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R E S E A R C H A R T I C L E Open Access
Global epidemiology of type 1 diabetes in young
adults and adults: a systematic review
Paula A Diaz-Valencia
1,2*
, Pierre Bougnères
1,3
and Alain-Jacques Valleron
1,2
Abstract
Background: Although type 1 diabetes (T1D) can affect patients of all ages, most epidemiological studies of T1D
focus on disease forms with clinical diagnosis during childhood and adolescence. Clinically, adult T1D is difficult to
discriminate from certain forms of Type 2 Diabetes (T2D) and from Latent Autoimmune Diabetes in Adults (LADA).
We searched the information available worldwide on the incidence of T1D among individuals over 15 years of age,
and which diagnostic criteria should be used use to qualify T1D in adults. We then studied the variation of T1D
incidence with age in adults, and compared it to the incidence in the <15 years-old.
Methods: A systematic review of the literature was performed to retrieve original papers in English, French and
Spanish published up to November 6, 2014, reporting the incidence of T1D among individuals aged over 15 years.
The study was carried out according to the PRISMA recommendations.
Results: We retrieved information reporting incidence of T1D among individuals aged more than 15 years in 35
countries, and published in 70 articles between 1982 and 2014. Specific anti-beta-cell proteins or C-peptide detection
were performed in 14 of 70 articles (20%). The most frequent diagnostic criteria used were clinical symptoms and
immediate insulin therapy. Country-to-country variations of incidence in those aged >15 years paralleled those
of children in all age groups. T1D incidence was larger in males than in females in 44 of the 54 (81%) studies
reporting incidence by sex in people >15 years of age. The overall mean male-to-female ratio in the review was
1.47 (95% CI = 1.33-1.60, SD = 0.49, n = 54, p = <0.0001). Overall, T1D incidence decreased in adulthood, after the
age of 14 years.
Conclusions: Few studies on epidemiology of T1D in adults are available worldwide, as compared to those
reporting on children with T1D. The geographical variations of T1D incidence in adults parallel those reported in
children. As opposed to what is known in children, the incidence is generally larger in males than in females.
There is an unmet need to evaluate the incidence of autoimmune T1D in adults, using specific autoantibody
detection, and to better analyze epidemiological specificities –if any –of adult T1D.
PROSPERO registration number: CRD42012002369.
Keywords: Type 1 diabetes, Systematic review, Adults, Incidence, Epidemiology
Background
The worldwide epidemiology of childhood Type 1 dia-
betes (T1D) was extensively described in the 6th edition
of the International Diabetes Federation (IDF) [1]. Data
were retrieved in approximately 45% of the countries
[1-4]. In contrast, we are unaware of a similar review on
the worldwide epidemiology of adult T1D diabetes,
although T1D is known to occur even late in adults
[5-7]. A major limitation of the epidemiology of T1D in
adults is certainly the difficulty there is to distinguish
it from Type 2 diabetes (T2D) requiring insulin treat-
ment or from Latent Autoimmune Diabetes in Adults
(LADA), when specific markers of autoimmunity are
not searched.
Here, our primary objective was to describe –through
a systematic review of the literature –the available pub-
lished information on adult T1D incidence, and the
diagnostic criteria used for case definition. A secondary
* Correspondence: paula.diaz@inserm.fr
1
Institut National de la Santé et de la Recherche Médicale, Inserm U-1169,
F-94276, Kremlin Bicêtre, Paris, France
2
Pierre et Marie Curie University, Paris, France
Full list of author information is available at the end of the article
© 2015 Diaz-Valencia et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Diaz-Valencia et al. BMC Public Health (2015) 15:255
DOI 10.1186/s12889-015-1591-y
objective was to study how the variations of T1D inci-
dence in adults mirrored those in children.
Methods
Literature review
A systematic review was conducted according to the
PRISMA recommendations to retrieve original papers
published in English, French and Spanish up to Novem-
ber 6th, 2014, in peer-reviewed journals reporting the in-
cidence of T1D among individuals aged more than
15 years, in population-based studies (i.e. collected in a
defined geographic area [8]) and reporting the diagnostic
criteria used to define T1D.
The databases used for the literature search were
Medline (PubMed), Google Scholar and Thomson
Reuters (Web of Knowledge). The protocol of the
search was registered in the International Prospective
Register of Systematic Reviews (PROSPERO) and is avail-
able on http://www.crd.york.ac.uk/PROSPERO/display_
record.asp?ID=CRD42012002369 (Registration number:
2012:CRD42012002369). Figure 1 presents the flow dia-
gram of the bibliographic search, Additional file 1 for the
full electronic search strategy, and Additional file 2 for the
PRISMA checklist.
Data collection
For each study, the following information was extracted:
–the identification of the study: authors, title, journal,
publication year,
–the period and country of study. The country was
categorized by its World Health Organization
(WHO) region and economic level: high-income
(HIGH) or low- and middle-income (LMIC) [9],
Articles screened based on
title and abstract
n = 178
113 Excluded
18 Articles excluded
o6: did not report incidence of T1D
o3: did not give diagnostic criteria
o5: concern LADA
o3: concern individuals aged less
than 16 years
o1: pdf not available on website, no
reply from the author*
Articles remaining based on
full text review
n = 59
Bibliographic search using
PubMed
2014/11/06
sliatedrofnoitauqehcraeS–1eliflanoitiddAeeS
Identification
Included Eligibility Screening
Full-text articles assessed
for eligibility
n = 65
Additional articles included from other
sources (Web of Knowledge, Google
Scholar, citing and cited references) or
published in other language different
than English
n = 11
Tot al of in cl ude d a rt icl es in t he
systematic review reporting
incidence of Type 1 diabetes among
individuals aged over 15 years:
n = 70 articles**
Figure 1 PRISMA Flow diagram bibliographic search strategies. * Kumar P, et al. Indian Med Assoc. 2008;106(11):708–711. ** The article:
Radosevic B, et al. Pediatr Diabetes. 2013;14(4):273–4 gives information from two countries: 1) Bosnia and Herzegovina: Republic of Srpska and
2) Slovenia, Nationwide.
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 2 of 15
–the geographic coverage of the study: nationwide
(when the study was performed in the entire nation)
and local (when it was restricted to a given region,
city, or a geographically defined population),
–the diagnostic criteria used to define T1D in adults:
detection of autoantibodies against beta-cells
(such as: islet cell antibody (ICA), insulin
autoantibody (IAA), islet antigen-2 autoantibody
(IA-2), anti-glutamic acid decarboxylase antibodies
(GAD)), measurement of the fasting C-peptide
level [7], need for permanent insulin therapy, time
when the administrationofinsulintherapywas
started, and clinical signals of T1D diabetes such as
ketosis, ketonuria and weight loss,
–the sources of data/registers reporting T1D incidence
in the studies, defined according to LaPorte et al. [10]
as: primary source of information: a “well-established
system of standardized registries for identifying new
cases”, for example national or regional registers,
secondary source of information: other different
sources of cases “that would provide a check on
the degree of ascertainment”,forexamplemedical
records or hospital discharges, and tertiary source
of information: a third approach for identifying
cases, for example, through surveillance system or
death certificates,
–the reported percentage of completeness/
ascertainment between sources of information
reporting incidence [10],
–the incidence rates reported in the text, tables or graph
(expressed as new cases per 100.000 persons/year) by
sex and age classes,
–additional information such as those concerning
rural/urban, or ethnic differences.
Data analyses
The country distribution of the T1D incidence informa-
tion and the analysis of the diagnostic criteria used were
performed on the entire set of articles retrieved. For the
few papers for which the results were presented by eth-
nic origin, we estimated the mean value of the incidence
for the given period in the countries/regions concerned.
Correlation between adult and children T1D incidences
In the geographical correlation analyses between chil-
dren and adult incidences, we considered for each coun-
try the more recent nationwide study published, or if
not available, the last published set of local studies
retrieved from a given area in the country; in addition,
we included all published papers reporting auto-
antibodies against beta-cells or C-peptide. To obtain an
estimate of the incidence of T1D in children in the
countries for which the adult incidence was available, we
used the data provided by the same adult paper, when
available. The incidence of T1D in children was not
available in 9 of these papers included in the geograph-
ical correlation analyses. In this case, it was estimated
through a separate systematic review focused on the cor-
responding countries and periods (see Additional file 3).
Statistics
Data were extracted from graphs using GraphClick [11].
The country-to-country co-variation of children and
adult incidences was quantified by the Spearman correl-
ation and a linear regression.
The R software (version 3.0.1) was used for statistical
and graphic analyses [12].
Results
Description of the information obtained from the
systematic review on adult T1D
Seventy articles reporting incidence of T1D in young
adults and adults aged over than 15 years concerned one
country, and one article concerning two countries were
retrieved in this systematic review, resulting in a total of
71 studies covering 35 countries (Table 1). Twenty-four
of the 71 studies were nationwide; 43 papers provided
information on the T1D incidence in the age class 15–
29 years, 26 in the age class 30–59 years, and 6 in the
persons aged >60 years.
Aprimary source of information was reported in 99%
(70 of 71) of the studies: among these reported sources,
60% (42 of 70) were from medical/hospital records, 36%
(25 of 70) from national or regional registers, and 4%
(3 of 70) from other sources, such as community-
based surveys; a secondary source of information was
reported in 90% (64 of 71) of the studies: among these
reported sources, 58% (37 of 64) were from medical/
hospital records, 16% (10 of 64) from associations of
patients, 14% (9 of 64) from drug or supplies prescription
registers, 8% (5 of 64) from national or regional registers,
and 5% (3 of 64) from death certificates and schools reg-
isters; finally, a tertiary source of information was re-
ported in 21% (15 of 71) of the studies: among these
reported sources, 27% (4 of 15) were from national or re-
gional registers, 27% (4 of 15) from associations of pa-
tients, 20% (3 of 15) from death certificates, 20% (3 of 15)
from drug or supplies prescription registers, and 7%
(1 of 15) from medical registers; see details in Table 1.
Percentage of ascertainment (completeness) between
sources of information was evaluated in 53 of 71 (75%)
studies. The mean percentage of ascertainment of these
53 studies was 94% (Table 1).
In the group of young adults (15–19), the lowest inci-
dence of T1D was reported in Mauritius, (1.1/100.000
persons/year) [13], and the highest in Estonia (39.9/
100.000 persons/year) [19]. In the 70–79 year age group,
the lowest incidence was reported in Navarra, Spain
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 3 of 15
Table 1 Systematic review of T1D in adults, diagnostic criteria and sources of information
Study information T1D diagnosis criteria in adults and young adults Source of information and validation of ascertainment between
sources
Country, area
reported in
the article
First author,
publication
year
Ref Age
range
Period Detect. AA/
C-Peptide
Need of
insulin
therapy
Administration
insulin therapy
Clinical
impression
Ketosis/
ketonuria
Weight
loss
Primary Secondary Tertiary % of
ascertainment
African Region, LMIC
Mauritius: NW Tuomileht J.,
1993
†
[13] 0-19 1986-1990 No Yes From diagnosis Yes NA NA Medical reports Medical statistics NA 95.0
United Republic
of Tanzania: Dar
es Salaam
Swai A. B.,
1993
†
[14] 0-19 1982-1991 No Yes From diagnosis Yes NA NA Medical reports Hospital records NA NA
Eastern Mediterranean Region, LMIC
Iran (Islamic
Republic of):
Fars
Pishdad
G. R., 2005
†
[15] 0-29 1990-1994 Yes (a) Yes From diagnosis Yes Yes Yes Medical
reports from
endocrinologists
Medical records NA 100
Libyan Arab
Jamahiriya:
Benghazi
Kadiki O. A.,
1996
†
[16] 0-34 1981-1990 No Yes From diagnosis NA Yes NA National Diabetes
Program
Hospital registers NA 95.0
Tunisia: Beja,
Monastir, Gafsa
Ben Khalifa F.,
1998
†
[17] 0-19 1990-1994 No Yes From diagnosis Yes NA NA Hospital records School health
centers
NA 96.0
European Region, LMIC
Croatia: Zagreb Roglic G.,
1995
†
[18] 0- >
55
1988-1992 No Yes Within 1 week
of diagnosis
Yes Yes NA National Diabetes
Program
Death certificates Diabetes
association
96.2
Estonia: NW Kalits I.,
1990
†
[19] 0- >
50
1988-1988 No Yes From diagnosis Yes Yes Yes NA NA NA NA
Lithuania: NW Ostrauskas R.,
2011
†
[20] 15-34 1991-2008 No Yes Within 2 weeks
of diagnosis
Yes Yes Yes National Diabetes
Program
Regional
endocrinologist
Notes of
patient
insurance
86.8
Lithuania: NW Pundziute-
Lycka A., 2003
[21] 0-39 1991-2000 No Yes Within 2 weeks
of diagnosis
Yes Yes NA National Diabetes
Program
Pediatrician and
endocrinologist
reports
Death
certificates
91.2
Lithuania: NW Ostrauskas R.,
2000
[22] 15-39 1991-1997 No Yes Within 2 weeks
of diagnosis
Yes Yes NA National Diabetes
Program
Pediatrician and
endocrinologist
reports
Death
certificates
91.2
Poland:
Bialystok
Kretowski A.,
2001
†
[23] 0-29 1994-1998 No Yes From diagnosis Yes Yes Yes Pediatric and
Internal medicine
records
Hospital discharge
registers
NA 98.5
Poland:
Province of
Rzeszow
Sobel-
Maruniak A.,
2006
†
[24] 0-29 1980-1999 No Yes From diagnosis Yes NA NA Pediatric and
Internal medicine
records
Others health
care registers
NA 99.0
Poland:
Province of
Rzeszow
Grzywa M. A.,
1995
[25] 0-29 1980-1992 No Yes From diagnosis Yes NA NA Pediatric and
Internal medicine
records
Others health
care registers
NA 99.0
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 4 of 15
Table 1 Systematic review of T1D in adults, diagnostic criteria and sources of information (Continued)
Poland: Warsaw Wysock M. J.,
1992
†
[26] 0-29 1983-1988 No Yes From diagnosis Yes NA NA Medical records
from diabetic
clinics
General
practitioners
and diabetologist
registers
Death
certificates
NA
Romania:
Bucharest
Ionescu-
Tirgoviste C.,
1994
†
[27] 0- ≥
85
1981-1991 No Yes From diagnosis Yes Yes NA Bucharest Diabetes
Registry
NA NA NA
Slovakia: NW Kyvik K O,
2004
†
[28] 15-29 1996-1997 No Yes From diagnosis Yes NA NA Pediatrician and
endocrinologist
reports
Other health
care registers
NA 80.0
European Region, HIGH
Austria: Upper Rami B.,
2001
†
[29] 0-29 1994-1996 No Yes From diagnosis Yes NA NA Pediatricians and
endocrinologists
reports
Austrian Diabetes
Association
NA 87.0
Belgium:
Antwerp
Weets I.,
2007
†
[30] 0-39 1989-2003 Yes Yes From diagnosis Yes NA NA Pediatricians and
endocrinologists
reports
General
practitioners and
diabetes nurses
reports
Diabetes
associations
and self-
reporting
97.0
Belgium:
Antwerp
Weets I.,
2002
†
[31] 0-39 1989-2000 Yes Yes From diagnosis NA NA NA Pediatrician and
endocrinologist
reports
General
practitioner and
diabetes nurse
reports
Diabetes
associations
and self-
reporting
93
Belgium:
Antwerp
Vandewalle
C., 1997
†
[32] 0-39 1989-1995 Yes Yes From diagnosis Yes Yes Yes Pediatrician and
endocrinologist
reports
General
practitioner and
diabetes nurse
reports
Diabetes
associations
and self-
reporting
85
Bosnia and
Herzegovina:
Republic of
Srpska
Radosevic B.,
2013
†
[33] 0-18 1998-2010 No Yes From diagnosis Yes NA NA Hospital records Insulin
prescription
registers
NA 100
Denmark:
Copenhagen
and
Frederiksborg
Molbak A. G.,
1994
†
[34] 30-95 1973-1977 Yes (b) Yes From diagnosis Yes Yes Yes Hospital discharges General
practitioners and
diabetologist
registers and
death certificates
Missing coding
of T1D
diagnosis in
hospital
admissions
99.0
Finland: NW Lammi N.,
2007
†
[35] 15-39 1992-1996 Yes Yes From diagnosis Yes NA NA National Diabetes
Program
Hospital discharge
registers
Drug
reimbursement
registers
88.0
France:
Aquitaine,
Lorraine, Basse
Normandie,
Haute
Normandie
Charkaluk M.
L, 2002
†
[36] 0-19 1988-1997 No Yes None declared NA NA NA Prospective
registers
French Social
Security registers
NA 96.0
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 5 of 15
Table 1 Systematic review of T1D in adults, diagnostic criteria and sources of information (Continued)
France:
Aquitaine,
Lorraine, Basse
Normandie,
Haute
Normandie
Levy-Marchal,
C., 1998
[37] 0-19 1988-1995 No Yes None declared NA NA NA Prospective
registers
French Social
Security registers
NA 96.0
Israel: NW Blumenfeld
O., 2014
†
[38] 0-17 1997-2010 No Yes From diagnosis Yes NA NA Israel juvenile
diabetes register
Israel Center for
Disease Control
NA NA
Israel: NW Sella T., 2011 [39] 0-17 2000-2008 No Yes None declared Yes NA NA Israel juvenile
diabetes register
Israel Center for
Disease Control
NA NA
Israel: NW Koton S., 2007 [40] 0-17 1997-2003 No Yes From diagnosis Yes NA NA Israel juvenile
diabetes register
NA NA NA
Italy: Lombardie Garancini, P.,
1991†
[41] 0-34 1981-1982 No Yes None declared NA NA NA Hospital discharge
records
Hospital admission
records
NA 85.7
Italy: Pavia Tenconi M. T.,
1995
†
[42] 0-29 1988-1992 No Yes From diagnosis Yes NA NA Hospital records Drug registers NA 100
Italy: Sardinia Muntoni S,
1992
†
[43] 0-29 1989-1990 No Yes From diagnosis Yes NA NA Hospital records Diabetes
association
NA 92.8
Italy: Sardinia
(Oristano)
Frongia O.,
1997
†
[44] 0-29 1993-1996 No Yes From diagnosis Yes NA NA Hospital records Drug registers NA 100
Italy: Turin Bruno G.,
2009
†
[45] 15-29 2000-2004 Yes Yes Within 6
months of
diagnosis
NA NA NA Hospital records Drug registers NA NA
Italy: Turin Bruno G.,
2005
†
[46] 30-49 1999-2001 Yes Yes Within 6
months of
diagnosis
NA Yes NA Diabetes clinics Drug registers NA 99.0
Italy: Turin Bruno G.,
1993
[47] 0-29 1984-1988 No Yes From diagnosis NA Yes NA Diabetic clinics
records
Hospital discharge
records
NA 97.0
Luxembourg:
NW
De Beaufort
C. E., 1988
†
[48] 0-19 1977-1986 No Yes None declared NA NA NA Pediatric and
Internal medicine
records
Dutch Diabetes
Association
NA 100
Malta: NW Schranz A. G.,
1989
†
[49] 0-24 1980-1987 No Yes Within 3 moths
of diagnosis
Yes Yes Yes Medical reports Diabetic clinic
records
NA NA
Netherlands:
NW
Ruwaard D.,
1994
†
[50] 0-19 1988-1990 No Yes None declared NA NA NA Pediatric and
Internal medicine
records
NA NA 81.0
Norway: NW Joner G.,
1991
†
[51] 15-29 1978-1982 No Yes From diagnosis NA NA NA Pediatricians and
endocrinologists
reports
Hospital records NA 90.0
Slovenia: NW Radosevic B.,
2013
†
[33] 0-18 1998-2010 No Yes From diagnosis Yes NA NA Slovenian National
Registry of
Childhood diabetes
Insulin prescription
registers
NA 100
Spain: Badajoz Morales-Perez
F. M., 2000
†
[52] 0-29 1992-1996 No Yes From diagnosis Yes Yes NA Pediatricians and
endocrinologists
reports
Diabetic clinic
records
NA 95.0
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 6 of 15
Table 1 Systematic review of T1D in adults, diagnostic criteria and sources of information (Continued)
Spain: Canarias
Islands
Carrillo
Dominguez,
A., 2000
†
[53] 0-30 1995-1996 No Yes None declared Yes NA Yes Hospital records
and Endocrinologist
reports
Diabetes
association reports
and sales on
blood glucose
monitors
NA 90.1
Spain: Catalonia Abellana R.,
2009
†
[54] 0-29 1989-1998 Yes (c) Yes From diagnosis Yes Yes NA Catalan Registry of
Type 1 Diabetes
Summer camps,
associations, and
prescription data
NA 90.0
Spain: Catalonia Goday A.,
1992
[55] 0-29 1987-1990 No Yes From diagnosis Yes NA NA Catalan Registry of
Type 1 Diabetes
Summer camps,
patient
associations, and
prescription data
NA 90.1
Spain: Navarra Forga L.,
2014
†
[56] 0- >
45
2009-2012 Yes Yes Within 6
months of
diagnosis
Yes Yes NA Hospital records Electronic medical
records, diabetes
associations
NA 98.4
Spain: Navarra Forga L.,
2013
†
[57] 0-79 2009-2011 Yes Yes Within 6
months of
diagnosis
Yes Yes NA Hospital records Electronic medical
records, diabetes
associations
NA 98.4
Sweden: NW Dahlquist G. G.,
2011
†
[58] 0-34 1983-2007 No Yes From diagnosis Yes Yes Yes National Diabetes
Program
Pediatricians and
endocrinologist
reports
NA 96.0
Sweden: NW Östman J.,
2008
[59] 15-34 1983-2002 No Yes From diagnosis Yes NA NA National Diabetes
Program
Pediatrician and
endocrinologist
reports
Computer-
based patient
administrative
register
82
Sweden: NW Pundziute-
Lycka A., 2002
[60] 0-34 1983-1998 No Yes From diagnosis Yes Yes Yes National Diabetes
Program
Pediatrician and
endocrinologist
reports
Computer-
based patient
administrative
register
91.2
Sweden: NW Nyström L.,
1992
[61] 0-34 1983-1987 No Yes None declared NA NA NA National Diabetes
Program
Hospital admission
and discharge
registers
NA 89
Sweden: NW Blohme G.,
1992
[62] 15-34 1983-1987 No Yes From diagnosis Yes Yes Yes National Diabetes
Program
Hospital admission
and discharge
registers
NA NA
Sweden:
Kronoberg
Thunander
M., 2008
†
[63] 0-100 1998-2001 Yes Yes Within 4 weeks
of diagnosis
Yes Yes NA Opportunistic
screening of all
adult patients in
contact with the
medical care
system
Departments of
ophthalmology
NA 98.0
United
Kingdom: NW
Imkampe A.
K., 2011
†
[64] 0-34 1991-2008 No Yes Within 3 moths
of diagnosis
Yes NA NA National Diabetes
Program
Pediatricians and
endocrinologist
reports
NA NA
United
Kingdom:
Oxford region
Bingley P. J.,
1989
[65] 0-21 1985-1986 No Yes From diagnosis Yes NA NA Medical reports
from general
practioners and
pediatricians
Regional hospital
records
NA 95.0
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 7 of 15
Table 1 Systematic review of T1D in adults, diagnostic criteria and sources of information (Continued)
Region of the Americas, LMIC
Barbados: NW Jordan O. W.,
1994
†
[66] 0-29 1982-1991 No Yes From diagnosis Yes NA NA Hospital records Others health
care registers
NA 94.0
Region of the Americas, HIGH
Canada: Quebec Legault L.,
2006
†
[67] 0-18 2000 No Yes None declared NA NA NA Departmental
program: Régie
des Rentes du
Québec program
NA NA NA
United States of
America:
Alabama
(Jefferson
County)
Wagenknecht
L. E., 1991
†
[68] 0-19 1979-1988 No Yes None declared NA NA NA Hospital records Summer camps,
patient associations,
and prescription
data
NA NA
United States of
America:
Alabama
(Jefferson
County)
Wagenknecht
L. E.,1989
[69] 0-19 1979-1985 No Yes From diagnosis Yes NA NA Hospital records Association
registers
NA 95.0
United States of
America:
Colorado
Vehik K.,
2007
†
[70] 0-17 2000-2004 No Yes Within 2 weeks
of diagnosis
Yes NA NA Pediatricians and
endocrinologists
reports
Other health
care registers
The SEARCH
Study
96.5
United States of
America:
Colorado
Kostraba J. N.,
1992
[71] 0-17 1978-1988 No Yes Within 2 weeks
of diagnosis
Yes NA NA Pediatricians and
endocrinologists
reports
Hospital registers NA 93.3
United States of
America:
Pennsylvania
(Allegheny)
Libman I. M.,
1998
†
[72] 0-19 1990-1994 No Yes From diagnosis Yes NA NA Medical reports General
practitioners and
diabetes nurses
reports
NA 97.7
United States of
America: Rhode
Island
Fishbein H. A.,
1982
†
[73] 0-29 1979-1980 No Yes None declared NA NA NA Medical reports Insulin prescription
registers
NA NA
United States of
America: five
areas
§
Bell R.,
2009
†
[74] 0-19 2002-2005 Yes Yes From diagnosis Yes NA NA Medical reports Other health
care registers
The SEARCH
Study
NA
United States of
America:
Wisconsin
Allen C.,
1986
†
[75] 0-29 1970-1979 No Yes From diagnosis Yes NA NA Hospital discharges Pediatricians and
endocrinologist
reports
NA 90.0
United States of
America: The
United States
Navy
Gorham C.,
1993
[76] 17-34 1974-1988 No NA* None declared Yes NA NA Hospital discharges NA NA NA
Western Pacific Region, HIGH
Australia: New
South Wales
Tran F.,
2014
†
[77] 10-18 2001-2008 No Yes NA Yes NA Yes Endocrine group
diabetes register
National diabetes
register
NA 96.0
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 8 of 15
Table 1 Systematic review of T1D in adults, diagnostic criteria and sources of information (Continued)
Australia:
Sydney
(Southern
Metropolitan
Health Region)
Sutton L.,
1989
†
[78] 0-19 1984-1987 No Yes From diagnosis Yes NA NA Medical reports
from general
practioners and
pediatricians
Schools in
the area
Syringe register NA
Japan: Osaka Sasaki A.,
1992
†
[79] 0-18 1978-1988 No Yes None declared Yes Yes NA Medical benefits
system
NA NA NA
New Zealand:
Canterbury
Scott, R. S.,
1991
†
[80] 0- ≥
80
1981-1986 No Yes Within 1 year
of diagnosis
Yes NA Yes Community-
based surveys
administrated
in pharmacies
where diabetic
patients acquired
their insulin
supplies
Hospital admission
and discharge
registers and
diabetologist
NA 95.0
Other Regions currently non WHO
Taiwan: NW Lin W.-H.,
2013
†
[81] 0- ≥
60
1999-2010 Yes Yes None declared Yes Yes NA National Health
Insure register
and Illness
certificates
Random sample
of a database
used to
reimbursements
NA 98.3
US Virgin
Islands: NW
Washington
R. E., 2013
†
[82] 0-19 2001-2010 No Yes From diagnosis Yes Yes Yes Medical reports Medical providers NA 98.7
WHO Member States are divided into high-income (HIGH) or low- and middle-income (LMIC) states [30]. AA: autoantibodies, NW: Nation-wide study, NA: Unavailable data. (a) When there were diagnostic doubts, (b) Only
for patients aged over 40 years at onset, (c) Not performed in all cases; the author of this study was contacted to confirm the proportion of these cases, but by the time of submission of this paper no answer was available.
T1D: Type 1 Diabetes. Highlighted: reports of the systematic review using the autoantibodies/C-peptide as diagnosis criteria. (
†
) Studies used in the statistical analyses. (*) Data were not available but researchers assumed that
patients have had T1D based on their average of age. (
§
) Ohio (8 counties), Washington State (5 counties), South Carolina, Colorado, California.
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 9 of 15
(0.8/100.000 persons/year) [57] and the highest in
Kronoberg, Sweden (55/100.000 persons /year) [63].
The details of all retrieved incidence by study and age
classes are in Additional file 4: Table S1.
Diagnostic criteria used to define T1D in adults reported
in 71 epidemiological studies
Autoantibodies against beta-cell antigens or the C-peptide
were included in the T1D diagnostic criteria in 14 studies
[15,30-32,34,35,45,46,54,56,57,63,74,81], detection of ICAs
was reported in 9 studies [15,30-32,34,45,46,54,63], IAA in
4 studies [30-32,54], IA2 in 5 studies [30-32,56,57], and
GAD in 11 studies [30-32,35,45,46,56,57,63,74,81]. The
C-peptide was measured in 7 studies. In one paper differ-
ence of auto-antibodies by age group (0–19) was explored
but no significant differences were detected [74]. The other
reported diagnostic criteria for T1D were the need for in-
sulin therapy (reported in 70 of 71 studies), clinical symp-
toms of diabetes (reported in 56 of 71 studies), low or
normal body weight (14 of 71 studies), and ketosis or keto-
nuria (26 of 71 studies). The details are shown in Table 1.
Comparison of adult and children T1D incidences
The variations of incidence of T1D in adults with country
and age were studied in each area for which we retrieved
information on a geographically defined population. This
concerned 35 countries.
Variation of T1D incidence with age in adults
In 23 out of 35 (66%) countries (55 of 71 studies), the in-
cidence of T1D was higher in the age range of 0–14
compared with 15–19 years. When restricted to the 14
reports for which the criteria of diagnosis of T1D were
auto-antibodies against beta-cells or C-peptide detection,
the variation of adult incidence with age showed a con-
sistent decrease after the age of 14 years (Figure 2 and
Additional file 4: Table S1).
Geographical correlation of adult and child T1D incidence
A significant geographical correlation, as measured by
the Spearman correlation coefficient, was found between
adult T1D incidence and 0–14 incidence in the age clas-
ses 15–19 years, 20–24 years, 25–29 years, 30–34 years
0
10
20
30
40
50
60
70
80
0_4 5_9 10_14 15_19 20_24 25_29 30_34 35_39
Incidence of T1D per 100.00 per year
Grou
p
of a
g
e
BE1: Weets I, 2007
BE2: Weets I, 2002
BE3: Vandewalle C, 1997
DK: Molbak A. G, 1994
ES1: Abellana R, 2009
ES2: Forga L, 2014
ES3: Forga L, 2013
FI: Lammi N, 2007
IR: Pishdad GR, 2005
IT: Bruno G, 2005
IT: Bruno G, 2009
SE: Thunander M, 2008
TW: Lin W-H, 2013
US: Bell R, 2009
Figure 2 Age variation of incidence from childhood to adult age. On this figure, the adult estimates of incidence were taken from the 14
reports of the systematic review using the autoantibodies/C-peptide as diagnostic criteria. Full lines correspond to articles from which both child
as well as adult information could be retrieved. The dotted lines are those for which the child information was searched in the same country as
in the adult paper, but was from a different paper (see Additional file 3 for details on this literature search). The corresponding countries are
shown as: BE1: Belgium (2007) [30]; BE2: Belgium (2002) [31]; BE3: Belgium (1997) [32]; DK: Denmark [34]; ES1: Spain, Catalonia [54]; ES2: Spain,
Navarra (2014) [56]; ES3: Spain, Navarra (2013) [57]; FI: Finland [35]; IR: Iran (Islamic Republic of) [15]; IT: Italy [45,46]; SE: Sweden [63], TW: Taiwan
[81]; US: United States of America [74].
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 10 of 15
Figure 3 (See legend on next page.)
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 11 of 15
and overall in the entire 15–60 group (r= 0.75, p-value:
5.7 ×10
−10
). The correlation was not significant in the
oldest class where sparse data were available, but the re-
lation was similar (Figure 3).
Comparison of male and female T1D adult incidences
T1D incidence was larger in males aged 15 to 39 years
than in females in 44 (81%) of the 54 studies reporting
incidence by sex (Additional file 5: Table S2). The mean
male-to-female ratio in our review was 1.47 (95% CI for
mean 1.33-1.60, SD = 0.49, n= 54, p=< 0.0001).
Discussion
A first result of this systematic review is the paucity of
data available on adult incidence of T1D as compared to
those concerning children. The 71 studies retrieved pro-
vided information on adult T1D in only 35 countries,
40% of the 88 countries with primary childhood T1D
incidence information in the 6th IDF atlas [1].
A second result is that only a small proportion (n=14)
of the 71 studies used detection of specific autoantibodies
and/or dosage of C-peptide [83] as diagnostic criteria of
adult T1D.
A third result was that in a majority of the retrieved
studies, adult T1D incidence was greater in men than in
women, which contrasts with incidence of T1D in chil-
dren where sex ratio is around one [2,84]. Using com-
parative data, Karvonen et al. also described a male
excess among young adults in the 15–39 years of age
[85]. Sex differences in exposure to possible environ-
mental triggers of T1D, in hormonal/genetic suscep-
tibility, in lifestyle have been proposed as possible
explanations for this difference [62].
A last striking observation of the current analysis is
the strong geographical correlation of the incidences in
adults and children. This correlation may be explained
by the fact that adults with T1D share the gene alleles
known to be associated to incidence of T1D in children,
[86,87], and/or some predisposing environmental causes
[4]. For example, in a previous study on incidence of
T1D in children, a significant positive correlation
was detected between the percentage of urban popu-
lation and the incidence of T1D in children (r=0.41
p-value: < 0.0001) [4]; in this review a significantly
higher urban proportion of T1D incidence among
adults was found in 4 of the 7 studies reporting differences
between rural vs urban areas [15,21,42,75].
There was an overall decrease of incidence with age in
adults and young adults after the age of 14. A second
peak of T1D around the age of 50, as described by
Krolewski et al. [88], was only reported in 7% (4 of 58)
of the studies [18,63,80,89].
The paucity of data made it impossible to document
an increase in adult T1D incidence that would parallel
the dramatic increase observed in children [2,3,90]. In-
deed, successive studies in the same region over different
periods reporting incidence in people aged >30 years of
age were only found for Belgium [30-32], Lithuania
[20-22] and Sweden [58-62]. Similarly, this review did
not dispose of sufficient data to document differences in
the clinical presentation of T1D of adults and children
as suggested elsewhere [32,40]; indeed only two of the
71 studies describe differences in clinical presentation of
T1D between adults and children [89,91].
Improving the quantity and quality of information on
adult T1D is not only useful to better understand the
epidemiology and natural history of T1D, but can have
practical consequences, as delay of T1D diagnosis may
mean retardation in insulin treatment, lost opportunities
for potential prevention of acute and chronic complica-
tions, and even death [92]: in Croatia [18], 14% of the
incident cases were identified solely through death cer-
tificates, and high mortality was found in the newly-
diagnosed T1D aged over 50.
Conclusions
Overall, the results of this systematic review should en-
courage the launching of epidemiological studies of adult
T1D with specific diagnostic criteria.
Availability of supporting data
All the supporting data are included as additional files.
Additional files
Additional file 1: Search equation used for the bibliographic
analysis.
Additional file 2: PRISMA checklist.
Additional file 3: List of selected papers reporting incidence of T1D
in 0–14 year-olds in 9 countries.
Additional file 4: Table S1. Geographic repartition, and reported adult
T1D incidences found in the systematic review. Incidence was per
100.000 persons per year. T1D: Type 1 Diabetes. NW: Nation-wide study.
HIGH, LMIC: High, Low-Medium Income Level. Highlighted: reports of the
systematic review using the autoantibodies/C-peptide as diagnosis
(See figure on previous page.)
Figure 3 Geographical correlation of T1D incidence between individuals aged 0–14 years and adults. Studies using autoantibodies/C-Peptide
for T1D case definition are identified by Red diamonds. The corresponding countries are shown as: BE1: Belgium (2007) [30]; BE2: Belgium (2002) [31];
BE3: Belgium (1997) [32]; DK: Denmark [34]; ES1: Spain, Catalonia [54]; ES2: Spain, Navarra (2014) [56]; ES3: Spain, Navarra (2013) [57]; FI: Finland [35]; IR:
Iran (Islamic Republic of) [15]; IT: Italy [45,46]; SE: Sweden [63], TW: Taiwan [81]; US: United States of America [74]. Sp. Cor: Spearman correlation.
Diaz-Valencia et al. BMC Public Health (2015) 15:255 Page 12 of 15
criteria. (a) 0–9 years of age, (b) 10–19 years of age, (c) 10–18 years of
age, (d) 15–17 years of age, (e) 15–18 years of age, (−−-): unavailable
data. (*): Data was retrieved from a different study; for details see
Additional file 3. (†) Studies used in the geographical correlation
analyses. (‡) Special population. (§) The five areas were Ohio (8 counties),
Washington State (5 counties), South Carolina, Colorado and California;
the table presents the mean incidence calculated, retrieved from 5
populations: African American, Asian Pacific Islander, Navajo, Hispanic
and non-Hispanic young.
Additional file 5: Table S2. T1D incidences by sex in young adults and
adults found in the Systematic Review. Male-to-Female ratios >1 are
highlighted. Ref: Reference. First author and publication year in reports of
the systematic review using the autoantibodies/C-peptide as diagnosis
criteria are highlighted. Inc: incidence per 100.000 persons per year. NW:
Nation-wide study. HIGH, LMIC: High, Low-Medium Income Level. (†) Studies
used for analyses. (§) The five areas were Ohio (8 counties), Washington
State (5 counties), South Carolina, Colorado and California; the table
presents the mean incidence calculated retrieved from 5 populations:
African American, Asian Pacific Islander, Navajo, Hispanic and non-Hispanic
young. Incidence was calculated as the mean of retrieved information: (a) in
Jews and other non-Arabs and Arabs; (b) in White and Black populations;
(c) in Non-Hispanic Whites and Hispanic Whites. (d) Study giving the total
incidence by sex, not by age classes.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
PAD-V conducted the data collection and analyses. PAD-V, PB and AJV,
contributed to the writing of the manuscript. All authors read and approved
the final manuscript.
Acknowledgements
We thank Anne-Lise Haenni of the Institut Jacques Monod, CNRS - Paris-Diderot
University, for critically reading and reviewing the English of this manuscript.
Funding
This study was supported by grants from the Programme Hospitalier de
Recherche Clinique, and from Colciencias, the Administrative Department of
Science, Technology and Innovation for Colombia. The funders had no role
in study design, data collection and analysis, decision to publish, or preparation
of the manuscript.
Author details
1
Institut National de la Santé et de la Recherche Médicale, Inserm U-1169,
F-94276, Kremlin Bicêtre, Paris, France.
2
Pierre et Marie Curie University, Paris,
France.
3
Paris-Sud University, Paris, France.
Received: 1 December 2014 Accepted: 27 February 2015
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