diabetes

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

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

3. Newsweek, September 4,
2000 Time, September 4, 2000

6. Global Projections for the Diabetes Epidemic:
2000-2030 (in millions)
NA
19.7
33.9
72%
LAC
13.3
33.0
248%
EU
17.8
25.1
41%
A+NZ
1.2
2.0
65%
SSA
7.1
18.6
261%
World
2000 = 171 million
2030 = 366 million
Increase 213%
China
20.8
42.3
204%
Wild, S et al.: Global prevalence of diabetes:
Estimates for 2000 and projections for 2030
Diabetes Care 2004 In press
India
31.7
79.4
251%
MEC
20.1
52.8
263%

7. Estimated Number of People with Diabetes
in 2000 and 2030 (and % change)
Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030
Diabetes Care 2004. In press
+176%
+26%
-13%

8. Estimated Number of People with Diabetes in
2000 and 2030 (and % change)
Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and
projections for 2030 Diabetes Care 2004 In press
+308%
+247%
+189%

9. Estimated Number of People with Diabetes in
2000 and 2030
Wild, S et al.: Global prevalence of diabetes: Estimates for 2000
and projections for 2030 Diabetes Care 2004 In press
+242%
+212%
+75%

10. Are these projections realistic?
Based on:
1990s estimates of diabetes prevalence
Demographic projections
Assume constant (current) age-sex specific
prevalence of diabetes

11. Changing Prevalence of Type 2
Diabetes

12. 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/prev/national/fig1.htm

13. Diabetes in the United States
1958-1993
0
3
6
9
12
1958 '62 '66 '70 '74 '78 '82 '86 '90 1994
Prevalence (%)
> 65 years
55-65 years
45-54 years
< 45 years
Data from the US National Health Interview Survey

14. Diabetes in the United States
1980-2000
0
3
6
9
12
15
1980 '85 '90 '95 2000
Prevalence (%)
< 45 years
65-74years
45-64years
75+years
Data from the US National Health Interview Survey:
http://www.cdc.gov/diabetes/statistics/prev/national/fig3.htm

17. 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)

18. Importance of IGT and IFG

19. IFG
IGT
'Impaired Glucose Tolerance’ (IGT)
2h post-load Plasma Glucose of 140-199mg/dl [7.8-11.0mmol/l]
and FPG <126mg/dl [<7.0mmol/l]
Impaired Glucose Homeostasis
'Impaired Fasting Glucose' (IFG)
FPG of 100-125mg/dl [5.6 -<7.0mmol/l]

20. Incidence of Diabetes in people with
Impaired Glucose Homeostasis

21. Prevalence and Incidence of Diabetes (%)
in Impaired Glucose Homeostasis
Prevalence of Impaired
Glucose Homeostasis
5-year Cumulative
Incidence of DM
Hoorn
50-75y
19.4 29.7
Mauritius
25-74y
19.3 24.5
Pima Indians
15+y
15.1 24.8
Nhanes III
40-74y
19.3 ? 25% ?

22. Projections of Numbers with Diabetes* among
persons aged 40-74years in USA (Millions)
14.5
18
21.5
25
28.5
32
35.5 39
0
10
20
30
40
1995 2000 2005 2010 2015 2020 2025 2030
YEAR
No.
with
Diabetes
(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

23. Proportion of new cases of Diabetes (%) in persons
with NGT and Impaired Glucose Homeostasis
Proportion from
persons with NGT
Proportion from
those with IGT or
IFG
Hoorn
50-75y
38% 62%
Mauritius
25-74y
40% 60%
Pima Indians
15+y
44% 56%
Nhanes III
40-74y
? 40% ? ? 60% ?

24. Projections of Numbers with Diabetes* among
persons aged 40-74years in USA (Millions)
19.4
24.3
29.2
34.1
39
43.3
48.2
14.5
18
21.5
25
28.5
32
35.5
39
0
10
20
30
40
50
1995 2000 2005 2010 2015 2020 2025 2030
YEAR
No.
with
Diabetes
(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

26. Mortality attributable to diabetes

27. Number of Deaths with Diabetes as Underlying Cause of Death,
United States, 1980-1996.
CDC, Diabetes surveillance, 1999

28. 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 DMs*No. with DM
• Mortality rate; RR of death in DM; No. with diabetes

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

32. Consequences of the Epidemic

33. Consequences of Epidemic
• Disproportionate increase in
duration-related complications
• Increase in number with diabetes

34. Effect of Epidemic of Diabetes on Duration-related complications
16 new cases/yr. Death occurs after 30y DM; Complication incidence 50% after 15y DM
0 5 10 15 20 25 30 35 40 45 50
Time (years)
0
150
300
450
No.
of
Cases
0
10
20
30
40
50
Percent
with
complications
Cumulative No. of DM cases
% with DM>15y duration
Prevalence of complications (%) among those with DM

35. Incidence of Type 2 Diabetes in Pima Indians
in two time periods
1965-75
1975-85
Time Period
0 10 20 30 40 50
Incidence per 1000 person-years
Age-sex adjusted rates
60% increase

36. Age-standardized mortality from Ischemic Heart
Disease in diabetic and non-diabetic
Pima Indians aged 35+ years, (30 year follow-up)
1965-74 1975-84
Non-diabetic
1985-94 1965-74 1975-84
Diabetic
1985-94
0
1
2
3
4
5
6
Mortality
/1000
person-years

37. Renal disease

38. 1965 1970 1975 1980 1985 1990 1994
Year
0
5
10
15
20
25
Cases
Dialysis
Deaths
Frequency of Renal Failure among Pima Indians

39. 1965-74 1975-84 1985-94
Time Period
0
4
8
12
Cases
per
1000/year
Incidence of Renal Failure

40. Number of persons beginning treatment for
ESRD attributable to diabetes in USA by year
http://www.cdc.gov/diabetes/statistics/esrd/Fig1Detl.htm

41. DIABETES IN END-STAGE RENAL FAILURE: AUSTRALIA
1980 - 2000
Year of Entry
Number of Diabetics Number of New Patients
0
100
200
300
400
500
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00
0
300
600
900
1200
1500
1800
Type 2 (Ins Requiring)
Type 2 (Non Insulin)
Type 1
Total New Patients

42. Crude and Age-adjusted incidence of ESRD
related to diabetes in the United States
1984-2001
0
100
200
300
400
1985 '90 '95 2000
Incidence/100,000
Diabetic persons
Age-adjusted
rate
Data from the US Renal Data System:
http://www.cdc.gov/diabetes/statistics/esrd/fig7.htm
Crude rate

43. Projections for number of patients with diabetes
initiating ESRD treatment in USA*
2000 2030
(using WHO
estimate)
2030
Revised
projections
Number
with
Diabetes
18 million 31 million 39-48
million
No with
new ESDR
40,000 68,000 86-105,000
* Assuming current incidence rates for initiating ESRD treatment remain constant

44. 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

45. 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

46. 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

48. Thank you

49. Age-adjusted incidence of ESRD related
to diabetes in the United States
1984-2001
0
100
200
300
400
500
600
1985 '90 '95 2000
Incidence/100,000
Diabetic persons
White female
Black female
Hispanic male
Black male
Data from the US Renal Data System:
http://www.cdc.gov/diabetes/statistics/esrd/fig5.htm
White male
Hispanic female
Amer. Indian male
Amer. Indian female

50. Are there better ways to predict future
trends?
• Incidence = No. of new cases/ period of time
• Mortality = No. of deaths/ period of time
• Prevalence=Cumul.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)