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DIABETES ATLAS Second edition Second edition The mission of the International Diabetes Federation is to

DIABETES

ATLAS

DIABETES ATLAS Second edition Second edition The mission of the International Diabetes Federation is to work

Second edition

Second edition

The mission of the International Diabetes Federation is to work with our member associations to enhance the lives of people with diabetes.

Diabetes Atlas committee Bjørnar Allgot (co-chair) Delice Gan (co-chair) Hilary King Pierre Lefèbvre Jean-Claude Mbanya Martin Silink Linda Siminerio Rhys Williams Paul Zimmet

Editor and project manager: Delice Gan Project coordinator: Catherine Regniers

Diabetes Atlas, second edition, and other IDF publications are available from:

International Diabetes Federation Executive Office 19 Avenue Emile de Mot B-1000 Brussels Belgium Tel +32-2-5385511 Fax +32-2-5385114 idf@idf.org www.idf.org

Electronic version of Diabetes Atlas:

www.idf.org/e-atlas

© International Diabetes Federation, 2003

No part of this publication may be reproduced or transmitted in any form or by any means without the prior written permission of the International Diabetes Federation.

First published, 2000 Second edition, 2003

Permission has been obtained to use material from the following organizations:

(1) United Nations (2) World Bank (3) World Health Organization

Copyright permission has been obtained from Martin Dunitz to adapt ‘The St Vincent Declaration: experience gained for better outcome of cardiovascular, eye and kidney complications in the future’ in Chapter 8.

ISBN 2-930229-27-6

Design and layout: perplex | Aalst, Belgium Cover: De Blauwe Peer, Gent, Belgium Printer: Imprimerie L Vanmelle SA, Gent/Mariakerke, Belgium

Diabetes Atlas Second Edition

Acknowledgements

The International Diabetes Federation (IDF)

would like to express its thanks to the World Diabetes Foundation for its generous support

in making the Diabetes Atlas, second edition,

possible.

IDF would also like to thank Novo Nordisk A/S for its generous support.

IDF would like to thank Novartis Pharma AG for its generous support in making possible the report on impaired glucose tolerance in Chapter 1.

IDF would also like to thank Johnson and Johnson for its generous support in making possible the report on type 2 diabetes in the young in Chapter 2.

A publication such as this would not have

been possible without the commitment and contribution of many people around the world. IDF would like to thank and gratefully acknowledges the contributions of the following authors:

Diabetes Atlas Second Edition

Chapter 1

1.1 Sicree, J Shaw, P Zimmet

1.2 Tapp, J Shaw, P Zimmet

R

R

Chapter 2

2.1 Soltèsz, C Patterson, G Dahlquist

2.2 Singh, J Shaw, P Zimmet

G

R

Chapter 3

Introduction P Zimmet

3.1

3.2 CS Cockram, K Hynes

N Rigby, RJ Leach, WPT James

Chapter 4

R Williams

Chapter 5 J-C Mbanya, L Fezeu

Chapter 6

6.1 J Piette

6.2

6.3

L Siminerio

T Songer

Chapter 7

7.1 Ramaiya, R Sicree, C Patterson

7.2 Arab, AS Shera, R Sicree, C Patterson

K

M

7.3

M Massi-Benedetti, L Etu-Seppälä,

R

Sicree, C Patterson

7.4

Y

Vovides, B Wentzell, R Sicree,

C

Patterson

7.5

A

Pérez-Comas, R Sicree, C Patterson

7.6

H

Mahtab, MA Sayeed, R Sicree,

C

Patterson

7.7

G

Bunyan, R Sicree, C Patterson

Chapter 8

8.1 M Massi-Benedetti, J Akwe Akwi,

P

Ferolla, MO Federici

8.2 Vovides, B Wentzell

Y

8.3 CS Cockram

Chapter 9

C Regniers, D Gan, B Allgot

Chapter 10

P Lefèbvre

Profiles

J Colquhoun, D Lukoseviciene, N Ojha,

G Rafique, M Silink

Appendix 2

A Hornsby

Special thanks to S Murray for coordinating the work at the International Diabetes Institute.

IDF

also gratefully acknowledges the help of

the

following people in making this publication

possible:

N Abdella, K Ajlouni, C Alexander, AS Alkuwari,

MC Almaraz, A Al-Nuaim, FI Al-Zurba, T Aspray,

V

Augustiniene, B Balkau, TK Banerjee,

A

Barceló, T Beljic, P Bennett, O Bernard,

C

Berne, PR Betts, G Booth, E Briganti,

C

Castell, A Chan, S-Y Chen, B Choi, P Chou,

LM Chuang, SS Chung, R Colagiuri, S Colagiuri,

M

Comaschi, D Dabelea, M Dagmar, R Dankner,

H

Dean, D De Bacquer, B Detournay,

CL de Visser, M Dragan, R Duarte, T Dwyer,

R

Dyck, M Elbagir, M Eliasson, M Engelau,

J

Eriksson, E Eskelinen, J Feinglass, E Ford,

MC Foss, M M-T Fuh, MM Garcia de Belaunde,

C

Giorda, RT Go, A Goday, R Gupta, CH Han,

N

Hancu, M Harris, J Harvey, L de Hassine,

GE Holder-Nelson, G Hu, C Invitti, ED Janus,

J Jervell, F Johansen, AJ Karter, S Kiauka,

T

Kitagawa, D Koev, M Korecova, CF Kwok,

L

Lavery, A Lerario, N Levitt, S Likitmaskul,

B

McBride, M McGill, SM Makled, K Midthjell,

J

Mohith, Z Naeemullah, P Nilsson,

W Nitiyanant, F Nobels, H-H Parving,

J

Perusicova, G Piatt, E Placzkiewicz,

D

Ragoobirsingh, A Ramachandran,

U

Ramdanee, H Rashidi, W Rathmann,

I

Raz, G Rennert, G Roglic, A Rotchford,

E

Rudinskiene, M Sadikot, I Satman,

MA Sayeed, A Schranz, D Simon, A Sinha,

J Skrha, E Spichler, E Stern, S Tandhanand,

W

Thefeld, R Toomath, J Tuomilehto, G Uwaifo,

K

Van Acker, D Webb, S Wild, P Wilson, JP Yeo

IDF gratefully acknowledges the support and

help given by its member associations, task forces and consultative sections.

Special thanks to L Al Obaidi, S Ash,

V

Campanella de Lemes, L Cann, E Ng, N Ohja,

P

Onraed, L Rabemananjara and Y Vovides for

their invaluable contribution in the regions.

Diabetes Atlas Second Edition

Contents

Contents

Foreword

7

Introduction

9

Executive Summary

11

1. The Global Burden of Diabetes

15

1.1 Diabetes and Impaired Glucose Tolerance: Prevalence and Projections

17

1.2 Complications of Diabetes

72

2. Diabetes in the Young: a Global Perspective

113

2.1 Global Trends in Childhood Type 1 Diabetes

114

2.2 Type 2 Diabetes in the Young

135

3. The Widening Circle

157

3.1 Obesity

159

3.2 Cardiovascular Disease and Diabetes: Double Jeopardy

167

4. The Economic Impact of Diabetes

175

5. Access to Insulin and Diabetes Supplies

193

6. Diabetes Education

207

6.1 Effectiveness of Self-management Education

208

6.2 Educational Practices: a Global View

216

6.3 Cost-Effectiveness of Diabetes Education

221

7. Meeting the Challenges

225

7.1 Africa

226

7.2 Eastern Mediterranean and Middle East

231

7.3 Europe

237

7.4 North America

244

7.5 South and Central America

250

7.6 South-East Asia

255

7.7 Western Pacific

260

8. Reducing the Burden

267

8.1 The St Vincent Declaration

268

8.2 Declaration of the Americas on Diabetes

276

8.3 Western Pacific Declaration on Diabetes

278

8.4 Declaration of the Eastern Mediterranean and Middle East Region

280

Diabetes Atlas Second Edition

5

Contents

9. Diabetes Associations: from Patients to Partners

283

10. Prevention and Strategic Action

301

Appendices Appendix 1 Methodology

305

Appendix 2 Socio-economic Indicators

316

Appendix 3 IDF Member Associations Address List

329

Glossary

345

Acronyms

349

World Diabetes Foundation

352

Index

354

Index of Countries

357

6

Diabetes Atlas Second Edition

Foreword

Foreword

S everal years ago it was proposed by my predecessors that it would be helpful to bring together relevant data about diabetes and diabetes associations around the world. This culminated in the publication of the first edition of the Diabetes

Atlas at the 17th IDF Congress in Mexico. It was beautifully produced and instantly popular. It went to Ministers of Health in IDF member countries, WHO offices, diabetes associations and many others.

The Diabetes Atlas has proved to be an invaluable resource. It was decided that it should go on the IDF website to be updated regularly – but should reappear in hard copy for the 18th IDF Congress in Paris.

Many new sections have been included since the first edition. The epidemiology section has been updated, stressing again the rapid rise in prevalence, as has that on economics. A new section on impaired glucose tolerance (IGT) is included, giving an indication of the further rise in diabetes that is to come. This is the first time worldwide data on IGT have been collected together.

The prevalence of complications is now included – important for planners, health professionals and people with diabetes alike. It is also the first time that such information has been compiled in one publication. It is useful in showing not only the prevalence data but also the gaps in our knowledge in this area.

Another new chapter discusses the relationship between obesity and diabetes as well as the effect of diabetes on cardiovascular disease. The vital topic of access to insulin is also covered – an area of critical importance in many IDF member countries.

Diabetes education has an expanded section, emphasizing its role in the successful management of the disease. There are then very useful chapters on IDF regional activities and diabetes associations. Primary prevention and socio-economic indicators complete the text.

The evidence that we have shows beyond doubt that diabetes is on an epidemic increase and that the toll from this disease will be huge in economic, social and individual terms if action is not taken now.

There is also evidence that prevention of type 2 diabetes is possible. What remains now is for all of us – governments, health organizations, diabetes associations – to take the next step to use the knowledge that we have to curb the rise of diabetes and its complications.

Diabetes Atlas Second Edition

7

Foreword

I personally feel that the second edition is a major step forward and will prove invaluable to governments and diabetes associations as well as individuals. Production of the Diabetes Atlas is a costly undertaking. We should acknowledge the time given by many colleagues in IDF and also our various sponsors, particularly the new charity the World Diabetes Foundation, without whom the second edition of the Diabetes Atlas would not have been possible.

of the Diabetes Atlas would not have been possible. 8 Sir George Alberti IDF President, 2000

8

Sir George Alberti IDF President, 2000 - 2003

Diabetes Atlas Second Edition

Introduction

Introduction

S ince the publication of the first edition of the Diabetes Atlas in 2000, a number of things have changed. Our appreciation of the extent of the burden of diabetes in the world has been refined, our knowledge of the risks to health as a whole

and to diabetes in particular has increased and our conviction that type 2 diabetes is potentially preventable has been confirmed with solid evidence about the steps we need to make that potential a reality.

WHO and IDF continue their partnership in the fight to improve the wellbeing of people with diabetes and to include in this partnership other organizations with an important part to play in this endeavour.

In terms of the worldwide burden, the WHO Global Burden of Disease estimated that around 177 million people in the world had diabetes in the year 2000. This second edition of the Diabetes Atlas estimates 194 million in the year 2003, and around

two-thirds of these people live in developing countries. The projections for the future provide no comfort at all. If current trends prevail, the above figure may well more than double by the year 2025. We also know that already as much as a quarter or even

a third of acute sector health expenditures in some communities has to be devoted to diabetes and its long-term complications.

The World Health Report 2002 quantifies the impact of several major risk factors on current mortality and overall burden of disease. It brings into focus the importance of overweight and low levels of physical activity in increasing the risks of developing type 2 diabetes as well as a number of other conditions of enormous public health importance. In that Report it is estimated that 58% of the global burden of diabetes, 21% of ischaemic heart disease and 8-42% of certain cancers are attributable to BMI (body mass index) above 21 kg/m 2 .

Physical inactivity is related to diabetes risk both directly as a result of its effect on insulin sensitivity but also indirectly via obesity and the World Health Report estimates that 11-24% of people, depending on the region in which they live, are currently physically inactive.

The Report also quantifies the potential for future reduction of the burden of disease.

A relatively modest 25% reduction of current and future obesity and physical inactivity

could avoid at least one-half and one-third of the burden attributed to these respective risk factors in the year 2020. Several risk factors can be addressed in synergy with policies that promote a healthy diet and encourage physical activity.

Diabetes Atlas Second Edition

9

Introduction

As long as diabetes exists, the need to manage it effectively will always be here. However, by slowing the incidence of new cases, through reducing levels of risk in the population as a whole and in those at high risk, the management of existing diabetes can surely only be improved.

Recently published randomized controlled trials provide clear proof that behavioural changes which lead to weight reduction and/or increased physical activity or the use of some widely available drugs can delay, or at least postpone, the transition from impaired glucose tolerance to type 2 diabetes. Such evidence provides hope that the current inexorable rise in the numbers of people with diabetes may, one day, be slowed or even reversed.

While we work towards this promising future, IDF’s Diabetes Atlas provides one way of tracking this epidemic and, more importantly, galvanizing IDF member associations, governments, industry and other committed organizations to take action. Action is needed now to ensure that people who already have diabetes can lead fuller and more productive lives and that there is some hope of reducing the number of people at risk of developing diabetes and its life-threatening complications.

Derek Yach Executive Director Noncommunicable Diseases and Mental Health Cluster World Health Organization Geneva

10

Diabetes Atlas Second Edition

Executive Summary

Executive Summary

M any new topics have been included in the second edition of the Diabetes

Atlas to reflect the growing need to tackle the diabetes pandemic on all fronts. These topics emphasize the importance of looking not just at the epidemiology of diabetes but also at its risk factors, the management of the disease to prevent or delay complications and primary prevention of diabetes in high risk groups. This edition of the Atlas also shows the immense costs of diabetes, in financial and human terms, to both the individual and society as a whole.

The Diabetes Atlas therefore aims to communicate the global impact of diabetes and to underline the need for intervention now. In spite of the number of studies describing the epidemiology of diabetes, many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries.

The second edition of the Diabetes Atlas extends coverage to 212 countries and territories around the world. It provides current estimates of the prevalence of diabetes and impaired glucose tolerance (IGT) as well as forecasts the estimates for 2025, forewarning of the enormous burden to come. The future predictions of cost are as alarming as the future predictions of prevalence. They suggest that unless effective prevention measures are introduced, expenditure devoted to diabetes and its complications will

Diabetes Atlas Second Edition

dominate the health economies of many countries by the end of the first quarter of the current century.

The decision to include data on IGT was based on two major factors associated with its presence: a high sensitivity for future diabetes incidence and its association with future cardiovascular disease occurrence. IGT is now recognized as being a stage in the transition from normality to diabetes. Thus, individuals with IGT are at high risk of progressing to type 2 diabetes, although such progression is not inevitable. Some 70% of these individuals, however, are expected to develop the disease.

The reports in this edition of the Diabetes Atlas reconfirm that diabetes is now one of the most common non-communicable diseases globally. It is the fourth or fifth leading cause of death in most developed countries and there is substantial evidence that it is epidemic in many developing and newly industrialized nations.

It is estimated that currently some 194 million people worldwide, or 5.1% in the adult population, have diabetes and that this will jump to 333 million, or 6.3%, by 2025.

This situation is exacerbated by the estimated number of people with IGT – currently at 314 million, or 8.2% in the adult population, and expected to increase to 472 million, or 9.0%, by 2025.

It is estimated that currently some

194 million people

worldwide, or 5.1% in the adult population, have diabetes and

that this will jump to

333 million, or 6.3%,

by 2025.

11

12

Executive Summary

Type 2 diabetes constitutes about 85% to 95% of all diabetes in developed countries, and accounts for an even higher percentage in developing countries. It is now a serious global health problem, which, for most countries, has evolved in association with rapid cultural and social changes, ageing populations, increasing urbanization, dietary changes, reduced physical activity, and other unhealthy lifestyle and behavioural patterns. The change in lifestyle is a worldwide phenomenon, occurring in both developed and emerging nations, where it is most prevalent in urban areas.

The risk of developing type 2 diabetes is clearly linked to an increasing prevalence of obesity. Reports from the World Health Organization (WHO) and the International Obesity Task Force (IOTF) indicate that approximately 58% of diabetes mellitus globally can be attributed to body mass index above 21 kg/m 2 . However, there are indications that in western countries, around 90% of type 2 diabetes cases are attributable to weight gain.

Whereas previously type 2 diabetes affected only individuals in the older age groups, there are now ever increasing reports of type 2 diabetes in children worldwide, with some as young as eight years of age being affected. There is now growing recognition that type 2 diabetes in children is becoming a global public health issue with potentially serious health outcomes.

The purpose of the report on type 2 diabetes in the young is to call attention to this emergent problem by bringing together for the first time, the available epidemiological data on type 2 diabetes incidence and prevalence in the young from around the world. By the inclusion of such data it is hoped to highlight deficiencies in the knowledge of the disease and also to promote strategies to deal with it.

The studies on type 2 diabetes in children have important implications in that they highlight the risk of complications occurring at a relatively young age, which will place a significant burden on health budgets as well as society as a whole. Early detection and intervention is therefore essential to reduce the risk of future complications.

Governments will be forced to deal with the problem of type 2 diabetes in children in time to come. As such, it would be better to address the problem as a public health issue under the heading of primary care and prevention, rather than dealing with the consequences of an entrenched condition and its complications in a young population.

Although type 1 diabetes usually accounts for only a minority of the total burden of diabetes in a population it is the predominant form of the disease in younger age groups in most developed countries. The incidence of childhood onset diabetes is increasing in many countries in the world with an estimated overall annual increase of around 3%.

It is estimated that on an annual basis

some 65,000 children worldwide under the age of 15 years develop type 1 diabetes. Of the estimated total of about 400,000 prevalent cases of type 1 diabetes in childhood, more than a quarter come from the South-East Asian Region, and more than a fifth from the European Region where reliable, up- to-date estimates of incidence were available for the majority of countries.

The continued mapping of global trends

in incidence of type 1 diabetes in all age groups is important, and in conjunction with other scientific research may provide

a logical basis for intervention studies

and future primary prevention strategies which must be the ultimate goal.

Diabetes Atlas Second Edition

The new section on diabetic complications, which brings together available studies on the prevalence of the major complications, is a reminder of the urgent need for effective diabetes care. The main relevance of diabetes complications in a public health perspective is the relationship to human suffering and disability, and the huge socio-economic costs through premature morbidity and mortality. Indeed, diabetic complications are those aspects of the disease that are most feared such as blindness and amputation, and account for much of the social and financial burden of diabetes.

In virtually every developed society, diabetes is ranked among the leading causes of blindness, renal failure and lower limb amputation. Through its effects on cardiovascular disease (50-80% of people with diabetes die of cardiovascular disease), it is also now one of the leading causes of death.

Cardiovascular death rates on the whole are either high or appear to be climbing in countries where diabetes is prevalent. The outlook for cardiovascular disease (CVD) is alarming when one considers the number of people with diabetes worldwide and that this is set to more than double by 2025.

The recent decline in cardiovascular disease in the USA, Australasia and western Europe may be compromised significantly by this upsurge in diabetes. In other parts of the world where CVD have been proliferating in recent years, the additional impact of diabetes threatens to have devastating consequences.

The heavy financial burden is shown clearly in the chapter on the economic impact of diabetes in which estimates are made on the direct healthcare expenditure in countries covered by the Diabetes Atlas. The annual direct

Diabetes Atlas Second Edition

Executive Summary

healthcare costs of diabetes worldwide, for people in the 20-79 age group,

is currently estimated to be at least

153 billion international dollars and may

be as much as 286 billion.

If predictions of diabetes prevalence for

2025 are fulfilled, total direct healthcare expenditure on diabetes worldwide for that year will be between 213 billion and

396 billion international dollars. In some

countries this will be as much as 40% of their total healthcare budget.

Even while sophisticated medical technology and new medications are being developed in one part of the world, one cannot ignore the fact that there are people dying from the simple lack of access to insulin in another part.

Continuous accessibility to insulin is still

a major problem in many developing

countries especially those in sub-Saharan Africa such that there are reports of premature deaths due to the chronic lack of access to insulin in some of these countries.

At the same time, although the medical aspects of diabetes care such as eye exams and blood glucose monitoring have improved in recent years, outcomes for many people with diabetes remain poor. While many factors contribute to poor outcome, this apparent contradiction also reflects the central role that people with diabetes themselves play in determining their health status, and the challenges associated with supporting their efforts to manage their self-care.

The expanded section on diabetes education clearly shows that diabetes education is now considered an integral part of diabetes care. Diabetes self- management education assists people in coping with the mental and physical demands of their illness, given their unique economic, cultural and social circumstances.

If predictions of diabetes prevalence for 2025 are fulfilled, total direct healthcare expenditure on diabetes worldwide for that year will be between 213 billion and 396 billion international dollars. In some countries this will be as much as 40% of their total healthcare budget.

13

14

Executive Summary

Diabetes self-management education is therefore a multi-faceted process involving much more than helping people with diabetes monitor their blood glucose, or take their medication as prescribed. Diabetes education must be an ongoing process rather than a one- time event because a person’s health status and need for support changes over time. More importantly, self-management education is most likely to be successful when it is part of a comprehensive and coordinated approach to diabetes care.

Education for people with diabetes has therefore become one of the key activities of diabetes associations and regional organizations, as evidenced in the Atlas. In facing the challenges brought about by the diabetes epidemic, diabetes associations and regional organizations have galvanized into action. Declarations on diabetes, spelling out strategic actions, have been signed in five regions – Eastern Mediterranean and Middle East, Europe, North America together with South and Central America, and Western Pacific.

These declarations also reflect the significance of strategic alliances at all levels with organizations such as the World Health Organization (WHO). At the global level, IDF is collaborating with WHO to embark on a major course of action, the ‘Global awareness, advocacy and action in diabetes’ programme. This programme aims to raise awareness about diabetes and its complications amongst the public, health professionals and decision makers, with major emphasis on prevention particularly in low income countries.

By promoting diabetes prevention, IDF will also ensure that those millions who already have diabetes will not face the nightmare of a regression in the quality of care they deserve while, on the contrary, there is a great need in many parts of the world to improve it.

The ultimate goal of a publication such as the Diabetes Atlas would be to stimulate research and concrete action by governments and all those concerned with health and wellbeing to stem the rising tide of diabetes in order to bring about better lives for all.

Diabetes Atlas Second Edition

Chapter 1

The Global Burden of Diabetes

The Global Burden of Diabetes

Chapter 1

Burden of Diabetes The Global Burden of Diabetes Chapter 1 1.1 Diabetes and Impaired Glucose Tolerance:

1.1 Diabetes and Impaired Glucose Tolerance:

Prevalence and Projections

1.2 Complications of Diabetes

Diabetes Atlas Second Edition

D iabetes is now one of the most common non-communicable diseases

globally. It is the fourth or fifth leading cause of death in most developed countries and there is substantial evidence that it is epidemic in many developing and newly industrialized nations. Complications from diabetes, such as coronary artery and peripheral vascular disease, stroke, diabetic neuropathy, amputations, renal failure and blindness are resulting in increasing disability, reduced life expectancy and enormous health costs for virtually every society. Diabetes is certain to be one of the most challenging health problems in the 21st century.

The number of studies describing the epidemiology of diabetes over the last 20 years has been extraordinary, but many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries.

In addition to diabetes, the condition of impaired glucose tolerance (IGT) also constitutes a major public health problem, both because of its association with diabetes incidence and its own association with an increased risk of the development of cardiovascular disease.

This chapter provides estimates of the prevalence of diabetes mellitus and IGT for 212 countries and territories for the years 2003 and 2025, so that some

15

16

The Global Burden of Diabetes

concept of the likely future burden should be apparent. In adding to the scope of the first edition of the Diabetes Atlas, data are also provided on the prevalence of many of the complications of diabetes. The data on diabetes, IGT and diabetes complications were compiled at the International Diabetes Institute, Melbourne, Australia.

The data presented here should be cautiously interpreted as general indicators of diabetes frequency, and the estimates will need to be revised as new and better epidemiological information becomes available. When reporting data in this form, various assumptions need to be made that give rise to a number of limitations. Caution should be used when interpreting this report, and the data limitations will be discussed further throughout the text.

Comparisons of country, regional, and even global rates from one report to the next can be misleading and should be performed with extreme caution. Large changes in the prevalence or numbers of people with diabetes from one edition of the Diabetes Atlas to another are usually due to the use of a more recent study rather than a genuine change in the profile of diabetes within that country. Thus, the inclusion of recent, and more reliable research brings us closer to the actual rates of diabetes, but also brings with it dangers in comparing global reports and estimates over time. These limitations need always to be considered, and the reader must realize that the key purpose of a report such as this is to stimulate action in the form of preventive and management programmes, as well as further research.

Chapter 1

Diabetes Atlas Second Edition

Chapter 1

The Global Burden of Diabetes

1.1 Diabetes and Impaired Glucose Tolerance:

Prevalence and Projections

Introduction

At a glance

Diabetes mellitus and lesser forms of glucose intolerance, particularly impaired glucose tolerance, can now be found in almost every population in the world and epidemiological evidence suggests that, without effective prevention and control programmes, diabetes will likely continue to increase globally (1).

 

All diabetes and IGT

2003

2025

Total world population (billions)

6.3

8.0

Adult population (billions) (20-79 years)

3.8

5.3

Number of people with diabetes (millions) (20-79 years)

194

333

Major categories of glucose intolerance

Diabetes is recognized as a group of heterogeneous disorders with the common elements of hyperglycaemia and glucose intolerance due to insulin deficiency, impaired effectiveness of insulin action, or both (2).

World diabetes prevalence (%) (20-79 years)

5.1

6.3

Number of people with IGT (millions) (20-79 years)

314

472

IGT prevalence (%) (20-79 years)

8.2

9.0

 
 

Diabetes mellitus is classified on the basis of aetiology and clinical

presentation of the disorder into four types:

• type 1 diabetes

• type 2 diabetes

• gestational diabetes

• other specific types

Type 1 diabetes Type 1 diabetes results from cellular- mediated autoimmune destruction of pancreatic islet beta cells causing the loss of insulin production (3). It ranks as the most common chronic childhood disease in developed nations (4), but occurs at all ages (5) and the clinical presentation can vary with age (6, 7).

Type 2 diabetes Type 2 diabetes is characterized by insulin resistance and relative insulin deficiency, either of which may be present at the time that diabetes becomes clinically manifest (8, 9). The specific reasons for the development of these abnormalities are not yet known.

Diabetes Atlas Second Edition

The diagnosis of type 2 diabetes usually occurs after the age of 40 years although the age of onset is often a decade earlier in populations with a high diabetes prevalence (10). Type 2 diabetes can remain asymptomatic for many years and the diagnosis is often made from associated complications or incidentally through an abnormal blood or urine glucose test.

Type 2 diabetes is often, but not always, associated with obesity, which itself can cause insulin resistance and lead to elevated blood sugar levels. It is strongly familial, but major susceptibility genes have not yet been identified. In contrast to type 1 diabetes, persons with type 2 diabetes are not dependent on exogenous insulin and are not ketosis- prone, but may require insulin for control of hyperglycaemia if this is not achieved with diet alone or with oral hypoglycaemic agents.

17

The Global Burden of Diabetes

Chapter 1

Figure 1.1 Differences in the prevalence of type 2 diabetes among selected ethnic groups, 2003 (adapted from King et al (11))

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18

Type 2 diabetes constitutes about 85 to 95% of all diabetes in developed countries (1), and accounts for an even higher percentage in developing countries. Type 2 diabetes is now a common and serious global health problem, which, for most countries, has evolved in association with rapid cultural and social changes, ageing populations, increasing urbanization, dietary changes, reduced physical activity and other unhealthy lifestyle and behavioural patterns (1).

Figure 1.1 highlights the large range of type 2 diabetes prevalence even within the same or similar ethnic groups, when living under different conditions. Clearly, many of the differences between these rates reflect underlying behavioural, environmental and social risk factors, such as diet, level of obesity and physical activity.

Within ethnic groups, high rates of type 2 diabetes are usually found in migrant

or urbanized populations that may have experienced a greater degree of lifestyle change. The lowest rates are generally found in rural communities where people are living lifestyles incorporating high levels of physical activity.

The incidence and prevalence of type 2 diabetes is also reported to be increasing in children. Studies from America and Japan have demonstrated an increasing incidence (12, 13). Other ethnic groups with high adult diabetes prevalence such as the Pima Indians (14) are also reporting increasing adolescent prevalences. The importance of this problem and the need for further research are emphasized by the authors of this chapter. A section collating studies on type 2 diabetes in children and adolescents has been included in Chapter 2.

Impaired glucose tolerance (IGT) is an asymptomatic condition defined by elevated (though not diabetic) levels of blood glucose two hours after a 75g oral

Diabetes Atlas Second Edition

Chapter 1

glucose challenge. Along with impaired fasting glucose (IFG), it is now recognized as being a stage in the transition from normality to diabetes.

Thus, individuals with IGT are at high risk of progressing to type 2 diabetes, although such progression is not inevitable, and probably over 30% of individuals with IGT will return to normal glucose tolerance over a period of several years (15). Not surprisingly, IGT shares many characteristics with type 2 diabetes, being associated with obesity, advancing age, insulin resistance and an insulin secretory defect (16).

In addition to estimating the prevalence of diabetes for the years 2003 and 2025, data on case numbers and national prevalence of IGT are presented for both years in this section. The decision to include data on IGT was based on two major factors associated with its presence: a higher sensitivity for future diabetes incidence (17), and its association with future occurrence of cardiovascular disease (18, 19).

Gestational diabetes The most widely accepted definition of gestational diabetes mellitus (GDM) is “carbohydrate intolerance of varying degrees of severity with onset or first recognition during pregnancy” (20, 21). This definition applies regardless of whether insulin is used for treatment or the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy.

It is widely believed that differences in reported prevalence of GDM parallel the differences that have been found in the frequency of type 2 diabetes among different populations. Nonetheless GDM is increasing in prevalence in concert with the worldwide rise in type 2 diabetes. Studies currently in progress hold much hope of providing the data from which ‘outcome based’ diagnostic criteria and

Diabetes Atlas Second Edition

The Global Burden of Diabetes

appropriate strategies for the detection of GDM can be developed.

Classification criteria and reporting standards

Standardization of methods and reporting in diabetes epidemiology promotes comparison between studies and may permit the pooling of results from different investigations (22, 23). Standardized criteria for detecting and reporting glucose intolerance have evolved greatly since the 1960s (24).

In the late 1970s both the US National Diabetes Data Group (NDDG) and the World Health Organization (WHO) produced new criteria on which to diagnose diabetes mellitus. In 1985, WHO modified their criteria to be more consistent with NDDG values. More recently, the American Diabetes Association (ADA) (25) and WHO (26) have produced new recommendations for the diagnosis of diabetes. The major change recommended is the lowering of the diagnostic value of the fasting plasma glucose concentration to 7.0 mmol/l. For glucose tested in whole blood, the new recommended threshold is 6.1 mmol/l (26).

In many population studies, individuals have been categorized as having diabetes mellitus based on blood glucose values measured after an overnight fast and/or two hours after a 75g oral glucose load. Whilst WHO still recommends the oral glucose tolerance test (OGTT) as being the single best choice, they also state that “if it is not possible to perform the OGTT (eg for logistical or economic reasons), the fasting plasma glucose alone may be used for epidemiological purposes” (26).

It is important to realize that different screening and diagnostic criteria may have been used for different studies in this report. The impact that the recent diagnostic cut-off level changes have on prevalence estimates seems to vary from country to country (27). In this section,

19

20

The Global Burden of Diabetes

the criteria used will be reported when they are known.

Global estimates of diabetes

The global burden of diabetes has been estimated several times (28-31). In 1994, the International Diabetes Federation Directory (28) contained type 1 and type 2 diabetes estimates supplied by member nations. Using these data the International Diabetes Federation (IDF) estimated that over 100 million people worldwide had diabetes. Also in 1994, McCarty et al (29) used data from population-based epidemiological studies and estimated that the global burden of diabetes was 110 million in 1994 and that it would likely more than double to

239 million by 2010.

WHO (30) also produced a report using epidemiological information and estimated the global burden at

135 million in 1995, with the number

reaching 299 million by the year 2025. In 1997, Amos et al (31) estimated the global burden of diabetes to be 124 million people, and projected that this would increase to 221 million people by the year 2010. Despite using different methodologies, and at times showing large differences in country-specific estimates, these reports have arrived at remarkably similar global figures of diabetes.

Methodology

The principal details of the methodology are provided in Appendix 1.1, where details of the rationale and process of obtaining age-specific prevalences for those countries with adequate data are given.

The principal aspects of the determination of prevalence were:

1 Identification of studies through a detailed literature search, and contact with IDF member organizations.

2 Employing the methodology indicated in Appendix 1.1 to create smoothed

Chapter 1

curves for prevalence (with respect to age).

3 Applying the prevalence rates to the population distribution of that country, and where no data for countries were available, to those other countries of similar ethnicity and economic circumstances.

4 Assuming an urban:rural prevalence ratio of 2:1 for diabetes (but not IGT), except in those countries classified by WHO (30) as market economies, or former socialist economies. The urban proportion of the population was derived from UN estimates (32). The only other exception to this 2:1 urban:rural prevalence ratio was for India (and Nepal, for which data were derived from India), for which the cited data indicated that the urban:rural ratio was nearer to 4:1 for diabetes prevalence (33, 34).

5 The data for diabetes rates include both type 1 and type 2 diabetes, with a separate chapter providing estimates on type 1 diabetes in children and adolescents (see Chapter 2).

6 The prevalence of diabetes throughout the Diabetes Atlas includes both undiagnosed and previously diagnosed diabetes.

This section contains prevalence estimates of diabetes and IGT for the years 2003 and 2025, and although the Tables contain data listed to one decimal point, it should not be inferred that this indicates the degree of precision, but rather to facilitate calculations and the appearance of the tables. In general, no predictions of diabetes or IGT numbers should be taken as having reliability of more than one significant figure.

The consequence of applying current age and gender specific prevalence rates to estimate 2025 prevalences and number of cases is that only changes in the age and urban/rural distribution of the population will affect the estimates. Since it is likely that the age specific prevalence

Diabetes Atlas Second Edition

Chapter 1

The Global Burden of Diabetes

rates (the prevalence at any given age) will rise due to increasing obesity, the figures are probably underestimates.

Results

The main aim of this section is to estimate the prevalence of diabetes mellitus and IGT for each country for the years 2003 and 2025. Data are provided for 212 countries and territories, which have been allocated mostly on a geographical basis into one of the seven IDF regions: Africa (AFR), Eastern Mediterranean and Middle East (EMME), Europe (EUR), North America (NA), South and Central America (SACA), South-East Asia (SEA) and Western Pacific (WP).

Rates for each country have not been age-standardized, but are presented as the crude rates for the specific country and region according to the number of persons aged 20-79 years for that national and geographical entity.

The data presented are for all diabetes and IGT for adults from 20 to 79 years, and relate only to individuals 20 years of age or older because the majority of people who have type 2 diabetes and IGT are adults. Type 2 diabetes in children and adolescents is acknowledged as a very important and growing problem (see Chapter 2).

Furthermore as the emphasis is on numbers of persons with diabetes and IGT for each country, prevalence rates are markedly affected by the population age distribution so that those countries with older age distributions will inevitably have higher crude prevalences for the 20-79 year age group. It should be noted that column numbers in the Tables may not always exactly be the sum of the components because of rounding effects.

Demography

The total populations and the population aged from 20-79 years are shown in Figure 1.2. It is clear that the Western

Diabetes Atlas Second Edition

Figure 1.2 World population (20-79 age group) by region

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Figure 1.3 Prevalence of diabetes (20-79 age group) by region

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Pacific Region, which has China as a member, and the South-East Asian Region, which has India as a member, have the greatest numbers in people.

21

The Global Burden of Diabetes

Chapter 1

Figure 1.4 Number of people with diabetes (20-79 age group) by region

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Figure 1.5 Prevalence of impaired glucose tolerance (20-79 age group) by region

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22

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Diabetes

Prevalence In 2003, it is estimated that approximately 194 million people worldwide, or 5.1% in the age group 20-79, have diabetes. This estimate is expected to increase to some 333 million, or 6.3% in the adult population, by 2025.

The European Region with 48 million and Western Pacific Region with 43 million currently have the highest number of people with diabetes. However the prevalence rate of 3.1% for the Western Pacific Region is significantly lower than 7.9% in the North American Region and 7.8% in the European Region as seen in Figure 1.3.

By 2025, the region with the greatest number of persons with diabetes is expected to change to the South-East Asian Region with about 82 million as shown in Figure 1.4. The region’s prevalence of 7.5% will however continue to be lower than that of North America, estimated at 9.7%, and Europe at 9.1%.

Age distribution The 40-59 age group currently has the greatest number of persons with diabetes. By 2025, because of the ageing of the world’s population, there will be 146 million aged 40-59 and 147 million aged 60 or older.

Gender distribution The estimates for both 2003 and 2025 showed a female predominance in the number of persons with diabetes. The female numbers were about 10% higher than for males.

Urban/rural distribution In 2003, the number of people with diabetes in urban areas was 78 million, compared to 44 million persons with diabetes in rural areas in countries not considered to be established market economies, or former socialist economies. By 2025, it is expected that this discrepancy will increase to

Diabetes Atlas Second Edition

Chapter 1

The Global Burden of Diabetes

182 million urban and 61 million rural persons with diabetes.

Impaired Glucose Tolerance

Prevalence In 2003, it is estimated that approximately 314 million people worldwide, or 8.2% in the age group 20 – 79, have IGT. By 2025, the number of people with IGT is projected to increase to 472 million, or 9.0% in the adult population.

The South-East Asian Region currently has the highest number of people with IGT with some 93 million and the highest prevalence rate with 13.2%. While the Western Pacific Region is the next highest in terms of number with about 78 million, its prevalence rate of 5.7% is the lowest compared with the other regions as seen in Figure 1.5.

By 2025, the trend is expected to continue with the South-East Asian Region leading in prevalence with 13.5% and in number with some 146 million people as seen in Figure 1.6. The prevalence of IGT in the European Region will remain the next highest with 10.9%.

As can be seen in Figure 1.7, the prevalence of IGT is more than twice that of diabetes in the African and South-East Asian Regions, whereas in the Eastern Mediterranean and Middle East, and North American Regions the prevalence of IGT is slightly lower than that of diabetes.

Age distribution As with diabetes, the 40-59 age group currently has the greatest number of persons with IGT and this will remain true by 2025.

Gender distribution There was also a female predominance in the number of persons with IGT in the estimates for both 2003 and 2025. The female numbers were about 20% higher than for males.

Diabetes Atlas Second Edition

Figure 1.6 Number of people with impaired glucose tolerance (20-79 age group) by region

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Figure 1.7 Estimated prevalence of diabetes and impaired glucose tolerance (20-79 age group) by region

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23

The Global Burden of Diabetes

Chapter 1

Figure 1.8 Estimated number of people with diabetes and impaired glucose tolerance (20-79 age group) by region

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Regional estimates for diabetes and IGT for 2003 and 2025 are shown in Table 1.1, and highlight the large increases in absolute numbers of both conditions over the 22-year period as also shown in Figure 1.8.

Discussion

In order to make national, regional and global predictions for the prevalence of diabetes, a number of assumptions needed to be made, and therefore the results are subject to a number of limitations. In addition to those highlighted in the Methodology section in Appendix 1.1, some of these are that:

• The studies included in this section often used differing screening techniques. The majority of studies used an OGTT to screen for diabetes, however, some studies used a fasting blood glucose test (FBG), some a two-hour blood glucose (2BG), some

24

a random blood glucose (RBG), and some based their data on self-report (SR). It is difficult to control for this unless, for example, only those studies that used an OGTT were included. This would also have the effect of excluding studies lacking OGTT data, which would have increased the number of countries for which data were extrapolated from another country.

• There were some inconsistencies in the technique used for a particular test (eg for the Argentinian data, diabetes was measured according to a 50g two-hour post-glucose load test, and not a 75g load as recommended by WHO), and persons with previously diagnosed diabetes were excluded from the analysis.

• There were inconsistencies in the diagnostic criteria adopted, resulting from the updating of the diagnostic criteria in 1997 (25). The use of a lower fasting diagnostic criterion for diabetes will tend to result in a higher prevalence of diabetes and lower prevalence of IGT. The diagnostic criteria used for each country are indicated in the data source tables.

• Three of the datasets reported only previously diagnosed diabetes – New Zealand (35), Canada (36) and Germany (37). In order to account for those with undiagnosed diabetes, the figures from New Zealand were doubled based on Australian data showing that the ratio of known:unknown persons with diabetes is 1:1 (38, 39), as was data from Germany (40) while data from the USA (41) indicated that Canadian figures should be increased by 50%.

• If a country lacked data, it was assumed that their age and sex- specific prevalence rates of diabetes mellitus were the same as those rates in another socio-economically, ethnically and geographically similar country.

Diabetes Atlas Second Edition

Chapter 1

The Global Burden of Diabetes

Table 1.1 Regional estimates for diabetes and impaired glucose tolerance (20-79 age group), 2003 and 2025

   

2003

 

2025

   

No. of

No. of

 

No. of

No. of

Population

people with

Diabetes

people

IGT

Population

people with

Diabetes

people

IGT

(20-79)

diabetes

prevalence

with IGT

prevalence

(20-79)

diabetes

prevalence

with IGT

prevalence

Region

(millions)

(millions)

(%)

(millions)

(%)

(millions)

(millions)

(%)

(millions)

(%)

AFR

295

7.1

2.4

21.4

7.3

541

15.0

2.8

39.4

7.3

EMME

276

19.2

7.0

18.7

6.8

494

39.4

8.0

36.5

7.4

EUR

621

48.4

7.8

63.2

10.2

646

58.6

9.1

70.6

10.9

NA

290

23.0

7.9

20.3

7.0

374

36.2

9.7

29.6

7.9

SACA

252

14.2

5.6

18.5

7.3

364

26.2

7.2

29.5

8.1

SEA

705

39.3

5.6

93.4

13.2

1,081

81.6

7.5

146.3

13.5

WP

1,384

43.0

3.1

78.5

5.7

1,751

75.8

4.3

120.2

6.9

Total

3,823

194

5.1

314

8.2

5,251

333

6.3

472

9.0

With the forces of globalization and industrialization proceeding at an increasing rate, the prevalence of diabetes is predicted to increase dramatically over the next few decades. The resulting burden of complications and premature mortality will continue to present itself as a major and growing public health problem for most countries.

It

is hoped that this report will assist

in

monitoring the trends of diabetes

prevalence over time, by adopting the same methodology for future reports.

A report such as this should also be

an indicator of a country’s and region’s ‘database’ of research. It should stimulate research in those countries lacking data, as well as encourage further and improved research in those countries where available data may not be representative of national rates.

Finally, this report should act as a stimulus for intervention. Perhaps the most essential aspect of research is the action taken as a result of findings. Diabetes requires culturally appropriate intervention in order to reduce the enormous personal suffering and economic burden that grows with this epidemic.

Diabetes Atlas Second Edition

25

The Global Burden of Diabetes

Chapter 1

Map 1.1 Prevalence estimates of diabetes, 2003

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Map 1.2 Prevalence estimates of diabetes, 2025

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26

Diabetes Atlas Second Edition

Chapter 1

The Global Burden of Diabetes

Map 1.3 Prevalence estimates of impaired glucose tolerance, 2003

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Map 1.4 Prevalence estimates of impaired glucose tolerance, 2025

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Diabetes Atlas Second Edition

27

Top ten

The Global Burden of Diabetes

Chapter 1

Figure 1.9 Estimated top 10 prevalences of diabetes (20-79 age group), 2003

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Table 1.2 Estimated top 10: Prevalence of diabetes (20-79 age group), 2003 and 2025

2003

 

2025

Country

Prevalence (%)

 

Country

Prevalence (%)

1 Nauru

30.2

1

Nauru

33.0

2 United Arab Emirates

20.1

2

United Arab Emirates

24.5

3 Bahrain

14.9

3

Singapore, Republic of

19.5

4 Kuwait

12.8

4

Bahrain

18.3

5 Tonga

12.4

5

Kuwait

16.4

6 Singapore, Republic of

12.3

6

Tonga

15.9

7 Oman

11.4

7

Mauritius

14.7

8 Mauritius

10.7

8

Barbados

12.8

9 Germany

10.2

9

Hong Kong

12.8

10 Spain

9.9

10

Suriname

12.3

Only countries have been included for which surveys including glucose testing were undertaken for that country

Table 1.3 Estimated top 10: Number of people with diabetes (20-79 age group), 2003 and 2025

2003

 

2025

Country

Persons (millions)

 

Country

Persons (millions)

1 India

35.5

1

India

73.5

2 China, People’s Republic of

23.8

2

China, People’s Republic of

46.1

3 USA

16.0

3

USA

23.1

4 Russia

9.7

4

Pakistan

11.6

5 Japan

6.7

5

Russia

10.7

6 Germany

6.3

6

Brazil

10.7

7 Pakistan

6.2

7

Mexico

9.0

8 Brazil

5.7

8

Egypt

7.8

9 Mexico

4.4

9

Japan

7.1

10 Egypt

3.9

10

Germany

7.1

28

Diabetes Atlas Second Edition

Chapter 1

Top ten

The Global Burden of Diabetes

Figure 1.10 Estimated top 10 prevalences of impaired glucose tolerance (20-79 age group), 2003

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Table 1.4
Estimated top 10: Prevalence of impaired glucose tolerance
(20-79 age group), 2003 and 2025
2003
2025
Country
Prevalence (%)
Country
Prevalence (%)
1 Nauru
20.4
1
Nauru
21.2
2 Bahrain
17.2
2
United Arab Emirates
20.8
3 United Arab Emirates
17.2
3
Bahrain
20.7
4 Kiribati
17.2
4
Kuwait
19.6
5 Kuwait
16.8
5
Poland
18.5
6 Singapore, Republic of
16.6
6
Kiribati
18.1
7 Poland
16.6
7
Mauritius
17.7
8 Mauritius
16.2
8
Singapore, Republic of
17.5
9 India
14.2
9
Hong Kong
14.6
10 Japan
13.0
10
India
14.5

Only countries have been included for which surveys including glucose testing were undertaken for that country

Table 1.5 Estimated top 10: Number of people with impaired glucose tolerance (20-79 age group), 2003 and 2025

2003

 

2025

Country

Persons (millions)

 

Country

Persons (millions)

1 India

85.6

1

India

132.0

2 China, People’s Republic of

33.2

2

China, People’s Republic of

54.3

3 Russia

17.8

3

Indonesia

20.9

4 USA

13.9

4

USA

19.3

5 Indonesia

12.9

5

Russia

18.3

6 Japan

12.6

6

Japan

12.7

7 Brazil

7.5

7

Brazil

11.7

8 Ukraine

6.2

8

Pakistan

10.9

9 Pakistan

5.7

9

Bangladesh

10.1

10 Bangladesh

5.3

10

Nigeria

7.4

Diabetes Atlas Second Edition

29

The Global Burden of Diabetes

Chapter 1

Table 1.6 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT) – African Region

Country

Data used

Angola a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Benin b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Botswana c

South Africa (Omar et al, 1993 and Levitt et al, 1993) 46,47

Burkina Faso b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Burundi a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Cameroon

Cameroon (Mbanya et al, 1997) 44

Cape Verde b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Central African Republic b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Chad

Sudan (Elbagir et al, 1996) 48

Comoros a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Congo, Democratic Republic of a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Congo, Republic of b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Côte d’Ivoire b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Djibouti

Sudan (Elbagir et al, 1996) 48

Equatorial Guinea b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Eritrea a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Ethiopia a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Gabon b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Gambia b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Ghana

Ghana (Amoah et al, 2002) 45

Guinea b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Guinea-Bissau b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Kenya a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Lesotho c

South Africa (Omar et al, 1993 and Levitt et al, 1993) 46,47

Liberia b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Madagascar a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Malawi a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Mali b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Mauritania

Sudan (Elbagir et al, 1996) 48

Mozambique a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Namibia c

South Africa (Omar et al, 1993 and Levitt et al, 1993) 46,47

Niger b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Nigeria b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Reunion

Mauritius (Dowse et al, 1990) 49

Rwanda a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Sao Tome and Principe b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Senegal b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Seychelles

Mauritius (Dowse et al, 1990) 49

Sierra Leone b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Somalia a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

South Africa c

South Africa (Omar et al, 1993 and Levitt et al, 1993) 46,47

Swaziland c

South Africa (Omar et al, 1993 and Levitt et al, 1993) 46,47

Tanzania a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Togo b

Cameroon (Mbanya et al, 1997) 44 and Ghana (Amoah et al, 2002) 45

Uganda a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Western Sahara

Sudan (Elbagir et al, 1996) 48

Zambia a

Tanzania (McLarty et al, 1989 and Aspray et al, 2002) 42,43

Zimbabwe a

South Africa (Omar et al, 1993 and Levitt et al, 1993) 46,47

a. The prevalence was calculated after the combination of the data of the two studies, notwithstanding the different criteria. IGT figures were calculated from the McLarty data, as the Aspray study only used FBG criteria.

b. The prevalence was calculated as the average of the two studies as their sample sizes differed considerably.

c. The prevalence was calculated after the combination of the data of the two studies. IGT figures were based only on the study of Omar et al.

30

Diabetes Atlas Second Edition

Chapter 1

The Global Burden of Diabetes

Chapter 1 The Global Burden of Diabetes OGTT/FBG WHO – 1985, 1999 7,781 15+ OGTT WHO

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985

1,208

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985

1,767

24-74

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985, 1999

6,500

24+

2BG

WHO – 1985

1,284

25-84

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985, 1999

6,500

24+

2BG

WHO – 1985

1,284

25-84

OGTT

WHO – 1985, 1999

6,500

24+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1999

4,733

25+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985

1,208

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985, 1999

6,500

24+

2BG

WHO – 1985

1,284

25-84

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985

1,208

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985

4,929

25-74

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT

WHO – 1985

5,080

25-74

OGTT

WHO – 1985, 1999

6,500

24+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985

1,208

15+

OGTT

WHO – 1985

1,208

15+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985, 1999

6,500

24+

OGTT/FBG

WHO – 1985, 1999

7,781

15+

2BG

WHO – 1985

1,284

25-84

OGTT/FBG

WHO – 1985, 1999

7,781

15+

OGTT

WHO – 1985

1,208

15+

Diabetes Atlas Second Edition

31

The Global Burden of Diabetes

Chapter 1

Table 1.7 Prevalence estimates of diabetes mellitus (DM), 2003 – African Region

 

Population

DM

Number of people with DM (000’s) in the 20-79 age group

 

(20-79)

prevalence

Country

(000’s)

%

Rural

Urban

Male

Female

20-39

40-59

60-79

Total

Angola

5,846

2.7

33.1

123.7

84.0

72.8

51.6

69.5

35.8

156.8

Benin

2,911

2.1

23.6

38.9

32.7

29.8

19.0

28.1

15.5

62.5

Botswana

716

3.6

3.2

22.3

8.8

16.7

4.1

13.9

7.5

25.5

Burkina Faso

4,969

2.7

90.4

44.8

67.8

67.4

40.1

55.2

40.0

135.3

Burundi

2,860

1.3

22.0

16.0

19.4

18.6

12.6

15.6

9.8

38.0

Cameroon

7,278

0.8

19.5

38.9

23.9

34.5

9.4

42.3

6.7

58.4

Cape Verde

228

2.3

1.1

4.2

2.2

3.1

2.0

1.7

1.7

5.3

Central African Republic

1,780

2.3

16.3

25.0

21.1

20.2

10.7

17.6

13.0

41.3

Chad

3,674

2.7

60.7

39.9

39.1

61.5

12.2

54.5

33.9

100.6

Comoros

355

2.5

1.9

7.0

4.8

4.1

3.2

3.9

1.8

8.9

Congo, Democratic Republic of

22,436

2.5

136.6

415.4

294.7

257.3

182.3

237.4

132.3

552.0

Congo, Republic of

1,403

2.6

7.6

28.3

18.4

17.6

10.5

15.2

10.3

35.9

Côte d’Ivoire

7,959

2.3

63.9

121.9

107.3

78.6

51.4

83.0

51.5

185.8

Djibouti

300

4.9

1.3

13.5

4.8

9.9

1.3

8.3

5.2

14.8

Equatorial Guinea

226

2.5

1.8

3.8

2.9

2.7

1.5

2.5

1.7

5.6

Eritrea

1,906

1.9

13.6

22.7

19.7

16.6

11.8

15.6

8.8

36.2

Ethiopia

29,562

1.9

214.6

335.8

299.4

250.9

176.6

234.9

138.8

550.4

Gabon

647

2.9

5.0

13.9

9.9

9.0

4.0

8.1

6.8

18.9

Gambia

703

2.2

7.4

8.0

8.3

7.0

4.1

7.2

4.0

15.4

Ghana

9,986

3.3

143.8

190.2

185.0

149.0

93.4

152.8

87.8

334.0

Guinea

3,855

2.0

37.6

41.2

42.8

36.0

23.3

35.5

20.1

78.9

Guinea-Bissau

588

2.0

7.0

4.8

6.3

5.5

3.1

5.2

3.5

11.8

Kenya

14,604

2.5

78.1

281.5

193.6

166.0

133.7

152.3

73.5

359.6

Lesotho

1,040

3.1

17.3

14.8

12.3

19.8

4.2

17.6

10.4

32.1

Liberia

1,573

2.0

10.5

21.3

17.0

14.8

11.6

11.6

8.6

31.8

Madagascar

7,782

2.5

47.3

144.6

104.3

87.5

63.2

85.5

43.2

191.9

Malawi

5,131

1.7

38.0

49.3

46.6

40.6

28.8

35.5

23.0

87.2

Mali

5,231

2.0

54.4