabetes in future years will increase
especially in developing countries

Summary
Because of the current epidemic of diabetes,
reflected in increasing age specific prevalence, the
proportion of the diabetic population with
complications will increase.
This will result in a greater relative increase in
complications than in diabetes prevalence.
Because serious complications e.g. ESRD, typically
develop after 15-20 years duration, the incidence of
ESRD due to diabetes will continue to increase for at
least the next 20 years

Conclusions
Increase in Type 2 diabetes (and obesity)
represents the major public health challenge for the
21st century
The estimates of future burden currently used
seriously underestimate what is going to happen!

Thank you

Age-adjusted incidence of ESRD related


to diabetes in the United States
1984-2001

Incidence/100,000
Diabetic persons

Amer. Indian male


Amer. Indian female

Black male
Black female
Hispanic male

Hispanic female

White male
White female

Data from the US Renal Data System:


http://www.cdc.gov/diabetes/statistics/esrd/fig5.htm

Are there better ways to predict future


trends?

Incidence = No. of new cases/ period of time


Mortality = No. of deaths/ period of time
Prevalence=Cumul.incidence Cumul. Mortality
= Number of cases at a point in time
Future no. of cases = No. of prevalent cases + no.
of new cases- No. of deaths(among all cases)

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