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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.
Outline
• Prevalence of Diabetes
• Estimates of future prevalence (projections)
• Mortality attributable to diabetes
• Effect of the epidemic on rates of complications
• Projections for ESRD
Newsweek, September 4,Newsweek, September 4, 20002000
Newsweek, September 4,Newsweek, September 4, 20002000 Time, September 4, 2000Time, September 4, 2000Time, September 4, 2000Time, September 4, 2000
Diabetes in 2000 & 2025in USA and the World
King,H, Aubert,RE, Herman,WH: Global burden of diabetes, 1995-2025: Diabetes Care 21:1414 - 1431, 1998
151million300 million
15 22USA
Diabetes in 2000 & 2030in USA and the World
Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030. Diabetes Care 2004 In press
171million366 million
17.7 30.3USA
Global Projections for the Diabetes Epidemic: Global Projections for the Diabetes Epidemic: 2000-2030 (in millions)2000-2030 (in millions)
NA19.733.972%
LAC13.333.0
248%
EU17.825.141%
A+NZ1.22.065%
SSA 7.118.6261%
World2000 = 171 million2030 = 366 million
Increase 213%
China20.842.3204%
Wild, S et al.: Global prevalence of diabetes:Estimates for 2000 and projections for 2030 Diabetes Care 2004 In press
India31.779.4251%
MEC20.152.8
263%
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%
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%
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%
Are these projections realistic?
Based on:1990s estimates of diabetes prevalenceDemographic projectionsAssume constant (current) age-sex specific
prevalence of diabetes
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
Diabetes in the United States1958-1993
Prevalence (%)
> 65 years
55-65 years
45-54 years
< 45 years
Data from the US National Health Interview Survey
Diabetes in the United States1980-2000
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
Mokdad A. H et al. Diabetes Care 23: 1278-1283Mokdad A. H et al. Diabetes Care 24: 412
1991 1999%
Increase
Men 4.1% 6.0% 46%
Women 5.6% 7.6% 36%
Diabetes Epidemic in the United States, 1991-1999
Percent with Diagnosis of Diabetes(Aged 18 years and over)
increase = 5%/ year
1991 1998%
Increase
Men 11.7% 17.7% 51.5%
Women 12.2% 18.1% 47.4%
Obesity Epidemic in the United States, 1991-1998
Percent with BMI > 30 kg/m2
Mokdad A.H. et al. JAMA 1999; 282:1519 - 1522
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)
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]
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% ?
Projections of Numbers with Diabetes* among persons aged 40-74years in USA (Millions)
14.518
21.525
28.532
35.5 39
0
10
20
30
40
1995 2000 2005 2010 2015 2020 2025 2030
YEAR
No.
with
Dia
bete
s (m
illion
s)
*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
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% ?
Projections of Numbers with Diabetes* among persons aged 40-74years in USA (Millions)
19.424.3
29.234.1
3943.3
48.2
14.518
21.525
28.532
35.539
0
10
20
30
40
50
1995 2000 2005 2010 2015 2020 2025 2030
YEAR
No.
with
Dia
bete
s (m
illio
ns)
*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
Number of Deaths with Diabetes as Underlying Cause of Death,United States, 1980-1996.
CDC, Diabetes surveillance, 1999
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
DECODE study group, Lancet 1999; 354, 617-621
1
1.49
1.99
1
1.54
2.6
NGT IGT DM0
0.5
1
1.5
2
2.5
3
Rel
ativ
e R
isk
Men
Women
Hazard Ratios for death in Normal (NGT), Impaired glucose tolerance (IGT) and diabetes
(DECODE Study, 25364 subjects aged 25+, mean follow-up 7.3 years)
Age-standardized Mortality (22 year follow-up)in Diabetic and Non-diabetic adults
(NHANES I, aged 25 or older)
DiabeticMen
Non-diabeticmen
DiabeticWomen
Non-diabetic women
0
10
20
30
40
50
Mor
tali t
y /1
000
p er s
o n-y
ears
All causes
Gu,K et al. Diabetes Care 21, 1138-1145, 1998
2.03 x
2.22 x
Global Projections of Excess Deaths attributable to Diabetes (in 000’s)
and percent of all deaths in year 2000
AMRA251.19.75%
AMRD32.26.1%
EUR609.06.4%
WPR469.34.1%AFR
319.22.6%
WorldIn 2000 = 3.164 million
(5.4% of all deaths)
SEAR1154.16.9%
Roglic et al.: Burden of mortality attributable to diabetes:Estimates for the year 2000. In preparation
EMR125.37.2%
AMRB194.07.6%
Consequences of Epidemic
• Disproportionate increase in duration-related complications
• Increase in number with diabetes
Effect of Epidemic of Diabetes on Duration-related complications
16 new cases/yr. Death occurs after 30y DM; Complication incidence 50% after 15y DMAfter 30 years No. of new cases equals no. of deaths.
0 5 10 15 20 25 30 35 40 45 50
Time (years)
0
150
300
450
No.
of
Cas
es
0
10
20
30
40
50
Percent w
ithcom
plicationsCumulative No. of DM cases
% with DM>15y duration
Prevalence of complications (%) among those with DM
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
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
1985-940
1
2
3
4
5
6
Mo
rtal
ity
/100
0 p
erso
n-y
ears
1965 1970 1975 1980 1985 1990 1994
Year
0
5
10
15
20
25C
ases
Dialysis
Deaths
Frequency of Renal Failure among Pima Indians
Number of persons beginning treatment for
ESRD attributable to diabetes in USA by year
http://www.cdc.gov/diabetes/statistics/esrd/Fig1Detl.htm
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
Crude and Age-adjusted incidence of ESRD related to diabetes in the United States
1984-2001Incidence/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
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
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
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
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
Conclusions
Increase in Type 2 diabetes (and obesity) represents the major public health challenge for the 21st century
The estimates of future burden currently used seriously underestimate what is going to happen!
Age-adjusted incidence of ESRD related to diabetes in the United States
1984-2001Incidence/100,000 Diabetic persons
White female
Black femaleHispanic male
Black male
Data from the US Renal Data System:http://www.cdc.gov/diabetes/statistics/esrd/fig5.htm
White maleHispanic female
Amer. Indian maleAmer. Indian female
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)