Global burden of Diabetes:

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Global burden of Diabetes Prevalence and
projections
Peter H. Bennett, M.B., F.R.C.P.
National Institute of Diabetes and Digestive and
Kidney Diseases,
Phoenix, Arizona, U.S.A.
Belllagio, March 16th 2004
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Outline

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

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Global Projections for the Diabetes Epidemic
2000-2030 (in millions)
EU 17.8 25.1 41
NA 19.7 33.9 72
China 20.8 42.3 204
MEC 20.1 52.8 263
LAC 13.3 33.0 248
SSA 7.1 18.6 261
India 31.7 79.4 251
ANZ 1.2 2.0 65
World 2000 171 million 2030 366
million Increase 213
Wild, S et al. Global prevalence of
diabetes Estimates for 2000 and projections for
2030 Diabetes Care 2004 In press
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Estimated Number of People with Diabetes in 2000
and 2030 (and change)
176
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-13
Wild, S et al. Global prevalence of diabetes
Estimates for 2000 and projections for 2030
Diabetes Care 2004. In press
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Estimated Number of People with Diabetes in 2000
and 2030 (and change)
247
308
189
Wild, S et al. Global prevalence of diabetes
Estimates for 2000 and projections for 2030
Diabetes Care 2004 In press
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Estimated Number of People with Diabetes in 2000
and 2030
212
242
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Wild, S et al. Global prevalence of diabetes
Estimates for 2000 and projections for 2030
Diabetes Care 2004 In press
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Are these projections realistic? Based
on 1990s estimates of diabetes
prevalence Demographic projections Assume
constant (current) age-sex specific prevalence
of diabetes
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Changing Prevalence of Type 2 Diabetes
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No of persons with Physician-diagnosed Diabetes
in USA by year
Data from the US National Health Interview
Survey http//www.cdc.gov/diabetes/statistics/pre
v/national/fig1.htm
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Diabetes in the United States1958-1993
Prevalence ()
gt 65 years
55-65 years
45-54 years
lt 45 years
Data from the US National Health Interview Survey
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Diabetes in the United States1980-2000
Prevalence ()
65-74years
75years
45-64years
lt 45 years
Data from the US National Health Interview
Survey http//www.cdc.gov/diabetes/statistics/pre
v/national/fig3.htm
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Why were former projections inaccurate?

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

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Importance of IGT and IFG
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Impaired Glucose Homeostasis
IGT
'Impaired Glucose Tolerance (IGT) 2h post-load
Plasma Glucose of 140-199mg/dl 7.8-11.0mmol/l
and FPG lt126mg/dl lt7.0mmol/l
IFG

• 'Impaired Fasting Glucose' (IFG)
• FPG of 100-125mg/dl 5.6 -lt7.0mmol/l

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Incidence of Diabetes in people with Impaired
Glucose Homeostasis
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Prevalence and Incidence of Diabetes () in
Impaired Glucose Homeostasis
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Projections of Numbers with Diabetes among
persons aged 40-74years in USA (Millions)
Based on diabetes incidence (5 / year) in the
20 of persons with impaired glucose homeostasis
300,000 diabetes deaths / year Net increase
c.700,000 cases of diabetes / year
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Proportion of new cases of Diabetes () in
persons with NGT and Impaired Glucose Homeostasis
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Projections of Numbers with Diabetes among
persons aged 40-74years in USA (Millions)
Based on diabetes incidence (5 / year) in the
20 of persons with impaired glucose homeostasis
40 of new cases from persons with NGT 450,000
diabetes deaths / year Net increase c.830,000
cases of diabetes / year
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Mortality attributable to diabetes
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Number of Deaths with Diabetes as Underlying
Cause of Death,United States, 1980-1996.
CDC, Diabetes surveillance, 1999
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Excess Deaths attributable to Diabetes

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

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Global Projections of Excess Deaths
attributable to Diabetes (in 000s) and percent
of all deaths in year 2000
EUR 609.0 6.4
AMRA 251.1 9.75
EMR 125.3 7.2
SEAR 1154.1 6.9
AMRD 32.2 6.1
WPR 469.3 4.1
AFR 319.2 2.6
AMRB 194.0 7.6
World In 2000 3.164 million (5.4 of all
deaths)
Roglic et al. Burden of mortality attributable
to diabetes Estimates for the year 2000. In
preparation
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Consequences of the Epidemic
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Consequences of Epidemic

• Increase in number with diabetes

• Disproportionate increase in duration-related
  complications

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Effect of Epidemic of Diabetes on
Duration-related complications
Cumulative No. of DM cases
with DMgt15y duration
Prevalence of complications () among those with
DM
50
450
40
300
30
No. of Cases
Percent with complications
20
150
10
0
0
0
5
10
15
20
25
30
35
40
45
50
Time (years)
16 new cases/yr. Death occurs after 30y DM
Complication incidence 50 after 15y DM
After 30 years No. of new cases equals no. of
deaths.
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Incidence of Type 2 Diabetes in Pima Indians
in two time periods
Time Period
1965-75
1975-85
60 increase
0
10
20
30
40
50
Incidence per 1000 person-years
Age-sex adjusted rates
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Age-standardized mortality from Ischemic Heart
Disease in diabetic and non-diabetic
Pima Indians aged 35 years, (30 year follow-up)
6
5
4
Mortality
/1000 person-years
3
2
1
0
1965-74
1975-84
1985-94
1965-74
1975-84
1985-94
Non-diabetic
Diabetic
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Renal disease
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Frequency of Renal Failure among Pima Indians
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Deaths
20
Dialysis
15
Cases
10
5
0
1965
1970
1975
1980
1985
1990
1994
Year
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Incidence of Renal Failure
12
8
Cases per 1000/year
4
0
1965-74
1975-84
1985-94
Time Period
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Number of persons beginning treatment for ESRD
attributable to diabetes in USA by year
http//www.cdc.gov/diabetes/statistics/esrd/Fig1De
tl.htm
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DIABETES IN END-STAGE RENAL FAILURE AUSTRALIA
1980 - 2000
Number of Diabetics
Number of New Patients

Year of Entry
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Crude and Age-adjusted incidence of ESRD related
to diabetes in the United States1984-2001
Incidence/100,000 Diabetic persons
Crude rate
Age-adjusted rate
Data from the US Renal Data System http//www.cdc
.gov/diabetes/statistics/esrd/fig7.htm
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Projections for number of patients with diabetes
initiating ESRD treatment in USA
Assuming current incidence rates for initiating
ESRD treatment remain constant
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Summary

• Based on demographic changes alone The numbers
  of persons with diabetes in the world will more
  than double in the next 30 years
• In developed countries they will increase by
  30-70 (mostly in older persons)
• In developing countries they will increase
  by c. 250 (mostly in 45-64y age group)
• These projections do not take into account any
  increase that is attributable to future increases
  in obesity

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Summary

• c.3.2 million (excess) deaths were attributable
  to diabetes in year 2000.
• In the USA this is 9 of all deaths
• e.g. In USA c.200,000 excess deaths vs. 14,500
  for AIDs
• The numbers of deaths attributable to diabetes in
  future years will increase especially in
  developing countries

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Summary

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

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Thank you
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Age-adjusted incidence of ESRD related to
diabetes in the United States1984-2001
Incidence/100,000 Diabetic persons
Amer. Indian male
Amer. Indian female
Black male
Black female
Hispanic male
Hispanic female
White male
White female
Data from the US Renal Data System http//www.cdc
.gov/diabetes/statistics/esrd/fig5.htm
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Are there better ways to predict future trends?

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