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Journal of Epidemiology and Global Health
Vol . 0(0); Month (2019), pp. 0–0
DOI: https://doi.org/10.2991/jegh.k.191028.001; ISSN 2210-6006; eISSN 2210-6014
https://www.atlantis-press.com/journals/jegh
Research Article
Epidemiology of Type 2 Diabetes – Global Burden of
Disease and Forecasted Trends
Moien AB Khan1, Muhammad Jawad Hashim1,*, Jeff King1, Romona Devi Govender1, Halla Mustafa1, Juma Al Kaabi2
1Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
2Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
1. INTRODUCTION
Type 2 diabetes is recognized as a serious public health concern
with a considerable impact on human life and health expenditures.
Rapid economic development and urbanization have led to a rising
burden of diabetes in many parts of the world [1]. Diabetes affects
individuals’ functional capacities and quality of life, leading to sig-
nificant morbidity and premature mortality [2]. Recently, concerns
have been raised that more than one-third of the diabetes-related
deaths occur in people under the age of 60 [3]. Increased consump-
tion of unhealthy diets and sedentary lifestyles, resulting in high
Body Mass Index (BMI) and high fasting plasma glucose, have been
blamed for these trends [4]. In particular, persons with higher BMI
are more likely to have type 2 diabetes [5]. The aging of the human
population is another contributor, as diabetes tends to affect older
individuals [6]. The cost of diabetes care is at least 3.2 times greater
than the average per capita healthcare expenditure, rising to 9.4
times in presence of complications [7]. Control of blood glucose,
blood pressure, and other targets remains suboptimal for many
patients [8]. This has been partly attributed to the lack of awareness
and health promotion needed for diabetes control [9].
Unfortunately, the global epidemiology of diabetes has not been
re-evaluated since the availability of recent high-quality data [10].
We found no studies providing global forecasts for the intermediate
future, which would be a critical piece of information for health
policymakers.
This research project examines the latest dataset of the Global
Burden of Disease (GBD) to assess the burden of type 2 diabetes
worldwide. The aim is to study the current global epidemiology
of diabetes and highlight the current distribution of disease and
emerging epidemiologic trends.
2. MATERIALS AND METHODS
We analyzed descriptive epidemiological data from the GBD data-
set managed by the Institute of Health Metrics and Evaluation at
the University of Washington, Seattle [11]. The GBD dataset is
actively maintained and updated based on research data, epide-
miology studies, and governmental publications from more than
100,000 sources. As a systematic public health project, it carefully
builds models and statistical estimates for health loss due to illness,
injury, and risk factors based on empirical data. GBD produces
annual estimates of disease measures, such as prevalence, inci-
dence, deaths, and Disability-Adjusted Life Years (DALYs). DALYs
combine years of life lost due to premature death and years lived
with disability, and are a more accurate reflection of human suf-
fering resulting from a disease than prevalence or mortality alone.
ARTICLE INFO
Article History
Received 26 June 2019
Accepted 27 October 2019
Keywords
Diabetes mellitus type 2
epidemiology
disease pattern
prevalence
ABSTRACT
e rising burden of type 2 diabetes is a major concern in healthcare worldwide. is research aimed to analyze the global
epidemiology of type 2 diabetes. We analyzed the incidence, prevalence, and burden of suering of diabetes mellitus based on
epidemiological data from the Global Burden of Disease (GBD) current dataset from the Institute of Health Metrics, Seattle.
Global and regional trends from 1990 to 2017 of type 2 diabetes for all ages were compiled. Forecast estimates were obtained using
the SPSS Time Series Modeler. In 2017, approximately 462 million individuals were aected by type 2 diabetes corresponding
to 6.28% of the world’s population (4.4% of those aged 15–49 years, 15% of those aged 50–69, and 22% of those aged 70+), or a
prevalence rate of 6059 cases per 100,000. Over 1 million deaths per year can be attributed to diabetes alone, making it the ninth
leading cause of mortality. e burden of diabetes mellitus is rising globally, and at a much faster rate in developed regions, such
as Western Europe. e gender distribution is equal, although the incidence peaks at around 55 years of age. Global diabetes
prevalence is projected to increase to 7079 individuals per 100,000 by 2030. e burden of type 2 diabetes continues to rise
globally and in all regions of the world. ere are concerning trends of rising prevalence in lower-income countries. Urgent
public health and clinical preventive measures are warranted.
© 2019 Atlantis Press International B.V.
This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).
*Corresponding author. Email: jhashim@uaeu.ac.ae
In Press, Uncorrected Proof
2 M.AB. Khan et al. / Journal of Epidemiology and Global Health. In Press
We used the latest data refresh from GBD (the 2017 update). This
dataset includes annual figures from 1990 to 2017 for type 2 dia-
betes in all countries and regions. We selected four world regions
(Asia, Europe, America, and Africa) instead of other classification
schemes based on economic development. All data were directly
retrieved from GBD without any adjustments. Estimates were not
age adjusted for differences in underlying population age distribu-
tions. Thus, the rates for different countries represent the actual
burden on their respective health systems.
2.1. Statistical Data Analysis
Forecasting was conducted using IBM SPSS version 25 (IBM SPSS
Inc., 2019). The Time Series Modeler was used to develop a forecast
model using the Expert Modeler option without any events. None
of the observed values were marked as outliers.
3. RESULTS
Globally, an estimated 462 million individuals are affected by type 2
diabetes, corresponding to 6.28% of the world’s population (Table 1).
More than 1 million deaths were attributed to this condition in
2017 alone, ranking it as the ninth leading cause of mortality. This
is an alarming rise when compared with 1990, when type 2 diabetes
was ranked as the eighteenth leading cause of deaths. In terms of
human suffering (DALYs), diabetes ranks as the seventh leading
disease.
Tab le 1 | Disease burden of type 2 diabetes, 2017
Region Prevalence
(cases per 100,000)
Burden of suffering
(DALY per 100,000)
Global 6059 751
Europe 8529 842
Germany 9091 820
France 6843 564
Italy 9938 1083
Spain 8796 773
Netherlands 11,344 924
Switzerland 10,040 815
Sweden 10,448 877
Turkey 6483 889
Russia 6865 740
United Kingdom 8663 644
Asia 5961 729
China 6262 635
India 4770 663
Japan 6737 553
South Korea 8835 1044
Taiwan 10,012 1294
Saudi Arabia 7661 623
Iran 7000 851
Australia 5235 593
America 7060 1036
United States 8911 1046
Canada 7095 829
Brazil 4240 780
Africa 3916 537
South Africa 7360 1374
The prevalence of type 2 diabetes shows a distribution pattern that
matches socio-economic development (Figure 1). Developed
regions, such as Western Europe, show considerably higher
prevalence rates that continue to rise despite public health mea-
sures (Figure 2). The rate of increase does not appear to be slow-
ing down.
Remarkably, certain regions, such as Pacific Ocean island nations,
are sustaining the highest prevalence of disease. These countries
include Fiji (20,277 per 100,000), Mauritius (18,545), American
Samoa (18,312), and Kiribati (17,432). Southeast Asian countries,
such as Indonesia, Malaysia, Thailand, and Vietnam, have moved
up the ranks in the last two decades. Owing to their large popula-
tion sizes, China (88.5 million individuals with type 2 diabetes),
India (65.9 million), and the US (28.9 million) retain the top spots
as the countries with the greatest total number of individuals with
this condition.
Males show a slightly higher prevalence than females (6219 com-
pared with 5898 cases per 100,000), although this difference is
within the margin of uncertainty. The age of onset of new diagnosis
is also somewhat earlier among males and shows expected patterns
of rising prevalence with increasing age, whereas the incidence
peaks at 55–59 years (Figure 3). There appears to be no major shift
in the age distribution from 1990 to 2017.
Even though it afflicts individuals later in life, type 2 diabetes ranks
seventh among the leading causes of disability and years of life lost.
It has jumped ranks from nineteenth position in 1990, indicating
a global transition in disease patterns toward noncommunicable
diseases.
Statistical forecasting using a model based on the 1990–2017 data
showed that global diabetes prevalence could increase to 7079 per
100,000 by 2030 and 7862 by 2040. This estimate for 2040 is flanked
by an upper confidence limit of 9904 and a lower limit of 5821
per 100,000.
4. DISCUSSION
This study reports on the current trends in the global burden of
diabetes with emphasis on the burden of human suffering. The
high prevalence of type 2 diabetes worldwide continues to rise, and
there are no signs of it stabilizing. A concerning finding is the rap-
idly rising burden in lower-income countries. These findings have
implications for health policy planners, physicians, healthcare pro-
fessionals, and the public.
The burden of suffering due to diabetes, as measured by DALYs, is
increasing despite significant investment in clinical care and phar-
maceutical research. This increase is in excess of population growth
and aging. Notably, Western Europe has a rate of increase greater
than that of global and Asian averages. Even with the high levels
of clinical and public health expenditure, this region is losing the
battle against diabetes. One explanation might be non-modifiable
risk factors, such as age and family history [12]. However, factors
like a highly processed, calorie-dense western diet and a seden-
tary lifestyle may also be contributing. Developed countries like
Italy and the US endure the highest burdens of human suffering
(DALYs) due to diabetes. Advanced economies in Asia, such as South
Korea and Taiwan, are joining the ranks of these countries, based on
M.AB. Khan et al. / Journal of Epidemiology and Global Health. In Press 3
Figure 1 | Global distribution of diabetes mellitus type 2 prevalence. Note: Colors indicate prevalence rates per 100,000 population in 2017.
Figure 2 | Trends in the prevalence of type 2 diabetes. Note: Forecast
estimates using SPSS Time Series Modeler (Ljung Box Q, p = 0.16). Dotted
lines indicate upper and lower confidence limits.
GBD data. Thus, our findings support the correlation between
diabetes and economic development [13]. We speculate that our
current approach to diabetes management, which focuses on
expensive oral medications and insulin, is not working. Lowering
blood glucose levels is perhaps not sufficient by itself nor effective
in reducing all-cause mortality among these patients.
Prevention of new cases of diabetes appears to be not working
either, based on our findings from global data. Although research
is ongoing to reduce the progression from metabolic syndrome
and prediabetes to diabetes, most interventions being tried seem to
be unsuccessful in affecting the incidence. According to our data,
there is no evidence of a decrease in incidence. Alarmingly high
incidence rates recorded in island nations in the Pacific region are
an indication of the interaction between genetic predisposition and
the effect of rapid nutritional change on these indigenous popula-
tions. Meanwhile, the sheer number of individuals with diabetes
is testing health systems in China, India, and the US to the limit.
Rapid urbanization and its effects on diet and lifestyle has been
implicated [14]. These findings have direct implications for health
systems planning and resource allocation. Clearly, hospital- based
management and subspecialist care are not sustainable strate-
gies. Resource allocation in healthcare budgets for prevention of
diabetes needs to be comparable to expenditures on treatment.
Strengthening of primary care and community restructuring for
active lifestyles and healthy nutrition are perhaps more likely to be
cost effective [15]. Sadly, the rising tide of type 2 diabetes is out-
pacing preventive efforts by a wide margin [16].
The rising incidence of type 2 diabetes at earlier ages warrants
closer attention. Previous clinic-based studies have reported a
high number of young adults being diagnosed with type 2 dia-
betes, most of whom are obese [17]. There appears to be an age
gradient with early-onset type 2 diabetes patients (those younger
than 45) showing more obesity, dyslipidemia, smoking, seden-
tary lifestyles, and low-grade inflammation [18]. In our study,
although the incidence of diabetes in young adults has increased
over the past decades, the rise is across all ages. Thus, there
appears to be no clear indication that the age of onset of type 2
diabetes has shifted to younger age groups. In any case, rising life
expectancy in many countries will lead to a substantially greater
burden of diabetes in the elderly.
The main limitations of our study include reliance on secondary
data, which in turn is affected by the accuracy of measurement,
changes in case definition, and heterogeneity in study designs. Yet
as GBD evolves and matures, its estimation techniques have become
more accurate and reliable. These statistical estimates provide a
more complete and continuous picture of disease epidemiology than
4 M.AB. Khan et al. / Journal of Epidemiology and Global Health. In Press
relying on raw data from isolated studies [11]. Ultimately, the goal
is to guide decision making in clinical care and public health policy.
5. CONCLUSION
Type 2 diabetes continues to increase in prevalence, incidence, and
as a leading cause of human suffering and deaths. Despite signifi-
cant investments in clinical care, research, and public health inter-
ventions, there appears to be no sign of reduction in the rate of
increase. Certain regions of the world, such as Western Europe and
island states in the Pacific, are experiencing a disproportionately
high burden. This epidemic will require an urgent and unwavering
commitment to aggressive solutions at national levels with public
policies, public health funding, and economic incentives for local
communities to start diabetes prevention programs. Healthy eating
options need to be subsidized, and unhealthy foods need to be
taxed or otherwise disincentivized. Healthcare organizations and
individual healthcare providers from multiple disciplines (doctors,
nurses, pharmacists, dieticians, and diabetes educators) must be
given time and resources to collaborate as they educate and care
for individual and groups of patients. Unless urgent measures are
instituted to reduce unhealthy eating, sedentary lifestyles, rapid
urbanization, and other factors related to economic development,
the burden of diabetes is expected to continue rising.
CONFLICTS OF INTEREST
The authors declare they have no conflicts of interest.
AUTHOR CONTRIBUTIONS
M.K. contributed to writing the manuscript including the literature
review. M.J.H. designed the study/basic concept, wrote sections of
the manuscript, analyzed the data, and provided overall supervi-
sion of the study. J.K. wrote parts of the manuscripts, proofread,
and provided insights into the interpretation. R.D.G. revised the
manuscript and provided additional interpretation of results. H.M.
compiled data and wrote the table. J.A.K. revised and proofread the
manuscript and provided additional interpretation of results.
FUNDING
This study did not receive any external grants from government,
private or commercial sources.
ACKNOWLEDGMENT
We would like to thank the Institute of Health Metrics, Seattle for com-
piling global epidemiological statistics and allowing access to data.
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