Incidence and prevalence rates of diabetes mellitus in Saudi Arabia: An overview

Abstract

Objective
This study aimed to report on the trends in incidence and prevalence rates of diabetes mellitus in Saudi Arabia over the last 25 years (1990–2015).

Design
A descriptive review.

Methods
A systematic search was conducted for English-language, peer reviewed publications of any research design via Medline, EBSCO, PubMed and Scopus from 1990 to 2015. Of 106 articles retrieved, after removal of duplicates and quality appraisal, 8 studies were included in the review and synthesised based on study characteristics, design and findings.

Findings
Studies originated from Saudi Arabia and applied a variety of research designs and tools to diagnosis diabetes. Of the 8 included studies; three reported type 1 diabetes and five on type 2 diabetes. Overall, findings indicated that the incidence and prevalence rate of diabetes is rising particularly among females, older children/adolescent and in urban areas.

Conclusion
Further development are required to assess the health intervention, polices, guidelines, self-management programs in Saudi Arabia.

Full text

Incidence and prevalence rates of diabetes mellitus in Saudi Arabia: An
overview
Abdulellah Alotaibi
a,b,
⇑
, Lin Perry
b,c
, Leila Gholizadeh
b
, Ali Al-Ganmi
b,d
a
Faculty of Applied Medical Science, Shaqra University, Saudi Arabia
b
Faculty of Health, University of Technology Sydney (UTS), Australia
c
South Eastern Sydney Local Health District, Australia
d
Faculty of Health, University of Baghdad, Iraq
article info
Article history:
Received 20 May 2017
Received in revised form 26 July 2017
Accepted 2 October 2017
Available online 7 October 2017
Keywords:
Diabetes mellitus
Prevalence
Incidence
Saudi Arabia
abstract
Objective: This study aimed to report on the trends in incidence and prevalence rates of diabetes mellitus
in Saudi Arabia over the last 25 years (1990–2015).
Design: A descriptive review.
Methods: A systematic search was conducted for English-language, peer reviewed publications of any
research design via Medline, EBSCO, PubMed and Scopus from 1990 to 2015. Of 106 articles retrieved,
after removal of duplicates and quality appraisal, 8 studies were included in the review and synthesised
based on study characteristics, design and findings.
Findings: Studies originated from Saudi Arabia and applied a variety of research designs and tools to
diagnosis diabetes. Of the 8 included studies; three reported type 1 diabetes and five on type 2 diabetes.
Overall, findings indicated that the incidence and prevalence rate of diabetes is rising particularly among
females, older children/adolescent and in urban areas.
Conclusion: Further development are required to assess the health intervention, polices, guidelines, self-
management programs in Saudi Arabia.
Ó2017 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Contents
1. Introduction . . . ...................................................................................................... 212
2. Methods . . . . . . ...................................................................................................... 212
2.1. Review design . . . . . . . . . .......................... ............................................................... 212
2.2. Search strategy . . . . . . . . ................................ ......................................................... 212
2.3. Quality appraisal . . . . . . . ................................................................ ......................... 212
2.4. Data extraction . . . . . . . . .................... ..................................................................... 213
2.5. Data synthesis . . . . . . . . . ...................................................... ................................... 213
3. Findings . . . . . . ...................................................................................................... 213
3.1. Type 1 diabetes . . . . . . . . ...................................................... ................................... 213
3.2. Type 2 diabetes . . . . . . . . ...................................................... ................................... 214
4. Discussion. . . . . ...................................................................................................... 216
4.1. Limitations of this review ................ ......................................................................... 217
5. Conclusion . . . . ...................................................................................................... 217
References . . . . ...................................................................................................... 217
https://doi.org/10.1016/j.jegh.2017.10.001
2210-6006/Ó2017 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer review under responsibility of Ministry of Health, Saudi Arabia.
⇑
Corresponding author at: Faculty of Health, University of Technology Sydney (UTS), Australia.
E-mail addresses: Abdulellah.M.Alotaibi@student.uts.edu.au,abaadi1982@hotmail.com (A. Alotaibi), Lin.Perry@uts.edu.au (L. Perry), Leila.Gholizadeh@uts.edu.au
(L. Gholizadeh), ali.h.al-ganmi@student.uts.edu.au (A. Al-Ganmi).
Journal of Epidemiology and Global Health 7 (2017) 211–218
Contents lists available at ScienceDirect
Journal of Epidemiology and Global Health
journal homepage: www.elsevier.com/locate/jegh

1. Introduction
Diabetes Mellitus (DM) is a growing global health concern. In
2000, diabetes affected an estimated 171 million people world-
wide; by 2011 this had increased to more than 366 million and
numbers are expected to exceed 552 million by 2030 [1].DMisa
metabolic disease of multiple aetiologies, characterised by hyper-
glycaemia resulting from defects in insulin secretion, insulin action
or both, and associated with disturbance of carbohydrate, fat and
protein metabolism [2]. The three commonest types of diabetes
are Type 1 Diabetes Mellitus (T1DM), Type 2 Diabetes Mellitus
(T2DM) and Gestational Diabetes Mellitus (GDM) [3].
The highest prevalence of diabetes overall is anticipated to
occur in the Middle East and North Africa due to rapid economic
development, urbanisation and changes in lifestyle patterns in
the region [1]. The Kingdom of Saudi Arabia (KSA) is not excluded
from this global epidemic [4] and diabetes is the most challenging
health problem facing this country [5]. According to a report by the
Saudi Arabian Ministry of Health, approximately 0.9 million people
were diagnosed with diabetes in 1992, but this figure rose to 2.5
million people in 2010, representing a 2.7 times increase in the
incidence rates in less than two decades. In 2015, 4660 patients
with diabetes attended the family and medical clinics across Saudi
Arabia [6]. This increasing burden of diabetes is due to various fac-
tors, including a rising obesity rate and an aging population [7].
Patients with diabetes commonly experience other associated
chronic conditions, resulting in serious complications [3]. For
example, the incidence of end stage renal disease is higher among
patients with diabetes [8] and accounts for between 24% and 51%
of those receiving renal replacement therapy [9]. Compared to
the general population, patients with diabetes are two to four
times more likely to develop cardiovascular disease, and two to
five times more likely to die from this disease [10]. In addition to
its impact on individuals, diabetes places a significant burden on
healthcare services and the community as a whole [11]. Globally,
diabetes accounted for 11% of the total healthcare expenditure in
2011; in Saudi Arabia, the annual cost of diabetes has been esti-
mated at more than $0.87 billion [12].
It is essential to understand the epidemiology of diabetes in
order to identify public health priorities, to generate policy initia-
tives and evaluate the effect of services in reducing the individual
and social burden of diabetes [13]. Although prevalence estimates
by countries and regions are provided by the International Dia-
betes Federation, there are substantial variations in time trends
as these estimates are based on imputation [14]. To date, no sys-
tematic review has been reported on the incidence and prevalence
of diabetes in Saudi Arabia. Considering the major socio-economic
changes that have occurred in this country during the past few
decades, and their marked impact on the lifestyles, eating habits
and physical activities of the people of this region, along with the
aging of the population, this is an important omission [12]. This
review has therefore been conducted to report the trends in inci-
dence and prevalence rates of diabetes mellitus in Saudi Arabia
between 1990 and 2015.
2. Methods
2.1. Review design
This review employed a descriptive design to review and anal-
yse studies reporting the incidence and prevalence rates of dia-
betes in Saudi Arabia. This approach is also referred to as
correlational or observational design and is commonly used to
obtain information about naturally occurring health states [15].
This descriptive study followed the Joanna Briggs Institute (JBI)
(2014) protocol for the review of prevalence and incidence studies,
including search strategy, quality appraisal, data extraction and
synthesis, results, discussion and conclusion.
2.2. Search strategy
A systematic literature search was performed to identify publi-
cations reporting the incidence and prevalence rates of diabetes in
Saudi Arabia. Included publications focused specifically on studies
describing the incidence and prevalence rates in relation to either a
diagnosis of diabetes, or explicit blood glucose-level criteria for
diagnosis of diabetes. Studies considering type 1 or type 2 diabetes,
or both, were included as these account for over 90% of all diabetes
[16]. Medical Subject Heading terms (MeSH) were used, including
prevalence, incidence, diabetes mellitus, and Saudi Arabia. Syno-
nyms for the identified concepts were generated including, ‘‘epi-
demiology” and ‘‘trend”; ‘‘type 1 diabetes” and ‘‘type 2 diabetes”.
These concepts were combined using Boolean Operators (AND,
OR). Four academic databases (Medline, EBSCO, PubMed and Sco-
pus) were searched for relevant literature. The search was limited
to English language papers published between 1990 and 2015.
Papers published in languages other than English, and publication
types other than primary studies (such as systematic reviews and
meta-analyses, discussion papers, conference abstracts and disser-
tations) were excluded. In total, 106 citations of potential rele-
vance were identified (Table 1). Initial screening of titles and
abstracts revealed that 90% of these retrieved studies did not meet
the review inclusion criteria, with 16 papers retained for full-text
evaluation. Full text screening for relevance resulted in the exclu-
sion of five further papers. Two articles were added from the refer-
ence lists of the reviewed articles and Google scholar.
2.3. Quality appraisal
These 13 articles were critically appraised for quality using the
JBI Critical Appraisal Checklist for studies reporting prevalence
data [15]. All papers were evaluated on the basis of data relevance
and methodological rigor, and papers that met a minimum of five
of the nine criteria (see column headings, Tables 2 and 3) were
included. The process resulted in the exclusion of four papers
(Table 2;Fig. 1). The remaining nine studies employed appropriate
quantitative designs for incidence and prevalence studies (Table 3).
Table 1
Search terms, database and search output.
Search No Search Terms Medline results EBSCO results PubMed results Scopus results Total
S 1 Prevalence or epidemiology or trend 579,280 1,061,711 2,656,747 2,749,216 7,046,954
S 2 Incidence 229851 249,619 2355894 1,014,650 3,850,014
S 3 Diabetes mellitus 495873 258,094 564756 699,008 2,017,731
S 4 Saudi Arabia 9627 59,039 44900 34,024 147,590
S 5 S1and S2 and S3 and S4 with limits: date (1990–2015), Peer Reviewed,
Human, Journal Article and English Language)
12 15 61 18 106
212 A. Alotaibi et al. / Journal of Epidemiology and Global Health 7 (2017) 211–218

2.4. Data extraction
Data were extracted using a specifically designed data extrac-
tion table (Table 4), and examined, compared, discussed and
agreed with all authors. Data were analysed descriptively, compar-
ing and contrasting results across studies, taking into consideration
the differences in date of study, sampling technique and sample
size, age, setting, methods and type of diabetes.
2.5. Data synthesis
Multiple sources of heterogeneity (research region and site,
types of diabetes and age groups) were observed across the
included studies. The heterogeneity was explored qualitatively by
comparing the characteristics of the included studies. Studies were
grouped according to the type of diabetes (Table 5).
3. Findings
Of the nine included studies, two examined incidence rates
[17,18], four reported the prevalence rates of T1DM among chil-
dren and adolescents [19–22], while six studies reported the
prevalence rate of T2DM among adults [19,21–25]. These studies
included only Saudi nationals, with sample sizes ranging from
419 to 45,682. Four studies were conducted nationwide
[20,21,24,25], one study was conducted in Dhahran (Eastern
region) [17]; one recruited across the entire Eastern province
[23], and one each were conducted in Riyadh (Central region)
[19], Jeddah (Western region) [22] and Al-Madina (Western region)
[18]. Four were conducted using random sampling techniques, two
used convenience sampling, one used multistage stratified cluster
sampling and the remaining two did not report the sampling tech-
nique used. The research settings of three studies were tertiary
hospitals [17,18,22], two were set in primary health centres
[19,24], three in households [20,21,25] and one was conducted in
a range of settings including governmental public hospitals and
primary health centres [21,23]. The reported prevalence and inci-
dence rates of diabetes varied widely across different geographical
areas (Tables 4 and 5).
3.1. Type 1 diabetes
Two studies reported the incidence rates of T1DM between
1990 and 2009 in Dhahran, Eastern KSA [17] and in Al Madina,
North West KSA [18]. The samples in these two studies were chil-
dren and adolescents from 0 to 14 years old. The cumulative inci-
dence rates of T1DM among these children and adolescents were
very similar, at 27.52 per 100,000 and 26.7 per 100,000, respec-
tively (Table 4). In the Dhahran study, an increasing trend in child-
hood and adolescence incidence rate of T1DM between 1990 and
2007 was observed (Fig. 2). The incidence rates of T1DM doubled
among children in less than two decades, from 18.05 per 100,000
Table 2
JBI critical appraisal checklist applied for excluded studied reporting incidence and prevalence data.
Author Name/Year Sample was
representative?
Participants
appropriately
recruited?
Sample
size was
adequate?
Study
subjects
and the
setting
described?
Data
analysis
conducted
Objective,
standard
criteria,
reliably
used?
Appropriate
statistical
analysis
used
Confounding
factors/ subgroups/
differences
identified and
accounted?
Subpopulations
identified using
objective
criteria
Abou-Gamel et al.
(2014)
No No No Unclear Yes Yes Unclear Unclear Unclear
Al-Orf (2012) No Unclear No Unclear Yes Yes Yes No Unclear
Alsenany and Al
Saif (2015)
Yes No No Unclear Yes Unclear Unclear Unclear Yes
Karim et al.,
(2000)
Yes No Yes No No Unclear Unclear Unclear Unclear
Table 3
JBI critical appraisal checklist applied for included studies reporting incidence and prevalence data.
Author
Name/Year
Sample was
representative?
Participants
appropriately
recruited?
Sample
size was
adequate?
Study
subjects and
the setting
described?
Data
analysis
conducted
Objective,
standard
criteria,
reliably
used?
Appropriate
statistical
analysis
used
Confounding factors/
subgroups/
differences identified
and accounted?
Subpopulations
identified using
objective
criteria
Abduljabbar
et al. [17]
Yes No Yes Yes Yes No Yes Unclear No
Al-Baghli
et al. [23]
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Al-Daghri
et al. [19]
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Al-Herbish
et al. [20]
Yes Yes Yes Yes Yes No Unclear Unclear Unclear
Al-Nozah
et al. [24]
Yes Yes Yes Yes Yes Yes Yes Yes Unclear
Al-Qurashi
et al. [22]
Yes No Yes Yes Yes Unclear Yes Yes Yes
Al-Rubeaan
et al.
(2015)
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Al-Rubeaan
[21]
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Habeb et al.
[18]
No No No Yes Yes Yes Yes Yes Yes
A. Alotaibi et al. / Journal of Epidemiology and Global Health 7 (2017) 211–218 213

children between 1990 and 1998 to 36.99 per 100,000 children
between 1999 and 2007, indicating an average annual increase in
incidence of 16.8% [17]. In Al-Madina, no significant increase was
observed in the overall annual incidence rate between 2004 and
2009 in Al-Madina[18]; children aged 0 to 4 years had an esti-
mated incidence rate of 17.1 per 100,000, while children aged 5
to 9 and 10 to 12 years had incidence rates of 30.9 and 46.5 per
100,000, respectively. Children aged 5 to 9, and 10 to 12 years
had 1.8 and 2.7 times greater risk of developing T1DM than chil-
dren aged 0 to 4 years [18].
A nationwide study reported the prevalence of T1DM among
children and adolescents aged up to 19 years at 109.5 per
100,000 between 2001 and 2007 [20]. The prevalence rate was
highest among adolescents aged 13 to 16 years (at 243 per
100,000) and lowest among children aged 5 to 6 years at 100 per
100,000 [20]. Another nationwide study found the prevalence of
T1DM between ages 13 and 18 years, at (0.46%), higher than
amongst those who aged under 12 years at (0.37%) between 2007
and 2009 [21]. In addition, two studies conducted in Riyadh [19]
and Jeddah [22] found that the prevalence rates of diabetes at
younger ages between 7–17 and 12–19 years respectively, were
higher in female than male populations.
In terms of gender, the incidence of T1DM was significantly
higher among females (at 31.17 per 100,000) than males (at
24.07 per 100,000) in Dhahran, KSA between 1990 and 2007
[17]. In females the highest incidence rate was reported for those
aged 7–11 years and for males similar rates were reported for
those aged 8–12 years [17]. Females had significantly higher inci-
dence rates than males (at 33.0 per 100,000 compared to 22.2
per 100,000 respectively) in Al-Madina between 2004 and 2009
[18]. A nationwide study found that prevalence was higher among
females than males between 2007 and 2009. [21].
The highest prevalence rate (at 126 per 100,000) was recorded
in the central region where the capital city of Riyadh is located and
the environment is mostly urban; the lowest prevalence rate (at 48
per 100,000) was reported in the eastern region of KSA, which is
predominantly rural [20]. Between 2007 and 2009, the majority
(77.2%) of cases of T1DM was documented in urban rather than
rural areas (at 22.7%) [21].
3.2. Type 2 diabetes
Prevalence rates of T2DM were reported in six studies, three of
which were nationwide [21,24,25]. Of the remainder, one study
was conducted in Riyadh [19], one in Jeddah [22] and one in the
Eastern province [23]. All these studies reported prevalence rates
of T2DM in different years between 1995 and 2011 and included
only Saudi nationals aged between 7 and 80 years (Table 4). The
Fig. 1. Flowchart of study selection.
214 A. Alotaibi et al. / Journal of Epidemiology and Global Health 7 (2017) 211–218

studies demonstrated varying prevalence rates in different geo-
graphical regions in the country, ranging from 18.2% (in 2004–
2005) in the study conducted in the Eastern province [23] to
31.6% in 2011 in the study conducted in Riyadh [19], nationwide
prevalence rate increased from 23.7% between 1995 and 2000 to
25.4% between 2007 and 2009 [24,25]. When plotted figuratively,
these six studies indicate a clear trend of overall increasing
prevalence of T2DM with time (Fig. 3). Four studies reported
Table 4
Summary table of included studies.
Authors
(Date of
publication)
Date of study Sample
size
Age Type of
diabetes
Sampling technique Setting (urban /
rural)
Method
used
Incidence /
prevalence per
100,000 or%
Overall
per
100,000
or%
Male Female
Abduljabbar
et al. [17]
1990–2007 438 <15 years T1DM
a
Not reported Dhahran, Eastern
KSA (urban)
Not
mentioned
24.07 31.17 27.52
Al-Herbish
et al. [20]
2001–2007 45, 682 0–19 years T1DM
a
Multi-stage stratified
random sampling
Nationwide (rural
& urban)
Self-report 56.9 52.6 109.5
Habeb et al.
[18]
2004–2009 419 0–12 years T1DM
a
Not reported Al-Madinah
(urban)
Self-report 22.2 33.0 27.6
Al-Baghli
et al. [23]
2004–2005 197,
681
30 years T2DM
b
Convenience sampling
(approached participantsin
their workplaces, major
public places, malls and
other venues)
Eastern Province
(urban & rural)
FPG
c
CFBG
d
CCBG
e
&
15.9% 18.6% 18.2%
Al-Daghri
et al. [19]
2011 9, 149 7–80 years T2DM
b
Cluster random sampling Riyadh (Unknown) FPG
c
34.7% 28.6% 31.6%
Al-Nozha
et al. [24]
1995–2000 16, 917 30–70
years
T2DM
b
2 stage, stratified cluster
sampling
Nationwide
(urban & rural)
FPG
c
26.2% 21.5 23.7%
Alqurashi
et al. [22]
2009 6, 024 12–70
years
T2DM
b
Convenience sampling
(patients attending a
primary care clinic)
Jeddah (King
Fahad Armed
Forces Hospital.)
Self-report 34.1% 27.6% 30.0%
Al-Rubeaan
et al.
(2015)
2007–2009 18, 034 30 years T2DM
b
Random sampling Nationwide
(urban & rural)
FPG
c
29.1% 21.9% 25.4%
Al-Rubeaan
[21]
2007–2009 23,523 0– 18
years
T1DM
a
/
T2DM
b
Multistage stratified cluster
sampling
Nationwide
(urban & rural)
FPG
c
44.32%
(T1DM)
47.06%
(T2DM)
55.68%
(T1DM)
52.94%
(T2DM)
10.84%
a
Type 1 Diabetes Mellitus.
b
Type 2 Diabetes Mellitus.
c
Fasting Plasma Glucose.
d
Capillary Fasting Blood Glucose.
e
Casual Capillary Blood Glucose.
Table 5
General characteristics of included studies.
Central region East region West region Nationwide
Country regions 1 study 2 study 2 studies 4 studies
Al-Daghri et al. [19] Abduljabbar et al. [17],
Al-Baghli et al. [23]
Habeb et al. [18], Alqurashi et al. [22] Al-Herbish et al. [20], Al-Rubeaan [21],
Al-Nozha et al. [24], Al-Rubeaan et al. [25]
Type of diabetes Type 1 diabetes Type 2 diabetes Both types
4 studies 6 studies 4 studies
Abduljabbar et al. [17] Al-Daghri et al. [19] Al-Daghri et al. [19], Al-Rubeaan [21]
Habeb et al. [18] Al-Rubeaan [21]
Al-Herbish et al. [20] Alqurashi et al. [22] Alqurashi et al. [22], Al-Nozha et al. [24]
Al-Rubeaan [21] Al-Baghli et al. [23]
Al-Nozha et al. [24]
Al-Rubeaan et al. [25]
Age groups Children/ adolescent Adult
4 studies 6 studies
Abduljabbar et al. [17] Al-Daghri et al. [19]
Habeb et al. [18] Al-Rubeaan [21]
Al-Herbish et al. [20] Alqurashi et al. [22]
Al-Rubeaan [21] Al-Baghli et al. [23]
Al-Nozha et al. [24]
Al-Rubeaan et al. [25]
Research setting Tertiary hospital Primary healthcare center (PHCC) Nursing home and households
4 studies 3 studies 3 studies
Abduljabbar et al. [17] Al-Daghri et al. [19] Al-Herbish et al. [20]
Habeb et al. [18] Al-Baghli et al. [23] Al-Rubeaan [21]
Alqurashi et al. [22] Al-Nozha et al. [24] Al-Rubeaan et al. [25]
Al-Baghli et al. [23]
A. Alotaibi et al. / Journal of Epidemiology and Global Health 7 (2017) 211–218 215

significantly higher prevalence rates for T2DM in males than in
females; one regional study from the Eastern province [23] and
two nationwide studies, conducted between 2004 and 2005 [25]
and between 2007 and 2009 [21] reported significantly higher
prevalence rates for T2DM among females than males but these
studies recruited by convenience and multistage stratified cluster
rather than random sampling. Of the studies, which recruited using
probability sampling (and for one of the two studies that used con-
venience sampling), there was an increasing prevalence of T2DM
for both genders between 1995 and 2011, with higher prevalence
rates among males than females (Fig. 3). Furthermore, T2DM was
reportedly more prevalent among people in urban areas (at 25.5%
compared to 19.5%) than in rural areas, and prevalence rates were
highest in the northern region (at 27.9%) and lowest in the south-
ern region (at 18.2%) between 1995 and 2000 [24].
Between 2007 and 2009, prevalence rates amongst those with
monthly incomes less than 4000 Saudi Riyal (SR; approx. 1067
USD) were higher among those in urban areas (27.2%) than those
in rural areas (25.7%) [21]. However, no significant difference
was reported in prevalence rates of urban and rural residents with
monthly incomes of 8000SR (approx.. 2134 USD) and higher [25];
at a certain level of wealth, affluence appears to overcome the
influence of residential area. Other differences noted included the
mean age of diagnosis of the disease, reported as 53.4 years for
females and 57.5 years for males [22]. In geographical terms,
T2DM was most prevalent in the northern regions and least in
the southern regions between 1995 and 2000 [24]. In terms of
socio-demographic characteristics, in the Eastern Province the
prevalence of T2DM was higher in individuals who were widowed
(39.1%), unemployed (31.9%), and uneducated (32.3%) between
2004 and 2005 [23].
4. Discussion
The findings of this review indicate that diabetes mellitus is a
growing health problem in Saudi Arabia. The findings broadly
reflect high incidence rates of T1DM across the country, with rates
rising particularly amongst children. One study conducted in the
western region showed no increase in T1DM for the 5-year period
between 2004 and 2009, but this may be due to the study’s
limitation of including children only up to age 12 years [18]. Other
studies indicate a significant increase in incidence rates of T1DM
amongst groups older than 12 years [17,20]. This review’s findings
concur with and expand on those of a report by the Saudi Arabian
Ministry of Health [17] as well as the latest report of the Interna-
tional Diabetes Federation (2015). The findings are also broadly
consistent with epidemiological studies from several areas of Asia,
Europe and North America, where the annual growth rates for
T1DM have been reported at 4.0%, 3.2% and 5.3% respectively
N
ote: Adapted from Abduljabbar et .al (2010) [17] and Habeb et .al (2011) [18]
0
10
20
30
40
50
60
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Dhahran (East Region)
Al Madinah (West Region)
Fig. 2. Incidence rate of T1DM between 1990 and 2009 in Saudi Arabia.
N
ote: Adapted from Al-Daghri et al. [19];Alqurashi et al. [22];Al-Baghli et al. [23]; Al-Nozha et al. [24];
Al-Rubeaan [21]
0%
10%
20%
30%
40%
50%
60%
1995-2000 2004-2005 2007-2009 2009 2011
Male
Female
Fig. 3. Prevalence rate of T2DM between 1995 and 2011 in Saudi Arabia.
216 A. Alotaibi et al. / Journal of Epidemiology and Global Health 7 (2017) 211–218

[26]. The latest report by the International Diabetes Federation
cites 16,100 children aged 0–14 living with T1DM in Saudi Arabia,
with an incidence of 31.4 new cases per 100,000 population [1].
The national incidence rate is higher than the incidence rates in
Dhahran [17] and Al-Medina [18], reported in this review at 27.5
per 100,000 and 26.7 per 100,000, respectively. This implies an
increase in new cases of T1DM in the country. Overall, studies
included in this review recorded a higher incidence of T1DM
among females than males. The International Diabetes Federation
reported that the highest incidence rate of diabetes should be
expected among females rather than males by 2030 [1]. The reason
for this is uncertain; gender differences are often related environ-
ment and culture, whilst genetic factors are generally assumed to
play a major role in the development of T1DM [27].
Contradiction of this reported higher incidence among females,
Cucca et al. [28] found a greater prevalence among males. This
seems to derive from the higher incidence rates of T1DM reported
amongst males of European populations, which is not the case in
non-European countries like Saudi Arabia [29]. Regardless of the
gender distribution, the high rates of T1DM among children in
Saudi Arabia are likely to increase burden on the country’s health-
care systems, as T1DM is implicated in the development of a wide
range of end-organ complications. It has recently has also been
associated with the development of obesity and overweight in
early adulthood [30], which are independent risk factors for health
problems such as cardiovascular disease and cancers. As with
T1DM, a steady rise was also noted in the prevalence rates of
T2DM especially during the years 2004–2005 and up to 2011,
affecting both genders. This finding is widely supported by a num-
ber of research studies conducted in Saudi Arabia and other Ara-
bian countries [31]. An alarming increase from 10.6% in 1989 to
32.1% in 2009 was documented in a systematic study conducted
in Saudi Arabia, although some of those included in the review
were non-Saudis [31]. Increased obesity, the popularity of fast
foods, smoking, and sedentary lifestyles may explain recent
increases in the prevalence of T2DM; the incidence of obesity, for
instance, has been reported to be as high as 75% among females liv-
ing in Saudi Arabia [32]. The higher prevalence of diabetes in urban
rather than rural areas, where lifestyle changes are more promi-
nent, lends support to the link between diabetes and life style risk
factors. However, whilst affluence was clearly influential, so was
poverty, in the Eastern province at least, and at higher incomes
the link with urban living was lost [23].
Prevalence rates of T2DM were found to be higher among males
than females although the age of onset was reported as earlier
among females than males (at 53.4 years and 57.5 years) [22]. This
finding is contrary to a study of Saudi adult patients at a primary
healthcare centre, which reported a higher incidence among
females (58%) than males (42%), but this discrepancy may be
related to the well-recognised greater willingness of females than
males to consult healthcare practitioners. In addition, females are
also reported as more willing than males to adhere to diabetes
daily management (e.g. restricted diet, monitoring blood-glucose,
taking medication and regular foot-care) [33]. These findings call
for prompt attention by the Ministry of Health especially because
the heaviest burden of diabetes (of both type 1 and type 2) is its
potential to progress to serious complications [34]. Awareness
campaigns are viewed as the best option to at least initiate recog-
nition of the need to modify unhealthy lifestyles, but recent cam-
paigns launched in Saudi Arabia have not been successful so far
[31]. Government-supported interventions are required to provide
programs aimed at both preventing the development of diabetes
and promoting self-care and management of the disease. The find-
ings of this review highlight the importance of introducing mea-
sures into the Saudi healthcare system to update the knowledge
and skills of all healthcare professionals involved with diabetes
management to provide high quality diabetes care [31]. This is par-
ticularly important given the knowledge deficits reported in the
nursing workforce both internationally and in Saudi Arabia [35,36].
4.1. Limitations of this review
Several limitations must be noted. First, this review was limited
to T1DM and T2DM; it did not include the prevalence and inci-
dence rates of gestational diabetes mellitus or childhood/adoles-
cent onset of T2DM. Future reviews should consider each of
these types of diabetes. Second, differences in assessment and
diagnosis methods for diabetes have resulted in changed diagnosis
criteria over time and heterogeneous methods and criteria were
observed over time, across regions, and for different types of dia-
betes in the studies, resulting in some lack of statistical precision.
5. Conclusion
This is the first comprehensive review of the incidence and
prevalence rates of T1DM and T2DM in Saudi Arabia. These were
found to be high and rising, particularly among women. Females
had higher incidence rates of T1DM among children and adoles-
cents than males, and older age groups of children and adolescents
had higher incidence rates of T1DM than younger age groups. The
incidence rate of T1DM was higher in the central region of the
country. Greater prevalence of T2DM was reported among those
living in urban than rural areas, but there were socio-economic
as well as geographical predisposing factors. This review recom-
mends that urgent attention is paid to develop, support and imple-
ment health interventions, guidelines and policies nationwide, to
assist in the prevention, diagnosis, management and promotion
of self-management of diabetes. For the future, well-designed epi-
demiological studies are required to allow for more accurate and
regular monitoring of the incidence and prevalence rates of dia-
betes across Saudi Arabia.
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