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C O M M E N T A R Y Open Access
Diabetes and its drivers: the largest
epidemic in human history?
Paul Z. Zimmet
Abstract
The “Diabesity”epidemic (obesity and type 2 diabetes) is likely to be the biggest epidemic in human history.
Diabetes has been seriously underrated as a global public health issue and the world can no longer ignore “the rise
and rise”of type 2 diabetes. Currently, most of the national and global diabetes estimates come from the IDF Atlas.
These estimates have significant limitations from a public health perspective. It is apparent that the IDF have
consistently underestimated the global burden. More reliable estimates of the future burden of diabetes are
urgently needed.
To prevent type 2 diabetes, a better understanding of the drivers of the epidemic is needed. While for years, there has
been comprehensive attention to the “traditional”risk factors for type 2 diabetes i.e., genes, lifestyle and behavioral
change, the spotlight is turning to the impact of the intra-uterine environment and epigenetics on future risk in adult
life. It highlights the urgency for discovering novel approaches to prevention focusing on maternal and child health.
Diabetes risk through epigenetic changes can be transmitted inter-generationally thus creating a vicious cycle that will
continue to feed the diabetes epidemic. History provides important lessons and there are lessons to learn from major
catastrophic events such as the Dutch Winter Hunger and Chinese famines. The Chinese famine may have been the
trigger for what may be viewed as a diabetes “avalanche”many decades later. The drivers of the epidemic are indeed
genes and environment but they are now joined by deleterious early life events. Looking to the future there is the
potential scenario of future new “hot spots”for type 2 diabetes in regions e.g., the Horn of Africa, now experiencing
droughts and famine. This is likely to occur should improved economic and living conditions occur over the next few
decades. Type 2 diabetes will remain one of the greatest challenges to human health for many years to come.
Keywords: Global diabetes epidemic, Drivers for diabetes, Epigenetics and diabetes
Background
In this lecture honoring Professor Stefan S. Fajans of the
University of Michigan, I am going to address four major
topics related to diabetes:
[a]Statistics about the global diabetes epidemic : facts
and fallacies;
[b]Epidemiological data about the diabetes epidemic:
secular rises and falls;
[c]The drivers of the type 2 diabetes epidemic; and
[d]Epigenetics and early life exposure of the fetus that
may influence the risk of diabetes in adult life.
The Black Death was one of the most devastating pan-
demics in human history, killing as much as 20% of the
world’s population in the 14th century [1]. But that was
then. In the 21st century, the question may be asked, is
type 2 diabetes the biggest epidemic in history? I believe
it is a much bigger epidemic than the Black Death and
in this talk I will try to prove it to you.
Statistics about the global diabetes epidemic: facts and
fallacies
The International Diabetes Federation (IDF) has asked a
very simple question, if you look at the world’s most
populous countries, where would diabetes fit? Numeric-
ally diabetes, if it were a nation, would surpass the
United States as the third most populated country in the
world. While there are approximately 320 million people
in the U.S., there are now 415 million people in the
Correspondence: Paul.Zimmet@bakeridi.edu.au
Monash University & Baker IDI Heart and Diabetes Institute, Melbourne, VIC,
Australia
© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. 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.
Zimmet Clinical Diabetes and Endocrinology (2017) 3:1
DOI 10.1186/s40842-016-0039-3
world with diabetes according to the IDF [2]. This is
clear evidence to suggest that we have a major global
problem with type 2 diabetes.
The IDF has attempted to create awareness of the im-
portance of type 2 diabetes. In the year 2000, IDF esti-
mated there were 151 million people with diabetes
globally and predicted that by 2030, there would be 324
million people in the world with diabetes [3]. The World
Health Organization (WHO) also estimated the global
prevalence of diabetes in 2000 and 2030–171 million
people with diabetes in 2000 and 366 million by 2030 [4].
They were terribly wrong, because by 2015 there were
already 415 million people with diabetes, far above what
was predicted in 2000 for 30 years later. And the situation
may even be worse than that. To perform its global pro-
jections, the IDF estimates how many people have dia-
betes in each country. If a country does not have data
about diabetes prevalence, the IDF extrapolates from an-
other country using regional data [3] or match geography,
World Bank income, ethnicity and language [2]. These ex-
trapolations are less reliable. If anything, the current IDF
estimates are still a quite serious underestimate.
This issue is of more than academic interest because
young researchers in epidemiology may think the IDF and
WHO data are gospel. Unfortunately, they may represent a
quick grab of data that go out for public relations purposes
and not necessarily for public health benefit and planning.
In 1978, a Kroc Foundation International Conference
on Epidemiology of Diabetes and Its Macrovascular Com-
plications was held in Santa Ynez Valley, California.
Attendees included Kelly West, Peter Bennett, Harry Keen
and other legendary figures in diabetes epidemiology. I
was also there, though as a “budding”epidemiologist! The
Santa Ynez Valley meeting produced a classification of dia-
betes, diagnostic criteria, and proper protocols for diabetes
epidemiology studies [5], so if a study was done in Japan,
it would be comparable to one performed in the United
States. This heritage of consensus and standardization has
been lost of late because of the practice of the IDF and
WHO and indeed the Global Burden of Disease Group [6]
and others to publish data which underestimate the bur-
den of diabetes and, if used for public health purposes,
probably underestimate the resources required to attack
the epidemic. So we have issued a word of caution and
hopefully the word will get out [6].
The WHO is at least, in part, at fault in this, as they
support the STEPS program which diagnoses diabetes
based on the fasting glucose level alone [7]. Notably,
Stefan Fajans and Jerome Conn did not even include the
fasting glucose in their criteria for the oral glucose toler-
ance test [8]. Whether they were wise or it was an over-
sight on their part, I cannot say, but we know the
measurement of fasting glucose alone underestimates the
prevalence of diabetes by 20–25% [9].
If epidemiologists of policy makers use country-
specific estimates provided by IDF or WHO for their
planning, they should carefully examine the appropriate-
ness of any extrapolation of data from one country to
another and evaluate the criteria used to diagnose dia-
betes. Inappropriate extrapolations and reliance on fast-
ing glucose alone may substantially bias country-specific
estimates and adversely impact planning.
Another issue demonstrates the problems researchers
have in getting access to primary data sources, especially
from the WHO [10]. WHO has historically not released
key information related to diabetes and other non-com-
municable diseases that are vital for public health. We need
a lot more transparency from major organizations in help-
ing both researchers and decision makers to understand the
true burden of diabetes, and that involves access to the pri-
mary data. These are the barriers that we are trying to ad-
dress now. We should not be using the data put out by
WHO or the IDF or even the Global Burden of Disease
Research Group [6, 11] uncritically when it comes to public
health planning in any country, even the United States.
Epidemiological data about the diabetes epidemic:
secular rises and falls
So what about this epidemic of diabetes? I started my dia-
betes epidemiology activities in the Pacific [12] and, later
on, the Indian Ocean island of Mauritius [13]. The inspir-
ation for me to get into diabetes research came from the
early studies of Ian Prior, a famous cardiovascular epi-
demiologist who, in the mid-1960s, published information
about high rates of diabetes in Polynesians living in New
Zealand and the Pacific islands [14]. In 1975, I was in
London training at Guys Hospital and it was Christmas. It
was snowing and cold and no one came to work. I was
sitting there by myself and I picked up an old British Med-
ical Journal and read about Ian Prior’s research showing
high rates of diabetes in Polynesians. Subsequently Peter
Bennett showed that Pima Indians living in Arizona had
the highest prevalence of diabetes in any community in the
world [15]. There was also a study in Australia showing
how indigenous people have high rates of diabetes [16]. So
when I returned to Australia from London, I decided to in-
vestigate the issue of diabetes in Pacific Island populations.
Our group “swept”through the Pacific and found
some of the highest rates of diabetes that had ever been
reported [12]. This was a warning to me that we were
going to face a diabetes epidemic. Indeed when we did
our first Pacific survey in Nauru in 1975, we found a
high rate of diabetes –34.4% in individuals >15 years
old [17]. Peter Bennett had reported that >50% of the
adult Pima Indian population over the age of 35 years had
diabetes [15]. There was clearly a warning there, and
indeed, our Melbourne daily newspaper, The Age, pub-
lished a warning about diabetes as “The Western Killer in
Zimmet Clinical Diabetes and Endocrinology (2017) 3:1 Page 2 of 8
Paradise.”Unfortunately, they put my photograph under
the headline and it almost killed the point of the story!
After our group showed very high rates of diabetes in
the Pacific, the WHO asked me to go to Mauritius to have
a look at the diabetes problem there as there were some
indications that diabetes was becoming a problem on that
beautiful and idyllic Indian Ocean Island. It was important
to understand diabetes in Mauritius because although it
had a relatively small population of 1.2 million, the popu-
lation represented three major ethnic groups: Asian
Indians from India, Creole- South African Black popula-
tion, and Chinese people [13]. Together, these three ethnic
groups represent approximately two-thirds of the world’s
population. Whatever was happening in Mauritius could
be extrapolated to other countries where there were
Indian, Chinese and Creole or Black populations.
With a team including Sir George Alberti, a great bio-
chemist; Jaakko Tuomilehto, whose name is synonymous
with the prevention of type 2 diabetes; my colleagues
from Australia, Jonathan Shaw and Dianna Magliano;
and Sudhirsen Kowlessur from Mauritius, we have sur-
veyed the population of Mauritius every 5 years or so
from 1987 to 2015. Figure 1 shows data from Mauritius
from the first study in 1987 to the most recent published
study from 2009 [18, 19]. As you can see, the prevalence
of diabetes went from 14.6 to 23.6%, a 62% increase over
20 years (Fig. 1a). The pattern was very similar in each
ethnic group. Based on these data, we concluded that we
were facing a global epidemic of type 2 diabetes, especially
in countries such as China and India.
This has now been borne out. In India there has been
an increase of nearly 5% (absolute) in diabetes prevalence
between the years 2000 and 2006 [20] (Fig. 1b). India now
has 80–90 million people with diabetes. In India and in
many middle and low-income countries, there are simply
not the resources to manage diabetes. In 1980, less than
1% of Chinese population had diabetes. In Beijing, the
McDonalds restaurant in Tiananmen Square was one of
the busiest McDonald franchise in the world (Fig. 2). Now
the estimate of diabetes prevalence in China is 9.7% [21]
(Fig. 1c). A study from Turkey has also documented an in-
credible 90% increase in diabetes prevalence over 11 years
from 2002 to 2013 [22].
Indigenous populations are disproportionately affected
by diabetes and its complications. In Australia, Indigenous
populations residing in the Northern Territory have one
of the highest rates of diabetes in the world and certainly
among Indigenous communities [23]. Indigenous people
in Australia have a 4-fold higher diabetes prevalence com-
pared to the general Australian, mainly European popula-
tion. They also have the one of the highest rates of end-
stage renal disease in the world [24]. Alice Springs, in the
center of Australia and the home to a large Indigenous
population, has the largest kidney dialysis unit in the
southern hemisphere per capita, another reflection of the
impact of diabetes [25]. Diabetes also impacts survival.
The prevalence of diabetes falls off in the Indigenous
population over 64 years of age, not because there is a de-
crease in the incidence of diabetes, but because of higher
mortality in those with diabetes in that age category. [26].
The drivers of the type 2 diabetes epidemic (Table 1)
In indigenous communities in Australia, as in the US
and Canada, it is very important to understand the atti-
tudes of affected people before trying to prevent or manage
diabetes. We have a “western”view that diabetes is caused
by bad behavior, too much sugary drinks, and eating too
much. Obesity and not enough exercise are the culprits. In
contrast, the Indigenous people of Australia have lost their
Fig. 1 The Increase in Diabetes Prevalence in aMauritius Adapted from
[18, 19], bIndia Adapted from [20], and cChina Adapted from [21]
Zimmet Clinical Diabetes and Endocrinology (2017) 3:1 Page 3 of 8
lands, are in disharmony with other communities, suffer
from poverty and other external pressures (Table 2). Rec-
ognizing and addressing these issues is one of the greatest
challenges we have in trying to prevent diabetes in the
communities of Australia that have the highest rates.
There are clear links among lifestyle, inactivity, ageing, obes-
ity, and modernization, that contribute to diabetes. Between
1980, when the first diabetes study was done in Australia, and
2000, the prevalence of obesity almost tripled and the preva-
lence of diabetes increased from 2.4 to 7.2% [27] (Fig. 3). If
Fig. 2 “Coca-colonization”in China and India. aMcDonald's in China bCoca-cola in India
Table 1 Reported drivers of diabetes
Lifestyle
Inactivity
Caloric excess
Obesity
Ageing
Modernization
Fetal Programming
Table 2 Indigenous communities: drivers of type 2 diabetes
“Western”view Indigenous view
Bad behaviors Dispossession of lands
Bad choices Disharmony/Imbalance
Lazy Poverty
Obesity Socio-cultural change
“Toxic”external pressures
Transgenerational trauma
With permission from Professor Alex Brown
Zimmet Clinical Diabetes and Endocrinology (2017) 3:1 Page 4 of 8
you look at the incidence of diabetes in the Australian
cohort from the year 2000, there was a 4-fold difference
in risk of developing diabetes between people who were
obese and those who were of normal weight [28].
Almost two-thirds of the Australian population in 2000
was overweight or obese, close to the rates of over-
weight and obesity in Americans.
So far, I’ve given you all the bad news about the epidemic
of diabetes. The question is, are there any studies that show
that the prevalence of diabetes is actually falling? Some re-
cent data from the United States now suggest there might
be a leveling off of obesity and diabetes [29]. There’ssome
debate as to why this may be happening; whether it is due
to improved public awareness or whether everyone who is
going to get diabetes already has it. In Nauru in 1994, the
prevalence of diabetes was approximately 50%. In a subse-
quent study about 10 years later, the rate had fallen [30].
Over the same time period, Nauru went from being the
wealthiest country in the world per capita (due to rich
phosphate deposits) to one of the poorest countries in the
world. So the decline in prevalence could have been an
effect of the economic collapse. Another study reported in
the British Medical Journal found that during an economic
crisis in Cuba, there was a decrease in obesity and a de-
crease in diabetes incidence and deaths from diabetes [31].
So there’ssomeevidencethateconomichardshipmaybe
the best way to prevent diabetes!
The prevention of type 2 diabetes is a major global
public health challenge that we now face. Over 20 years
ago, a study by the late Hilary King, an adventurous
young epidemiologist, found a 4% diabetes prevalence
on a small Island off of the coast of Papua New Guinea
[32]. This was quite high for Papua New Guinea. We
considered doing a prevention study there, but an earth-
quake occurred and the whole island disappeared. I did
not think it was a good way to prevent diabetes, but it
solved the problem there!
In 1982, Kerin O’Dea, one of our very well-known
Australian diabetes investigators, took a group of Indigen-
ous bush people for 7 weeks to live using traditional foods,
such as crocodile, kangaroo and native plants [33]. They
lost weight and their glucose tolerance, insulin sensitivity,
blood lipids, and blood pressure all improved (Table 3).
This was one of the first demonstrations that if you return
to a traditional lifestyle, you can reverse not just diabetes
but other components of the metabolic syndrome. These
results were extended by others including the classic study
of Jaakko Tuomilehto, the Finnish Diabetes Prevention
Study [34]. He observed a reduction of 58% in the risk of
progression to type 2 diabetes; this now seems to be an
accepted outcome now among persons at high-risk people
of diabetes.
Epigenetics and risk for diabetes
Although I have always been a strong believer in the
“CocaColonization”story, a term suggested by Arthur
Koestler [35], that changes of lifestyle in rural and trad-
itional island populations have caused the epidemics of
obesity and diabetes, I think there are emerging data that
Fig. 3 Prevalence of Diabetes and Obesity in Australia 1980/81 and 1999/2000 Adapted from [27, 28]
Table 3 Impact of 7 weeks of Back to Traditional Hunter
Gatherer Lifestyle Change in Australian Aborigines on type 2
diabetes
Weight loss
Striking improvement in glucose tolerance
Improved insulin response
Normalization of blood lipids
Reduction in blood pressure
Adapted from [33]
Zimmet Clinical Diabetes and Endocrinology (2017) 3:1 Page 5 of 8
suggest we need to rethink the story and consider the im-
pact of epigenetics. In 1990, David J. P. Barker first pro-
posed that in utero metabolic adaptation defines a
trajectory of growth that prepares the fetus for its likely
adult environment [36]. What happens in utero to the
fetus depends on the mother’s and the father’sbehaviors
before conception and the mother’s during pregnancy.
The story goes back to the Dutch winter famine [37]. At
the end of World War 2, there was a famine during the
Nazi Germany occupation of Holland. Women who were
pregnant were on very poor diets. Some 30 years later,
researchers looked to see what happened to the children
who were born at that time. They found high rates of
diabetes, obesity, hypertension, and indeed some mental
disorders like schizophrenia in the offspring of women
who were undernourished during early pregnancy. This
raised the issue of the famine and what happened many
years later when these children became adults. Their risks
of chronic diseases were increased.
Another example occurred during the Chinese famine
of 1958–1962 [38]. There was virtually minimal diabetes
in China before 1980 [39]. Some 30–40 years after that
famine, there are now over 120 million Chinese with
diabetes [40]. Again, this raises a question of the role of
a famine and the effect of the famine on children ex-
posed to intrauterine undernutrition. In very simple
terms, epigenetics reflects not a change in the genes of
the fetus, but a change in the DNA around the genes.
That DNA influences how the gene reacts with potential
environmental risk factors including those noted in the
figure (Fig. 4). This can also happen to children born
during a famine so that 20–30 years later, when they
come into an obesogenic environment, they get diabetes.
This is just an example of some of the risk factors that
can influence in utero this process and it’s been well
demonstrated in animal studies that this happens. All of
the data so far in humans is retrospective, but there is
now a prospective study in Singapore led by Professor
Sir Peter Gluckman, to assess the impact of epigenetics
at a human level [41]. What is also interesting is that
diabetes itself is one of the many factors that can cause
epigenetic changes. We know that mothers with pre-ges-
tational diabetes and mothers with gestational diabetes are
more likely to have offspring who are either obese or have
diabetes. And the epigenetic effect appears to be
intergenerational. It means you could have a vicious cycle
perpetuating the diabetes epidemic. Gluckman and
Hansen have authored a book, Mismatch [42], suggest-
ing that a baby born in a famine situation expects to
come out into the famine, but may arrive into an obeso-
genic environment. I have tried to make this phenomenon
a little clearer by pointing out that with undernutrition in
pregnancy, the adaptation is to expect a scarce resource
Fig. 4 Developmental plasticity, fetal programming and
intergenerational risk
Fig. 5 Mismatch: The relevance for prevention of type 2 diabetes
Zimmet Clinical Diabetes and Endocrinology (2017) 3:1 Page 6 of 8
environment. If the expectation is not met because the
baby arrives to an obesogenic environment, we may see
both early changes in the child, and an increased risk of
obesity, diabetes, and heart disease in adult life (Fig. 5).
I think this is a real story. Higher rates of diabetes also
may be linked to famine situations that occurred in the
Ukraine (1932–1933) [43] and in Cambodia (1975–79)
[44, 45]. We now have a famine in the Horn of Africa.
This raises very important issues as to how the United
Nations (UN), the WHO, and the UN Development
Program and other NGOs handle food relief during and
after a famine. These may be very important aspects of
preventing diabetes in communities many, many years
hence. So finally the message is out to be very wary of
national and international predictions of this diabetes
epidemic. We need to be looking more closely at mater-
nal and child health, and the whole issue of early devel-
opment in utero to reduce the risk to future generations.
The next epidemic may occur in countries in the Horn
of Africa if we do not pay attention to the correct way of
handling the nutritional and social issues particularly
with aid and food supplies.
Conclusion
The “Diabesity”epidemic (obesity and type 2 diabetes) is
likely to be the biggest epidemic in human history.
Diabetes has been seriously underrated as a global public
health issue and the world can no longer ignore “the rise
and rise”of type 2 diabetes. Currently, most of the
national and global diabetes estimates come from the
IDF Atlas. These estimates have significant limitations
from a public health perspective. It is apparent that the
IDF have consistently underestimated the global burden.
More reliable estimates of the future burden of diabetes
are urgently needed. To prevent type 2 diabetes, a better
understanding of the drivers of the epidemic is needed.
While for years, there has been comprehensive attention
to the “traditional”risk factors for type 2 diabetes i.e.,
genes, lifestyle and behavioral change, the spotlight is
turning to the impact of the intra-uterine environment
and epigenetics on future risk in adult life. It highlights
the urgency for discovering novel approaches to preven-
tion focusing on maternal and child health. Diabetes risk
through epigenetic changes can be transmitted inter-
generationally thus creating a vicious cycle that will con-
tinue to feed the diabetes epidemic. Yes, diabetes is the
greatest epidemic in human history. It has affected the
greatest numbers, it has had the greatest cost [46], and it
is not over yet.
Abbreviations
IDF: International Diabetes Federation; STEPS: STEPwise approach to
Surveillance; UN: United Nations; US: United States; WHO: World Health
Organization
Acknowledgements
I want to acknowledge collaborators who we have worked with on these
projects: [1] Baker IDI and key collaborators include Jonathan Shaw, Sir
George Alberti, Jaako Tuomilehto, Dianna Magliano, David Dunstan, Stefan
Soderberg, Merlin Thomas and William Herman. [2] Mauritius collaborators
include Sudhir Kowlessur, Pierrot Chitson, N Gopee and V Pauvaday.
I also wish to acknowledge my wife Vivien, my biggest supporter through all
these years dedicated to the cause of diabetes. I would also like to
acknowledge the support of our two sons, Hendrik and Marcel, who now
are contributing so much in medicine- in Heart Failure Cardiology and Fetal
Alcohol Syndrome Disorders, respectively.
This paper is adapted from the Stefan S Fajans Lecture delivered at
University of Michigan, Ann Arbor, on May 13, 2016 by Professor Zimmet.
Funding
N/A.
Availability of data and materials
N/A.
Authors’contributions
PZ prepared and delivered the 2016 Fajans lecture after which he adapted it
into a paper. PZ read and approved the final manuscript.
Authors’information
Professor Zimmet is Professor of Diabetes at Monash University, and former
Emeritus Director of Baker IDI Heart and Diabetes Institute in Melbourne,
Australia. He is an Honorary President of the International Diabetes
Federation.
Competing interests
None.
Consent for publication
N/A.
Ethics approval and consent to participate
N/A.
Received: 13 September 2016 Accepted: 30 November 2016
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