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IDF DIABETES ATLASSixth edition

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02 I IDF Diabetes Atlas I Sixth edition

© I st o c k ph ot o. c om

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IDF Diabetes Atlas I Sixth edition I 03

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T A B L E O F C O N T E N T S

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Table of contents

Acknowledgements 05Foreword 07Introduction 09Executive summary 11

What is diabetes? 19Type 1 diabetes 22Type 2 diabetes 23Gestational diabetes 23Impaired glucose tolerance and impaired fasting glucose 24Diabetes complications 24Other complications 26

The global burden 29Diabetes and impaired glucose tolerance 32

2.1 Diabetes 342.2 Undiagnosed diabetes 382.3 Impaired glucose tolerance 402.4 Diabetes in young people 422.5 Hyperglycaemia in pregnancy 442.6 Mortality 462.7 Health expenditure 48

Regional overviews 51A global perspective 543.1 Africa 563.2 Europe 583.3 Middle East and North Africa 603.4 North America and Caribbean 62

3.5 South and Central America 643.6 South-East Asia 663.7 Western Pacific 68

Global issues in diabetes 714.1 A global review of diabetic retinopathy 764.2 Rates of diabetic ketoacidosis at diagnosis in children with type 1 diabetes 784.3 Diabetes in Indigenous peoples 804.4 Diabetes in rural communities 82

Linking local to global 855.1 Driving the global agenda on diabetes 885.2 Including diabetes in development 905.3 The IDF Diabetes Scorecard 925.4 Training health professionals in diabetes 94

Resources and Solutions 996.1 Diabetes in older people 1026.2 IDF programmes and campaigns 1046.3 Clinical guidelines and Position Statements 1066.4 About the International Diabetes Federation 110

Appendices and references 113Country summary table: estimates for 2013 114Country details table: estimates for 2013 128Abbreviations and acronyms 142Glossary 143References 146List of tables, maps and figures 153

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© International Diabetes Federation, 2013No part of this publication may be reproduced, translated, or transmitted in any form or by any meanswithout the prior written permission of the International Diabetes Federation.

First published, 2000Second edition, 2003Third edition, 2006Fourth edition, 2009Fifth edition, 2011Sixth edition, 2013

Online version of IDF Diabetes Atlas : www.idf.org/diabetesatlas

ISBN: 2-930229-85-3

Design and layout: De Visu Digital Document DesignCover photos: © istockphoto.com – © Tim Nolan

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A C K N O W L E D G E M E N T S

Acknowledgements

Corporate sponsorsIDF would like to express its thanks to the followingsponsors for their generous support of the sixthedition:

Diabetes Atlas,sixth edition committeeNam Han Cho (chair), David Whiting (deputy chair),Leonor Guariguata, Pablo Aschner Montoya, NitaForouhi, Ian Hambleton, Rui Li, Azeem Majeed,Jean Claude Mbanya, Ayesha Motala, K.M. VenkatNarayan, Ambady Ramachandran, WolfgangRathmann, Gojka Roglic, Jonathan Shaw, MartinSilink, D.R.R. Williams, Ping Zhang.

Editorial teamLeonor Guariguata, Tim Nolan, Jessica Beagley,Ute Linnenkamp, Olivier Jacqmain.

ContributorsThe International Diabetes Federation (IDF) wouldlike to thank the following core contributors:

Florencia Aguirre, Alex Brown, Nam Han Cho,Gisela Dahlquist, the Diabetes EducationConsultative Section (DECS), Sheree Dodd, TrishaDunning, Sir Michael Hirst, Christopher Hwang,

Dianna Magliano, Chris Patterson, Courtney Scott,Jonathan Shaw, Gyula Soltész, Juliet Usher-Smith,David Whiting.

Other ContributorsCarlos Aguilar Salinas, Riyadh Alshamsan,Tabassum Ambia, Carmen Gloria Aylwin, CarolineBaan, Juliana Chan, Adel A. El-Sayed, LaercioFranco, Juan José Gagliardino, Jody Grundman,Lucy Hadley, Christian Herder, Hak C. Jang, PiliKamenju, Andre Pascal Kengne, Tawfik Khoja,Mandana Kooijmans, Silvia Lapertosa, Kerry

Lydon, Ronald Ching Wan Ma, Lydia Makaroff, ChrisMillett, Graham Ogle, Martijn Parker, NasheetaPeer, Lorenzo Piemonte, Salman Rawaf, JoachimRosenbauer, Segundo Seclén, ChamukuttanSnehalatha, Anne Mieke Spijkerman, TeresaTamayo, Sean Taylor, Sara Webber, Sarah H. Wild,Mary Vinocour, Bernard Zinman.

Lilly Diabetes

Merck and Co, Inc.

Novo Nordisk A/S – Supportedthrough an unrestricted grant by the NovoNordisk Changing Diabetes® initiative

Pfizer, Inc.

Sanofi Diabetes

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F O R E W O R D

Despite the grim picture painted by the newfigures, we already have the knowledge andexpertise to begin creating a brighter future forgenerations to come. We must increase awarenessof the importance of a healthful diet and physicalactivity, especially for children and adolescents.Crucially though, environments have to be createdthat lay the foundations for healthy living. Thesemeasures are most pressing in low- and middle-income countries, precisely those which are leastprepared to confront this huge-scale pandemic,and whose very development will be thwarted in itsaftermath. It is essential that health professionals

– particularly the primary care practitioners –receive adequate and appropriate training to beable to perform effectively on the front line againstdiabetes.

In the last two years, progress has been madetoward driving political change for diabetes.Building on the momentum of the 2011 UN PoliticalDeclaration on non-communicable diseases(NCDs), the 66th World Health Assembly in May 2013saw the unanimous adoption by Member States ofa voluntary Global Action Plan for the preventionand control of NCDs. Diabetes is now prominent

on the global health agenda, with specific targetsfor access to essential medicines and for haltingthe growth of obesity and diabetes. Still, we mustnot miss this opportunity. Governments and policy-makers, health professionals and those affected bythe disease must remain engaged in the fight sothat IDF may achieve its vision of living in a worldwithout diabetes.

Sir Michael HirstPresident,

International Diabetes Federation

It is a bittersweet pleasure to be presiding over theInternational Diabetes Federation upon the launchof this sixth edition of the IDF Diabetes Atlas . Theevidence published herein on the millions of peopleswept up by the diabetes pandemic vindicates theFederation’s relentless efforts to promote solutionsto this worldwide health crisis. Previous editionsof the Atlas were a crucial tool in the successfulcampaign for a UN Resolution on diabetes andour figures informed the subsequent politicaldeclaration on non-communicable diseases. Wehave achieved much: diabetes is now firmly onthe highest of decision-making agendas. But the

figures in this edition are a harsh reminder of howfar we still have to go.

Today, there are 382 million people living withdiabetes. A further 316 million with impairedglucose tolerance are at high risk from thedisease – an alarming number that is set to reach471 million by 2035. Diabetes is on the rise all overthe world and countries are struggling to keeppace. The misconception that diabetes is ‘a diseaseof the wealthy’ is still held by some – to the detri-ment of desperately needed funding to combat thepandemic. But the evidence published in the IDF

Diabetes Atlas disproves that delusion: a stag-gering 80% of people with diabetes live in low- andmiddle-income countries, and the socially disad-vantaged in any country are the most vulnerable tothe disease. Today’s emerging diabetes hotspotsinclude countries in the Middle East, WesternPacific, sub-Saharan Africa and South-East Asiawhere economic development has transformedlifestyles. These rapid transitions are bringingpreviously unheard of rates of obesity and diabetes;developing countries are facing a firestorm of illhealth with inadequate resources to protect their

population.By the end of 2013, diabetes will have caused5.1 million deaths and cost USD 548 billion inhealthcare spending. Without concerted actionto prevent diabetes, in less than 25 years’ timethere will be 592 million people living with thedisease. Most of those cases would be preventable.However, without a multi-sectoral, all-of-societyapproach, the disturbing projections in this editionof the IDF Diabetes Atlas will be realised.

Foreword

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E X E C U T I V E

S U M M A R Y

For the first time, the IDF Diabetes Atlas hasproduced estimates of high blood glucose in preg-nancy. This serious and underreported conditionis affecting many women and infants – an esti-mated 21.4 million live births in 2013. Not onlydoes diabetes pose a grave threat to the health ofa mother and her child but evidence shows highblood glucose levels during pregnancy can leadto an increased risk of type 2 diabetes later in lifefor the child, further contributing to the alreadydevastating epidemic.

More high-quality studies than ever before havecontributed to the estimates in this edition of theIDF Diabetes Atlas . Nevertheless, more studiesare needed to describe the burden of diabetes inorder to improve the precision of the estimates,and contribute to an evidence base that is funda-mental in driving powerful advocacy for peoplewith diabetes.

Professor Nam Han ChoChair,

IDF Diabetes Atlas Committee, 6th Edition

This 6th edition of the IDF Diabetes Atlas onceagain sets the standard for evidence on the globalepidemiology of diabetes. The new estimates buildon the groundwork laid by previous editions, andconfirm the precipitous rise in diabetes overthe last few years. An astounding 382 millionpeople are estimated to have diabetes, withdramatic increases seen in countries all over theworld. The overwhelming burden of the diseasecontinues to be shouldered by low- and middle-income countries, where four out of five peoplewith diabetes are living. Socially and economicallydisadvantaged people in every country carry the

greatest burden of diabetes and are often the mostaffected financially.

The new estimates show an increasing trendtowards younger and younger people developingdiabetes, a trend that is very worrisome for futuregenerations. If current demographic patternscontinue, more than 592 million people will beaffected with diabetes within a generation. Thisfigure takes into account changes only in the popu-lation and patterns of urbanisation, and is almostcertainly an underestimate. Estimates of type 1diabetes in young people also show unexplained

and rapid increases in several regions along withthe rise in type 2 diabetes in younger populations.

The burden of diabetes is reflected not only in theincreasing numbers of people with diabetes, butalso in the growing number of premature deathsdue to diabetes. In 2013, roughly half of all deathsdue to diabetes in adults were in people underthe age of 60, and in less-developed regions likesub-Saharan Africa, that proportion climbs to 75%.As life expectancy increases, while the infectiousdisease burden decreases, and development drivesrapid changes in lifestyles, it is the developing

regions that will see the greatest increases in theburden of diabetes.

Introduction

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S U M M A R Y

IDF’s most recent estimates indicate that 8.3% ofadults – 382 million people – have diabetes, andthe number of people with the disease is set to risebeyond 592 million in less than 25 years. Yet, with175 million of cases currently undiagnosed, a vastamount of people with diabetes are progressingtowards complications unawares. Moreover, with80% of the total number affected living in low- andmiddle-income countries, where the epidemic isgathering pace at alarming rates, the IDF DiabetesAtlas ’ latest figures provide a worrying indicationof the future impact of diabetes as a major threatto global development.

Diabetes in all its forms imposes unacceptably highhuman, social and economic costs on countriesat all income levels. Since the publication of thefirst International Diabetes Federation DiabetesAtlas in 2000 successive editions have providedconsistent evidence of the continuing growth inrates of diabetes incidence and prevalence world-wide. This 6th edition brings new evidence of thesame kind, and carries a bitter but unavoidablemessage: despite the array of tools at our disposalto tackle the disease – effective drug therapies,advanced technology, ever-improving educationand preventive strategies – the battle to protect

people from diabetes and its disabling, life-threat-ening complications is being lost.

Executive summary

56 M37 M

138 M24 M

72 M35 M

20 M

Number of people with diabetes by IDF Region, 2013

MIDDLE EAST ANDNORTH AFRICA MENA

SOUTH AND CENTRALAMERICA SACA

WESTERN PACIFIC WP

NORTH AMERICA ANDCARIBBEAN NAC

EUROPE EUR

AFRICA AFR

SOUTHEASTASIA SEA

WORLD

382 Mpeople living

with

diabetes

46%undiagnosed

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WORLD

382 M

Type 1 diabetes

Normal situation

gestational diabetes

Type 2 diabetes

of the long-term damage being caused by theirdisease. Gestational diabetes, which appearsduring pregnancy, can lead to serious health risksto the mother and her infant and increase the riskfor developing type 2 diabetes later in life.

All types of diabetes require close collabora-tion between those affected and their healthcare

providers in order to prevent a range of costly,dangerous complications, which can provokedamage to the eyes, kidneys, feet and heart, and,left untreated, result in early death.

What is diabetes? The three main types of diabetes – type 1 diabetes,type 2 diabetes and gestational diabetes –occurwhen the body cannot produce enough of thehormone insulin or cannot use insulin effectively.Insulin acts as a key that lets the body’s cells takein glucose and use it as energy.

People with type 1 diabetes, the result of an auto-

immune process with very sudden onset, needinsulin therapy to survive. Type 2 diabetes, on theother hand, can go unnoticed and undiagnosed foryears. In such cases, those affected are unaware

Diabetes is a huge

and growing problem,

and the costs to society

are high and escalating.

AFR ↗109.1%

WP ↗46%

SACA ↗59.8%

SEA ↗70.6%

MENA ↗96.2%

EUR ↗22.4%

2013 2035

NAC ↗37.3%

WORLD

592 Mpeople living

with diabetes

in 2035

increase:

↗55%

i n c r e a s e

CELLS

G L U C

O S E

CELLS

CELLS

BLOOD

BLOOD

G L U C

O S E

G L U C

O S E

PANCREAS

PANCREAS

PANCREAS

I N S U

L I N

I N S U

L I N

INSULIN

CELLS

CELLS

CELLS

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S U M M A R Y

Top 10 countries / territories of number

of people with diabetes (20-79 years), 2013

China

India

USA

Brazil

RussianFederation

Mexico

Indonesia

Germany

Egypt

Japan

Millions

0 10 20 30 40 50 60 10070 80 90

98.4

65.1

24.4

11.9

10.9

8.7

8.5

7.6

7.5

7.2

The Global Burden The majority of the 382 million people with diabetesare aged between 40 and 59, and 80% of them live

in low- and middle-income countries. All types ofdiabetes are on the increase, type 2 diabetes inparticular: the number of people with diabetes willincrease by 55% by 2035.

An additional 21 million cases of high blood glucosein pregnancy are estimated to contribute to theglobal burden of diabetes. That is equivalent to17% of live births to women in 2013 that had someform of high blood glucose in pregnancy.

In human as well as financial terms, the burdenof diabetes is enormous, provoking 5.1 million

deaths and taking up some USD 548 billion dollarsin health spending (11% of the total spent world-wide) in 2013.

Top 10 countries/territories for prevalence* (%) of diabetes (20-79 years), 2013

MIDDLE EAST ANDNORTH AFRICA

WESTERNPACIFIC

23%

23%

23%

24%

24%26%

29%

35%35%

37%

* comparative prevalence

VANUATU

COOK ISLANDS

MARSHALLISLANDS

FEDERATED STATESOF MICRONESIA

NAURU

SAUDI ARABIA QATAR

KUWAIT

KIRIBATI

TOKELAU

More than 21 million

live births were affected

by diabetes during

pregnancy in 2013.

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Diabetes caused

5.1 million deaths

in 2013. Every six

seconds a person dies

from diabetes.

Regional overviews Different regions are being affected to widelydiffering degrees. With more than 138 millionpeople affected, the Western Pacific has morepeople with diabetes than any other region. At theother end of the regional diabetes ranking, Africa’sdiabetes population is currently the smallestamong the regions. However, this is set to double

by 2035, and, ominously for Africa’s capacity todevelop, more than three-quarters of deaths fromdiabetes in 2013 occurred in people under 60 – thatis to say, in their prime productive years.

The outlook is similarly worrying in South andCentral America, where the diabetes populationis projected to increase by 60% by 2035. Rapiddevelopment has driven a fast-growing epidemic ofdiabetes in South-East Asia, accounting for close to

one-fifth of all cases worldwide. Similarly, wealthand development in the Middle East and NorthAfrica has led to high proportions of diabetes whereone in ten adults in the region have the disease.

A look at health spending on diabetes by regionreveals huge disparities in responses to the

epidemic. Two regions spent more on diabetesthan the rest of the regions put together: NorthAmerica and Caribbean, with an estimated USD 263billion – equal to nearly half the world’s healthexpenditure on diabetes; and Europe with USD 147billion. Despite their growing diabetes populations,spending in South-East Asia and Africa accountedfor less than 1% of all global health expenditureon the disease.

56 M37 M

138 M24 M

72 M35 M

20 M54%

62%

36%

48%

27%

24%

49%

c a s e s

u n d i a g n o s e d

Number of people with diabetes (20-79 years), 2013 Proportion of cases of d iabetes (20-79 years)that are undiagnosed, 2013

Global health expenditure due to diabetes

(20-79 years)

$$$

2013

2035

548billionUSD

627billionUSD

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E X E C U T I V E

S U M M A R Y

IDF

REGION

2013

MILLIONS

2035

MILLIONS

INCREASE

%

Africa 19.8 41.4 109%

Middle East and North Africa 34.6 67.9 96%

South-East Asia 72.1 123 71%

South and Central America 24.1 38.5 60%

Western Pacific 138.2 201.8 46%

North America and Caribbean 36.7 50.4 37%

Europe 56.3 68.9 22%

World 381.8 591.9 55%

147 B

14 B

263 B

26 B

88 B76%

28%

50%

38%

44%

55%

44%

m o r t a l i t y < 6 0

e x p e n d i t u r e s

IDF Regions and global projections of the number of people with diabetes (20-79 years),

2013 and 2035

MIDDLE EAST AND

NORTH AFRICA MENA

SOUTH AND CENTRAL

AMERICA SACA

WESTERN PACIFIC WP

NORTH AMERICA AND

CARIBBEAN NAC

EUROPE EUR

AFRICA AFR

SOUTHEAST

ASIA SEA

Health expenditure (USD) due to diabetes (20-79 years), 2013Proportion of deaths due to diabetes in peopleunder 60 years of age, 2013

4 B

6 B

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Global issuesin diabetesDespite the predominantly urban impact of theepidemic, type 2 diabetes is fast becoming a majorhealth concern in rural communities in low- andmiddle-income countries.

No countries are escaping the diabetes epidemic,and in states and territories worldwide it is thepoor and disadvantaged who are suffering most.Indigenous communities are among those espe-cially vulnerable to diabetes.

All nations – rich andpoor – are suffering

the impact of the

diabetes epidemic.

Indigenous peoples are

especially vulnerable

to diabetes.

of people with diabeteslive in low- and middle-

income countries

80%

age (years)

p r e v a l e n c e

Prevalence (%) of diabetes (20-79 years) by income group and age

20

10

0

%

LOWERMIDDLEINCOME

UPPERMIDDLEINCOME LOWINCOMEHIGHINCOME

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E X E C U T I V E

S U M M A R Y

Resourcesand solutionsThe International Diabetes Federation (IDF) isan umbrella organisation of over 200 nationaldiabetes associations in more than 160 countries.It represents the interests of the growing numberof people with diabetes and those at risk. TheFederation has been leading the global diabetescommunity since 1950. IDF’s mission is to promotediabetes care, prevention and a cure worldwide.

IDF is committed to promoting best practice in

diabetes through guidelines, position statements,and tools for health professionals to improve thelives of people with diabetes.

Linking local to global IDF plays a pivotal role in efforts to reduce expo-nentially the global impact of diabetes, catalysinggrass roots activism, influencing global health anddevelopment policy, and driving the global agendaon diabetes. In calling for a specific health target

14/11WORLD

DIABETESDAY

26/12WORLD

DIABETESCONGRESS

2013 2014

November NovemberSeptember

14/11

WORLDDIABETES

DAY

09/2015MILLENNIUM

DEVELOPMENTGOALS

SUMMIT

09/2014UN HIGH

LEVEL REVIEWOF THE POLITICAL

DECLARATIONON NCDs

2015

SeptemberDecember October

There are solutions

for managing and curbing

the diabetes epidemic.

Diabetes is more than a

health issue and requires

concerted policy action

across many sectors.

IDF isthe legitimate

voice of people with

diabetes

in the post-2015 development framework, theFederation is heading a campaign for an all-of-society approach to diabetes prevention, care andsupport.

As a leading supporter of people and organisa-tions working in diabetes education and care,IDF produces educational resources designedto improve the expertise of diabetes educatorsand other healthcare professionals. IDF publica-tions are used widely around the world, and theFederation’s programmes, campaigns and eventsprovide a global awareness-raising platform forpeople with diabetes and those at risk.

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1What isdiabetes?

c h a p t e r 1

W H A T I S D I A B E T E S ?

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People with type 2diabetes can remain

UNDIAGNOSED for many years, unaware of

the LONGTERM DAMAGE

being caused by the disease

main types

of diabetes:

type 1 diabetes

type 2 diabetes

gestational

diabetes3

P e o p l e w i t h t y p e 1 d i a b e t e s w i l l d i e w i t h o u t i n s u l i n

There are

382 M peopleliving with

diabetes

46%undiagnosed

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c h a p t e r 1


Effective managementof diabetes requiresa partnership between

the person with diabetesand health professionals

People with diabetes

have an increased risk of

developing a number of

serious health problems

Poorly manageddiabetes leadsto serious

COMPLICATIONS and early death

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What is

diabetes?Diabetes is a chronic disease that occurs when thebody cannot produce enough insulin or cannot useinsulin effectively.1 Insulin is a hormone producedin the pancreas that allows glucose from food toenter the body’s cells where it is converted intoenergy needed by muscles and tissues to function.A person with diabetes does not absorb glucose

properly, and glucose remains circulating in theblood (a condition known as hyperglycaemia)damaging body tissues over time. This damagecan lead to disabling and life-threatening healthcomplications.

There are three main types of diabetes:

• type 1 diabetes

• type 2 diabetes

• gestational diabetes

Type 1 diabetesType 1 diabetes is caused by an autoimmune reac-tion, where the body’s defence system attacks theinsulin-producing beta cells in the pancreas. As aresult, the body can no longer produce the insulin itneeds. Why this occurs is not fully understood. Thedisease can affect people of any age, but usuallyoccurs in children or young adults. People with this

form of diabetes need insulin every day in order tocontrol the levels of glucose in their blood. Withoutinsulin, a person with type 1 diabetes will die.

Type 1 diabetes often develops suddenly and canproduce symptoms such as:

• abnormal thirst and a dry mouth

• frequent urination

• lack of energy, extreme tiredness

• constant hunger

• sudden weight loss

• slow-healing wounds

• recurrent infections

• blurred vision

People with type 1 diabetes can lead a normal,

healthy life through a combination of daily insulintherapy, close monitoring, a healthy diet, andregular physical exercise.

The number of people who develop type 1 diabetesis increasing. The reasons for this are still unclearbut may be due to changes in environmental riskfactors, early events in the womb, diet early in life,or viral infections.

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c h a p t e r 1


Type 2 diabetesType 2 diabetes is the most common type ofdiabetes. It usually occurs in adults, but is increas-ingly seen in children and adolescents. In type 2diabetes, the body is able to produce insulin but

either this is not sufficient or the body is unable torespond to its effects (also known as insulin resist-ance), leading to a build-up of glucose in the blood.

Many people with type 2 diabetes remain unawareof their illness for a long time because symptomsmay take years to appear or be recognised, duringwhich time the body is being damaged by excessblood glucose. They are often diagnosed only whencomplications of diabetes have already developed(see below, Diabetes complications).

Although the reasons for developing type 2 diabetesare still not known, there are several importantrisk factors. These include:

• obesity

• poor diet

• physical inactivity

• advancing age

• family history of diabetes

• ethnicity

• high blood glucose during pregnancy

affecting the unborn child

In contrast to people with type 1 diabetes, themajority of those with type 2 diabetes usually donot require daily doses of insulin to survive. Manypeople are able to manage their condition througha healthy diet and increased physical activity ororal medication. However, if they are unable toregulate their blood glucose levels, they may beprescribed insulin.

The number of people with type 2 diabetes isgrowing rapidly worldwide. This rise is associated

with economic development, ageing populations,increasing urbanisation, dietary changes, reducedphysical activity, and changes in other lifestylepatterns.2

Gestational diabetesWomen who develop a resistance to insulin andsubsequent high blood glucose during preg-nancy are said to have gestational diabetes (alsoreferred to as gestational diabetes mellitus or

GDM). Gestational diabetes tends to occur aroundthe 24th week of pregnancy. The condition arisesbecause the action of insulin is blocked, probablyby hormones produced by the placenta.

As gestational diabetes normally develops later inpregnancy, the unborn baby is already well-formedbut still growing. The immediate risk to the babyis therefore not as severe as for those whosemother had type 1 diabetes or type 2 diabetesbefore pregnancy (a condition known as diabetes inpregnancy). Nonetheless, uncontrolled gestationaldiabetes can have serious consequences for both

the mother and her baby.Poorly managed blood glucose during pregnancycan lead to a significantly larger than averagebaby (a condition known as fetal macrosomia),which makes a normal birth difficult and risky.The newborn will be at risk for shoulder injury andbreathing problems. In many cases, a caesareansection is necessary, putting the mother’s health atrisk, particularly in low-resource settings, whereaccess to good healthcare is limited. For womenliving in outlying rural areas there is a life-threat-ening risk from prolonged obstructed labour. There

also exists the risk of preeclampsia, a conditionwhere sudden high blood pressure threatens thehealth (and in some cases the life) of the motherand her baby.

Gestational diabetes in mothers normally disap-pears after birth. However, women who havehad gestational diabetes are at a higher risk ofdeveloping gestational diabetes in subsequentpregnancies and of developing type 2 diabetes laterin life. Babies born to mothers with gestationaldiabetes also have a higher lifetime risk of obesityand developing type 2 diabetes.

Women with gestational diabetes or diabetesin pregnancy need to monitor and control theirblood glucose levels to minimise risks to the baby.Normally, this can be done by taking up a healthydiet and moderate exercise, but in some casesinsulin or oral medication may be needed as well.

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Impaired glucosetolerance andimpaired fastingglucosePeople whose blood glucose levels are high but notas high as those in people with diabetes are saidto have impaired glucose tolerance (commonlyreferred to as IGT) or impaired fasting glucose(IFG). IGT is defined as high blood glucose levelsafter eating; whereas IFG is defined as high bloodglucose after a period of fasting. The term ‘predia-betes’ is also used to describe people with theseconditions – a ‘grey area’ between normal glucoselevels and diabetes.

People with IGT are at high risk of developing type 2diabetes. Unsurprisingly, IGT shares many charac-teristics with type 2 diabetes and is associated withobesity, advancing age and the inability of the bodyto use the insulin it produces. Not everyone withIGT goes on to develop type 2 diabetes: a large bankof evidence supports the effectiveness of lifestyleinterventions – healthy diet and physical exercise– to prevent the progression to diabetes.3

DiabetescomplicationsPeople with diabetes are at risk of developing anumber of disabling and life-threatening healthproblems. Consistently high blood glucose levelscan lead to serious diseases affecting the heartand blood vessels, eyes, kidneys, and nerves.People with diabetes are also at increased risk ofdeveloping infections. In almost all high-incomecountries, diabetes is a leading cause of cardio-vascular disease, blindness, kidney failure, andlower-limb amputation. As the prevalence oftype 2 diabetes grows in low- and middle-incomecountries, so too does the impact of these costly

– in both human and economic terms – compli-cations. Maintaining blood glucose levels, bloodpressure and cholesterol close to normal canhelp delay or prevent diabetes complications.People with diabetes need regular monitoring forcomplications.

Cardiovascular diseaseCardiovascular disease is the most commoncause of death and disability among peoplewith diabetes. The cardiovascular diseases thataccompany diabetes include angina, myocardial

infarction (heart attack), stroke, peripheral arterydisease, and congestive heart failure. In peoplewith diabetes, high blood pressure, high choles-terol, high blood glucose and other risk factorscontribute to the increased risk of cardiovascularcomplications.

Kidney diseaseKidney disease (nephropathy) is far more commonin people with diabetes than in people withoutdiabetes; and diabetes is one of the leading causesof chronic kidney disease. The disease is caused bydamage to small blood vessels, which can causethe kidneys to be less efficient, or to fail altogether.Maintaining near-normal levels of blood glucoseand blood pressure can greatly reduce the risk ofnephropathy.

Eye diseaseMany people with diabetes develop some form ofeye disease (retinopathy), which can damage visionor provoke blindness. Persistently high levels ofblood glucose, together with high blood pressure

and high cholesterol, are the main causes of retino-pathy. The network of blood vessels that supplythe retina can become blocked and damaged inretinopathy, leading to permanent loss of vision.Retinopathy can be managed through regular eyechecks and by keeping blood glucose levels closeto normal.

Nerve damageWhen blood glucose and blood pressure are exces-sively high, diabetes can provoke damage to nerves

throughout the body (neuropathy). This damagecan lead to problems with digestion and urination,erectile dysfunction and a number of other func-tions. The most commonly affected areas are theextremities, particularly the feet. Nerve damage inthese areas is called peripheral neuropathy, andcan lead to pain, tingling, and loss of feeling. Lossof feeling is particularly dangerous because it canallow injuries to go unnoticed, leading to seriousinfections and ulceration, diabetic foot disease,and major amputations.

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c h a p t e r 1


Figure 1.1 The major diabetes complications

Eyes (retinopathy)

Oral health

Heart and coronary circulation

(coronary heart disease)

Brain and cerebral circulation

(cerebrovascular disease)

Kidney

(nephropathy)

Lower limbs

(peripheral vascular disease)

Peripheral nervous system

(neuropathy)

Diabetic foot

(ulceration and amputation)

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Other complications

Oral healthDiabetes can pose a threat to oral health. Forexample, there is an increased risk of inflamma-

tion of the gums (gingivitis) in people with poorglucose control. Gingivitis in turn is a major causeof tooth loss and may also increase the risk ofcardiovascular disease.

Sleep apnoeaRecent research demonstrates the likelihood of arelationship between type 2 diabetes and obstruc-tive sleep apnoea. Estimates suggest that up to40% of people with sleep apnoea have diabetes,although the incidence of new diabetes in peoplewith sleep apnoea is not known.5 In people withtype 2 diabetes, sleep apnoea may have effects ontheir ability to control blood glucose.

Diabetic footPeople with diabetes may develop a number ofdifferent foot problems as a result of damage tonerves and blood vessels. These problems caneasily lead to infection and ulceration, which

increase a person’s risk of amputation. Peoplewith diabetes face a risk of amputation that maybe more than 25 times greater than that in peoplewithout diabetes.4 However, with good manage-ment, a large proportion of amputations can beprevented. Even when a person undergoes ampu-tation, the remaining leg – and the person’s life– can be saved by good follow-up care from a multi-disciplinary foot team.4 People with diabetes mustexamine their feet regularly.

Pregnancy complicationsWomen with any type of diabetes during preg-nancy risk a number of complications if they donot carefully monitor and manage their condition.Women with diabetes require detailed planningand close monitoring before and during pregnancyto minimise complications. High blood glucoseduring pregnancy can lead to fetal abnormalitiesand cause it to gain excess size and weight, andoverproduce insulin. These can lead to problemsat delivery, injuries to the child and mother, anda sudden drop in blood glucose (hypoglycaemia)in the child after birth. Children who are exposed

for a long time to high blood glucose in the wombare at higher risk of developing type 2 diabeteslater in life.

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Box 1.1 InsulinInsulin is a hormone that is produced in thepancreas. Insulin allows glucose to enter thebody’s cells, where it is converted into energy.

People with type 1 diabetes cannot survivewithout daily insulin doses. Some people withtype 2 diabetes or gestational diabetes alsoneed doses of insulin together with othermedication.

In Canada in 1921, scientist Frederick Bantingand medical student Charles Best isolated asubstance from the pancreas of dogs, whichthey named isletin – and which is now known asinsulin. In a series of experiments, they found

that a pancreatectomised dog could be keptalive with injections of isletin. The followingyear, after much laboratory work to purify

insulin extracted from a fetal calf, a 14-year-old boy called Leonard Thompson became thefirst person with diabetes to receive an insulininjection, and his condition improved signifi-cantly. Prior to the discovery of insulin, peoplewith diabetes were put on a starvation diet andhad no hope of survival.

News of the success with insulin spread veryquickly, and demand for the drug skyrocketedworldwide. Since then, huge advances havebeen made in research and development.However, nearly a century since its discovery,people with type 1 diabetes in many parts of theworld cannot access insulin – either because

they cannot afford to pay for it or because it isnot readily available – and die soon after devel-oping diabetes.

Figure 1.2 Insulin production and action

LiverGlycogen Glucose

Glucagon

InsulinStimulates glucoseuptake from blood

Promotesglucagonrelease

Promotesinsulinrelease

Stimulatesformation

of glycogen

Stimulatesbreakdownof glycogen

Tissue Cells(muscle, brain, fat, etc.)

Pancreas

Highbloodglucose

Raisesbloodglucose

Lowbloodglucose

Lowersbloodglucose

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The globalburden

2 c h a p t e r 2

T H E G L O B A L B U R D E N

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175 million people

with diabetes are

undiagnosed

382 million peoplehave diabetes

By 2035 this will riseto 592 MILLION

The numberof people withtype 2 diabetesis increasingin every country

The greatestnumber of people

with diabetes arebetween 40 and59 years of age

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T H E

G L O B A L

B U R D E N

Diabetes caused at leastUSD 548 billion dollarsin health expenditure in2013 – 11% of total healthspending on adults

of people with diabeteslive in low- and middle-income countries

80%

More than

79,000 children developed type 1diabetes in 2013

More than

21 million live births were affectedby diabetes duringpregnancy in 2013

Diabetes caused 5.1 million

deaths in 2013

Every six seconds a persondies from diabetes

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The global

burdenIn addition to diabetes, impaired glucose tolerance(IGT), in which blood glucose levels are higher thannormal but not as high as in diabetes, is also amajor public health problem. People with IGT havea high risk of developing diabetes as well as anincreased risk of cardiovascular disease.

Prevalence and projectionsIn this edition of the IDF Diabetes Atlas, theprevalence of diabetes and IGT are estimated forthe years 2013 and 2035. Data are provided for219 countries and territories, grouped into theseven IDF Regions: Africa (AFR), Europe (EUR),Middle East and North Africa (MENA), NorthAmerica and Caribbean (NAC), South and CentralAmerica (SACA), South-East Asia (SEA), and theWestern Pacific (WP).

Full details of the methods used to generate the

prevalence estimates for diabetes in adults and theproportion undiagnosed, including how the datasources were evaluated and processed, can befound in the journal Diabetes Research and ClinicalPractice and on the IDF Diabetes Atlas website:www.idf.org/diabetesatlas.

Diabetes andimpaired glucosetoleranceDiabetes is one of the most common non-commu-nicable diseases (NCDs). It is the fourth or fifthleading cause of death in most high-income coun-

tries and there is substantial evidence that it isepidemic in many economically developing andnewly industrialised countries.

Diabetes is undoubtedly one of the most chal-lenging health problems of the 21st century.

The number of studies describing the possiblecauses and distribution of diabetes over the last20 years has been extraordinary. These studiescontinue to confirm that it is the low- and middle-income countries that face the greatest burdenof diabetes. However, many governments and

public health planners remain largely unaware ofthe current magnitude of and future potential forincreases in diabetes and its serious complications.

Population-based diabetes studies consistentlyshow that a substantial proportion of those foundto have diabetes had not been previously diag-nosed. Many people remain undiagnosed largelybecause there are few symptoms during the earlyyears of type 2 diabetes, or those symptoms maynot be recognised as being related to diabetes.

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B U R D E N

ComplicationsComplications due to diabetes (Chapter 1) are amajor cause of disability, reduced quality of life,and death. Diabetes complications can affectvarious parts of the body, manifesting in different

ways in different people.There are no internationally agreed standards fordiagnosing and assessing diabetes complications.Due to the variety of methods of these studies, itis difficult to make comparisons between differentpopulations. However, it is clear that diabetes

complications are very common, with at leastone present in a large proportion of people withdiabetes (50% or more in some studies) at the timeof diagnosis.

In this edition of the IDF Diabetes Atlas , estimatesof complications were not included due to the lackof available comparable data. International stand-ards for measuring complications are essentialto provide accurate estimates of this major causeof disability.

AT A GLANCE 2013 2035

Total world population (billions) 7.2 8.7

Adult population (20-79 years, billions) 4.6 5.9

DIABETES AND IGT (20-79 YEARS)

Diabetes

Global prevalence (%) 8.3 10.1

Comparative prevalence (%) 8.3 8.8

Number of people with diabetes (millions) 382 592

IGT

Global prevalence (%) 6.9 8.0

Comparative prevalence (%) 6.9 7.3

Number of people with IGT (millions) 316 471

Table 2.1 Top 10 countries/territories for prevalence* (%) of diabetes (20-79 years), 2013 and 2035

COUNTRY/

TERRITORY

2013

(%)

COUNTRY/

TERRITORY

2035

(%)

Tokelau 37.5 Tokelau 37.9

Federated States of Micronesia 35.0 Federated States of Micronesia 35.1

Marshall Islands 34.9 Marshall Islands 35.0

Kiribati 28.8 Kiribati 28.9

Cook Islands 25.7 Cook Islands 25.7Vanuatu 24.0 Saudi Arabia 24.5

Saudi Arabia 24.0 Vanuatu 24.2

Nauru 23.3 Nauru 23.3

Kuwait 23.1 Kuwait 23.2

Qatar 22.9 Qatar 22.8

*comparative prevalence

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2.1 DiabetesDiabetes can be found in every country. Withouteffective prevention and management programmes,the burden will continue to increase worldwide.1

Type 2 diabetes accounts for 85% to 95% of alldiabetes in high-income countries and may accountfor an even higher percentage in low- and middle-income countries.1 Type 2 diabetes is a common

condition and a serious global health problem.In most countries diabetes has increased along-side rapid cultural and social changes: ageingpopulations, increasing urbanisation, dietarychanges, reduced physical activity and unhealthybehaviours.1

Type 1 diabetes, although less common than type 2diabetes, is increasing each year in both rich andpoor countries. In most high-income countries, themajority of diabetes in children and adolescentsis type 1 diabetes.

Gestational diabetes is common and, like obesityand type 2 diabetes, is increasing throughout theworld.2 The risk of developing type 2 diabetes ishigh in women who have had gestational diabetes.The reported prevalence of gestational diabetesvaries widely among different populations aroundthe world. Much of the variability is due to differ-ences in diagnostic criteria and study populations.

PrevalenceSome 382 million people worldwide, or 8.3% ofadults, are estimated to have diabetes. About80% live in low- and middle-income countries. Ifthese trends continue, by 2035, some 592 millionpeople, or one adult in 10, will have diabetes. Thisequates to approximately three new cases every10 seconds, or almost 10 million per year. The

largest increases will take place in the regionswhere developing economies are predominant.

Age distributionAlmost half of all adults with diabetes are betweenthe ages of 40 and 59 years. More than 80% of the184 million people with diabetes in this age grouplive in low- and middle-income countries.

This age group will continue to comprise the greatestnumber of people with diabetes in the coming years.By 2035, it is expected that the number will increase

to 264 million. Again, more than 86% will be livingin low- and middle-income countries.

Gender distributionThere is little gender difference in the globalnumbers of people with diabetes for 2013 or2035. There are about 14 million more menthan women with diabetes (198 million men vs184 million women). However, this difference isexpected to increase to 15 million (303 million menvs 288 million women) by 2035.

Table 2.2 Top 10 countries/territories for number of people with diabetes (20-79 years),

2013 and 2035

COUNTRY/

TERRITORY

2013

MILLIONS

COUNTRY/

TERRITORY

2035

MILLIONS

China 98.4 China 142.7

India 65.1 India 109.0

United States of America 24.4 United States of America 29.7

Brazil 11.9 Brazil 19.2

Russian Federation 10.9 Mexico 15.7

Mexico 8.7 Indonesia 14.1

Indonesia 8.5 Egypt 13.1

Germany 7.6 Pakistan 12.8

Egypt 7.5 Turkey 11.8

Japan 7.2 Russian Federation 11.2

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G L O B A L

B U R D E N

countries, the number of people with diabetes inurban areas is 181 million, while 122 million livein rural areas. By 2035, the difference is expectedto widen, with 347 million people living in urbanareas and 145 million in rural areas.

Urban/rural distributionThere are more people with diabetes living inurban (246 million) than in rural (136 million)areas although the numbers for rural areasare on the increase. In low- and middle-income

Figure 2.1 Prevalence* (%) of diabetes (20-79 years)

by IDF Region, 2013 and 2035

12

10

8

6

4

2

0

AFR EUR MENA NAC SACA SEA WP

%

2013

2035 *comparative prevalence

Figure 2.2 Prevalence (%) of people with diabetes by age

and sex, 2013

20

15

10

5

0

20 25 30 35 40 45 50 55 60 65 70 75

age (years)

%

Female

Male

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M a p 2 . 1

P r e v a l e n c e * ( % ) o f d i a b e t e s i n a d u l t s ( 2 0 - 7 9 y e a r s ) , 2 0 1

3

< 4

4 - 5

5 - 7

7 - 9

9 - 1 2

> 1 2

* c o m p a r a t i v e p r e v a l e n c e

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G L O B A L

B U R D E N

M a p 2 . 2

N u m b e r o f p e o p l e w i t h

d i a b e t e s ( 2 0 - 7 9 y e a r s ) , 2 0 1 3

< 1 0 0 , 0 0 0

1 0 0 , 0 0 0 - 5 0 0 , 0 0 0

5 0 0 , 0 0 0 - 1 , 0 0 0 , 0 0 0

1 , 0 0 0 , 0 0 0 - 1 0 , 0 0 0 , 0 0 0

1 0 , 0 0 0 , 0 0 0 - 2 0 , 0 0 0 , 0 0 0

> 2 0 , 0

0 0 , 0 0 0

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CostsThe costs associated with diabetes includeincreased use of health services, productivityloss and disability, which can be a considerableburden to the individual, families and society. When

people have long-standing undiagnosed diabetes,the potential benefits of early diagnosis and treat-ment are lost. Furthermore, the costs related toundiagnosed diabetes are considerable. One studyfrom the USA found that undiagnosed diabeteswas responsible for an additional USD 18 billionin healthcare costs in one year.5

Identifying peoplewith diabetesOpportunistic identification of people with risk

factors for undiagnosed type 2 diabetes is feasibleand cost-effective.6 Risk scores and ‘tick tests’listing risk factors have been developed in manycountries based on epidemiological surveys ofthe local populations, and are widely available.While undiagnosed diabetes is a substantialproblem, population-wide screening for diabetesis not appropriate. Countries must first develophealth systems that can meet the needs ofpeople living with the disease. Priority shouldbe given to providing good care and treatment topeople already identified with diabetes. Targeted

screening for those at high risk of undiagnoseddiabetes may be considered once a working systemfor care is in place.

Estimating undiagnoseddiabetesPopulation-based studies provide the basis for esti-mating undiagnosed diabetes. A sample of peopleliving in a particular area is tested for diabetes,which identifies both known and previously undi-agnosed cases. The IDF Diabetes Atlas estimates

undiagnosed diabetes using representative popu-lation-based studies reporting the proportion ofpreviously undiagnosed cases. The findings fromthese studies are then combined by Region andincome group to generate an estimate that is laterapplied to the prevalence estimates. Full detailsof the methods and results are available in thepublished paper at www.idf.org/diabetesatlas.

2.2 UndiagnoseddiabetesIDF estimates that as many as 175 million peopleworldwide, or close to half of all people withdiabetes, are unaware of their disease. Most ofthese cases are type 2 diabetes. The earlier aperson is diagnosed and management of diabetesbegins, the better the chances of preventingharmful and costly complications. The need todiagnose and provide appropriate care to peoplewith diabetes is therefore urgent.

Disparities by regionNo country has diagnosed every person that hasdiabetes. In sub-Saharan Africa, where resourcesare often lacking and governments may not

prioritise screening for diabetes, the proportionof people with diabetes who are undiagnosed isas high as 90% in some countries.1 Even in high-income countries, about one-third of people withdiabetes have not been diagnosed. The South-EastAsia Region (35.1 million) and the Western PacificRegion (74.7 million) together account for over 60%of all people with undiagnosed diabetes. Globally,84% of all people who are undiagnosed live in low-and middle-income countries.

ComplicationsA person with type 2 diabetes can live for severalyears without showing any symptoms. But duringthat time high blood glucose is silently damagingthe body and diabetes complications may bedeveloping. The complications associated withdiabetes are so varied that even when symptomsdo exist, diabetes may not be recognised as thecause unless accurate and appropriate testing iscarried out. Those who are undiagnosed will not betaking steps to manage their blood glucose levelsor lifestyle. Studies have found that many peoplewith undiagnosed diabetes already have compli-

cations, such as chronic kidney disease and heartfailure, retinopathy and neuropathy.2-4

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B U R D E N

Map 2.3 Prevalence* (%) of undiagnosed diabetes (20-79 years), 2013


< 1

1-2.5

2.5-3

3-4.5

4.5-6

> 6

Table 2.3 Undiagnosed diabetes (20-79 years) by IDF Region and income group, 2013

IDF

REGION

PROPORTION

UNDIAGNOSED %

CASES

MILLIONS

Africa 12.4Low-income countries 75.1Middle-income countries 46.0

Europe 20.1Low-income countries 29.3Middle-income countries 35.1High-income countries 36.6

Middle East and North Africa 16.8Low-income countries 50.0Middle-income countries 50.0High-income countries 40.7

North America and Caribbean 9.9Low-income countries 29.4Middle-income countries 25.0High-income countries 27.7

South and Central America 5.8Middle-income countries 24.1

South-East Asia 35.1Low-income countries 43.6Middle-income countries 49.1

Western Pacific 74.7Low-income countries 63.0Middle-income countries 54.1High-income countries 49.4

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Figure 2.3 Number of people with IGT by age

(20-79 years), 2013 and 20352.3 Impaired glucosetoleranceImpaired glucose tolerance (IGT), along withimpaired fasting glucose (IFG), is recognised as

being a stage preceding diabetes when bloodglucose levels are higher than normal. Thus,people with IGT are at high risk of developingtype 2 diabetes, although all people with IGT donot always go on to develop the disease. In morethan one-third of people with IGT, blood glucoselevels will return to normal over a period of severalyears.1

Data on IGT are included in this report becauseIGT greatly increases the risk of developing type 2diabetes1 and it is linked with the development ofcardiovascular disease.2,3 In addition, some of the

best evidence on the prevention of type 2 diabetescomes from studies involving people with IGT.

PrevalenceSome 316 million people worldwide, or 6.9% ofadults, are estimated to have IGT. The vast majority(70%) of these people live in low- and middle-income countries. By 2035, the number of peoplewith IGT is projected to increase to 471 million, or8.0% of the adult population.

Age distributionThe majority of adults with IGT are under the ageof 50 (153 million) and, if left untreated, are athigh risk of progressing to type 2 diabetes laterin life. This age group will continue to have thehighest number of people with IGT in 2035, risingto 198 million, as shown in Figure 2.3. It is impor-tant to note that nearly one-third of all those whocurrently have IGT are in the 20 to 39 year agegroup, and are therefore likely to spend many yearsat high risk – if indeed they do not go on to developdiabetes.

The prevalence of IGT is generally similar to thatof diabetes, but somewhat higher in the Africa andEurope Regions and lower in the South-East AsiaRegion.

Figure 2.4 Prevalence (%) of IGT (20-79 years)

by age and sex, 2013

200

180

160

140

120

100

80

60

40

20

0

m i l l i o n s

20-39 40-59 60-79

age (years)

16

14

12

10

8

6

4

2

0

20 25 30 35 40 45 50 55 60 65 70 75

age (years)

%

Female

Male

2013

2035

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Table 2.4 Top 10 countries/territories for prevalence* (%) of IGT (20-79 years), 2013 and 2035

COUNTRY/

TERRITORY

2013

(%)

COUNTRY/

TERRITORY

2035

(%)

Kuwait 17.9 Poland 19.3

Qatar 17.1 Kuwait 18.1

United Arab Emirates 16.6 Qatar 17.4

Poland 16.5 United Arab Emirates 17.0

Bahrain 16.3 Bahrain 16.7

Malaysia 15.2 Malaysia 15.3

Hong Kong SAR 13.3 Hong Kong SAR 13.2

Nicaragua 12.9 Anguilla 13.0

Japan 12.6 Guadeloupe 13.0

Singapore 12.4 Macau SAR 12.9


Map 2.4 Prevalence* (%) of impaired glucose tolerance (20-79 years), 2013

< 6

6-8

8-10

10-12

12-14

> 14*comparative prevalence

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is less common. Also, several European studieshave suggested that, in relative terms, increasesare greatest among younger children.

There is also evidence that similar trends exist inmany other parts of the world, but in sub-Saharan

Africa incidence data are limited or non-existent.Special efforts must be made to collect more data,especially in those countries where diagnoses maybe missed.

Some 79,100 children under 15 years are estimatedto develop type 1 diabetes annually worldwide. Ofthe estimated 497,100 children living with type 1diabetes, 26% live in the Europe Region, where themost reliable and up-to-date estimates of inci-dence are available, and 22% in the North Americaand Caribbean Region.

Type 2 diabetes inyoung peopleThere is evidence that type 2 diabetes in childrenand adolescents is increasing in some countries.However, reliable data are sparse.4 As with type 1diabetes, many children with type 2 diabetes riskdeveloping complications in early adulthood, whichwould place a significant burden on the familyand society. With increasing levels of obesity andphysical inactivity among young people in manycountries, type 2 diabetes in childhood has the

potential to become a global public health issueleading to serious health outcomes. More informa-tion about this aspect of the diabetes epidemic isurgently needed.

2.4 Diabetesin young peopleType 1 diabetes is one of the most common endo-crine and metabolic conditions in childhood.The number of children developing this form ofdiabetes every year is increasing rapidly, espe-cially among the youngest children. In a growingnumber of countries, type 2 diabetes is also beingdiagnosed in children.

The challengesIn type 1 diabetes, insulin therapy is life-savingand lifelong. A person with type 1 diabetes needsto follow a structured self-management plan,including insulin use and blood glucose moni-toring, physical activity, and a healthy diet. In

many countries, especially in low-income families,access to self-care tools, including self-manage-ment education, as well as to insulin, is limited.This leads to severe disability and early death inchildren with diabetes.

Many children and adolescents may find it difficultto cope emotionally with their disease. Diabetescan result in discrimination and may limit socialrelationships. It may also have an impact on achild’s academic performance. The costs of treat-ment and monitoring equipment, combined withthe daily needs of a child with diabetes, may place

a serious financial and emotional burden on thewhole family.

Incidence and prevalenceThree major collaborative projects, the DiabetesMondiale study (DIAMOND),1 the Europe andDiabetes study (EURODIAB),2 and the SEARCH forDiabetes in Youth study3 have been instrumentalin monitoring trends in incidence (the number ofpeople developing a disease in a year). This hasbeen done by setting up population-based regional

or national registries using standardised defini-tions, data collection forms, and methods forvalidation.

The incidence of type 1 diabetes among children isincreasing in many countries, particularly in chil-dren under the age of 15 years. There are strongindications of geographic differences in trendsbut the overall annual increase is estimated tobe around 3%.1,2 Evidence shows that incidenceis increasing more steeply in some Central andEastern European countries, where the disease

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T H E

G L O B A L

B U R D E N

AT A GLANCE 2013

Total child population (0-14 years, billions) 1.9

TYPE 1 DIABETES IN CHILDREN (0-14 YEARS)

Number of children with type 1 diabetes (thousands) 497.1

Number of children per year (thousands) 79.1

Annual increase in incidence (%)1,2 3

Figure 2.5 Estimated number of children (0-14 years) with

type 1 diabetes by IDF Region, 2013

120

100

80

60

40

20

0


t h o u s a n d s

Map 2.5 New cases of type 1 diabetes (0-14 years per 100,000 children per year), 2013

< 1.5

1.5-5

5-8.5

8.5-14

14-24

> 24

No data

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PrevalenceIDF estimates that 21.4 million or 16.8% of livebirths to women in 2013 had some form of hyper-glycaemia in pregnancy. An estimated 16% of thosecases were due to diabetes in pregnancy and would

require careful monitoring during the pregnancyand follow-up post-partum.

There are some regional differences in the preva-lence (%) of hyperglycaemia in pregnancy, with theSouth-East Asia Region having the highest preva-lence at 25.0% compared to 10.4% in the NorthAmerica and Caribbean Region. A staggering91.6% of cases of hyperglycaemia in pregnancywere in low- and middle-income countries, whereaccess to maternal care is often limited.

The prevalence of hyperglycaemia in pregnancyincreases rapidly with age and is highest in womenover the age of 45 (47.7%), although there arefewer pregnancies in that age group. This explainswhy just 23% of global cases of hyperglycaemia inpregnancy occurred in women over the age of 35,even though the risk of developing the conditionis higher in these women.

Estimating prevalenceThere is great diversity in the methods and criteriaused for identifying women with hyperglycaemia inpregnancy, which increases the difficulty of making

comparisons between studies and generatingestimates on prevalence.2 However, the recentpublication of a guideline from the World HealthOrganization on diagnosing hyperglycaemia inpregnancy will contribute to a standard approachto estimating prevalence.3

Data on hyperglycaemia in pregnancy from studieswere available for 34 countries across all IDFRegions. Although each of the Regions was repre-sented, the majority of the studies were carriedout in high-income countries. More informationis available on the methods used to generate the

estimates at www.idf.org/diabetesatlas.

2.5 Hyperglycaemiain pregnancyHigh blood glucose, or hyperglycaemia, is one ofthe most common health problems of pregnancy.1 Hyperglycaemia in pregnancy can be a result ofeither previously existing diabetes in a pregnantwoman, or the development of insulin resistancelater in the pregnancy in a condition known asgestational diabetes. Unlike diabetes in pregnancy,gestational diabetes resolves once the pregnancyends. Hyperglycaemia in pregnancy is categorised(see Box 6.1) as either diabetes in pregnancy orgestational diabetes, depending on blood glucosevalues obtained during screening.

Risks and complications

Any unmanaged hyperglycaemia in pregnancycan result in birth complications that can affectboth mother and child including: increased riskof preeclampsia, obstructed labour due to fetalmacrosomia and hypoglycaemia at birth forthe infant.

As the prevalence of both obesity and diabetes inwomen of childbearing age continue to rise in allregions, so will the prevalence of hyperglycaemiain pregnancy. In addition, women who developgestational diabetes have an increased lifetimerisk of developing type 2 diabetes.2 Babies born to

mothers who have hyperglycaemia in pregnancyare also at an increased risk of developing type 2diabetes later in life.

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G L O B A L

B U R D E N

AT A GLANCE 2013

Total live births (20-49 years, millions) 127.1

HYPERGLYCAEMIA IN PREGNANCY IN WOMEN (20-49 YEARS)

Global prevalence (%) 16.9

Comparative prevalence (%) 14.8

Number of live births with hyperglycaemia in pregnancy (millions) 21.4

Proportion of cases that may be due to diabetes in pregnancy (%) 16.0

Table 2.5 Hyperglycaemia in pregnancy (20-49 years) by IDF Region, 2013

IDFREGION

Cases in live births MILLIONS

Prevalence* %

Proportion of cases that may bedue to diabetes in pregnancy

%

AFR 4.6 14.4 19.6EUR 1.7 12.6 10.9

MENA 3.4 17.5 17.7

NAC 0.9 10.4 24.9

SACA 0.9 11.4 17.3

SEA 6.3 25.0 9.5

WP 3.7 11.9 14.1


Map 2.6 Data sources providing information on prevalence of hyperglycaemia in pregnancy, 2013

1-3

3-5

5-7

7-9

9-15

> 15

No data

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TrendsThe number of deaths attributable to diabetes in2013 showed an 11% increase over estimates for2011.1,2 This increase was largely due to rises inthe number of deaths due to the disease in the

Africa, Western Pacific, and Middle East and NorthAfrica Regions. This can be explained in part by arise in diabetes prevalence in some highly popu-lated countries in each Region. While there hasbeen a documented decline in mortality from someNCDs in some countries,3 no such decline has beenreported for diabetes.

Accuracy of mortality dataThe mortality estimates should be interpreted withcaution. However, they are probably more realisticthan estimates based on routine sources of healthstatistics, which consistently underestimate theburden of mortality from diabetes largely becausediabetes is often omitted from death certificatesas the cause of death. A substantial proportionof these deaths are potentially avoidable throughpublic health action directed at population-basedprevention of diabetes and its complications andimprovements in care for all people with diabetes.4

2.6 MortalityDiabetes and its complications are major causesof early death in most countries. Cardiovasculardisease (see Chapter 1) is one of the leadingcauses of death among people with diabetes. It can

account for 50% or more of deaths due to diabetesin some populations. Estimating the number ofdeaths due to diabetes is challenging because onthe one hand, more than a third of countries donot have any data on diabetes-related mortality;and on the other, because existing routine healthstatistics underestimate the number of deaths dueto diabetes. To provide a more realistic estimate ofmortality, the IDF Diabetes Atlas uses a modellingapproach to estimate the number of deaths thatcan be attributed to diabetes.1

Burden of mortalityApproximately 5.1 million people aged between 20and 79 years died from diabetes in 2013, accountingfor 8.4% of global all-cause mortality amongpeople in this age group. This estimated numberof deaths is similar in magnitude to the combineddeaths from several infectious diseases that aremajor public health priorities,* and is equivalentto one death every six seconds. Close to half (48%)of deaths due to diabetes are in people under theage of 60. The highest number of deaths due todiabetes occurred in countries with the largest

numbers of people with the disease: China, India,USA, and the Russian Federation.

Gender distributionThere is very little difference between men andwomen in the total number of deaths due todiabetes. However, there are important differencesin the distribution of these deaths.

In all but the Middle East and North Africa, andWestern Pacific Regions, diabetes accounts fora higher proportion of deaths in women than in

men, representing up to a quarter of all deathsin middle-aged women. This disparity is likely tobe due to higher rates of mortality in men fromother causes.

* In 2009 there were 1.8 million deaths from HIV/AIDS,5 781,000 from malaria6 and 1.3 million from tuberculosis.7

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T H E

G L O B A L

B U R D E N

Map 2.7 Deaths attributable to diabetes (20-79 years), 2013

Figure 2.6 Deaths attributable to diabetes as a percentage of

all deaths (20-79 years) by IDF Region, 2013

15

10

5

0


%

< 100

100-1,500

1,500-8,000

8,000-40,000

40,000-100,000

> 100,000

No data

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Disparities inhealth spendingThere is a large disparity in health spending ondiabetes between regions and countries. Only20% of global health expenditure on diabetes wasmade in low- and middle-income countries, where80% of people with diabetes live. On average, theestimated health spending due to diabetes wasUSD 5,621 (ID 5,305) per person with diabetesin high-income countries, compared to USD 356(ID 545) in low- and middle-income countries.

The USA spent USD 239 billion of its health dollarson diabetes, or 36% of global health expenditure.Meanwhile, China, the country with the most peopleliving with diabetes, spent just USD 38 billion,less than 7% of the global total. The combinedspending of the top three countries, the USA,Germany and China, was equivalent to more thanhalf of all global health expenditure on diabetesin 2013. Norway spent an average of USD 10,368on diabetes healthcare per person with diabetes,while countries such as Somalia and Eritrea spentless than USD 30.

Economic burdenCompared with those living in high-income coun-tries, people living in low- and middle-incomecountries pay a larger share of health expendi-

ture because they lack access to health insuranceand publicly available medical services. In LatinAmerica, for instance, families pay between 40%and 60% of medical expenses from their ownpockets.1 In some of the poorest countries, peoplewith diabetes and their families bear almost thetotal cost of medical care.

Implementing inexpensive, easy-to-use interven-tions can reduce the huge economic burden ofdiabetes. Many of these interventions are cost-effective and/or cost saving, even in developingcountries.2 Nonetheless, these interventions are

not widely used.

2.7 HealthexpenditureDiabetes imposes a large economic burden on indi-viduals and families, national health systems, andcountries. Health spending on diabetes accountedfor 10.8% of total health expenditure worldwide in2013. About 90% of the countries covered in thisreport dedicated between 5% and 18% of their totalhealth expenditure to diabetes. Health expenditureincludes medical spending on diabetes by healthsystems, as well as by people living with diabetesand their families.

Global health expenditureGlobal health spending to treat diabetes and managecomplications totalled at least USD 548 billion in

2013. By 2035, this number is projected to exceedUSD 627 billion. Expressed in International Dollars(ID), which correct for differences in purchasingpower, global health spending on diabetes wasestimated to be at least ID 581 billion in 2013 andID 678 billion in 2035. An estimated average ofUSD 1,437 (ID 1,522) per person with diabeteswas spent globally on treating and managing thedisease in 2013.

Health spending due to diabetes is not evenlydistributed across age groups. The estimates showthat 76% of global health expenditure on diabetes

in 2013 was for people between the ages of 50 and79 years.

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T H E

G L O B A L

B U R D E N

*see Glossary

Map 2.8 Mean diabetes-related health expenditure per person with diabetes (20-79 years)

(USD), R=2*, 2013

Figure 2.7 Health expenditure due to diabetes by age

(USD, R=2), 2013

< 50

50-500

500-1,500

1,500-3,000

3,000-6,500

> 6,500

No data

160

140

120

100

80

60

40

20

0

20-29 30-39 40-49 50-59 60-69 70-79

b i l l i o n s

age (years)

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3Regionaloverviews

c h a p t e r 3

R E G I O N A L O V E R V I E W S

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More was spent onhealthcare for diabetes

in the North America andCaribbean than in anyother region

In the Middle East

and North Africa,

1 in 10 adults

has diabetes

/10

In South-East Asia,half of people withdiabetes are

undiagnosed

$

$

$

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Europe has the highestprevalence of CHILDRENwith type 1 diabetes

In the Western Pacific,

138 million adults have diabetes– the largest number

of any region

In Africa, 76%of deaths due todiabetes were in

people underthe age of 60

↗60%In South and CentralAmerica, the number

of people with diabetes

will increase by 60%

by 2035

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3 Regionaloverviews

lation compared with the other Regions althoughthis is projected to more than double by 2035. Interms of the prevalence of adults with diabetes,the Middle East and North Africa Region has thehighest, at 10.9%. MENA is followed closely bythe 9.6% rate found in the North America andCaribbean Region while 8.2% of adults in the

South and Central America Region have diabetes(Table 3.0).

The picture is similar for IGT. The Western PacificRegion is estimated to have the greatest numberof people with IGT and consequently at greatlyincreased risk for developing type 2 diabetes, withsome 110 million; although the North Americaand Caribbean Region has the highest compara-tive prevalence, with 12.1% of the adult populationaffected. Worldwide, the prevalence (%) of IGT islower than that of diabetes but there is a high riskthat, if not treated early, these people will progress

to diabetes.

Deaths due to diabetesMortality attributable to diabetes ranges from8.6% of all deaths in adults aged between 20and 79 in the Africa Region to almost 15.8% inthe Western Pacific Region. Almost half of alldeaths due to diabetes occurred in people underthe age of 60. Diabetes is a major cause of deathworldwide; investment in reducing this burden is justified and necessary.

A global perspectiveThe majority of people with diabetes live in theeconomically less-developed regions of the world.Even in Africa, the Region with the lowest preva-lence, it is estimated that around 522,600 peopledied due to diabetes in 2013. The disparities inthe world’s response to the epidemic are huge:

although 80% of people with diabetes live in low-and middle-income countries, only 20% of globalhealth expenditure on the disease was made inthose countries.

A global perspective of the epidemic is essentialto understand the true dimensions of the diabetesburden and its consequences. This chapterpresents an overview of each of the seven IDFRegions: Africa (AFR), Europe (EUR), the MiddleEast and North Africa (MENA), North Americaand Caribbean (NAC), South and Central America(SACA), South-East Asia (SEA), and the Western

Pacific (WP). Each Region is highly diverse insocioeconomic and geographical terms and indiabetes prevalence, related deaths, and healthexpenditure.

Prevalence of diabetes andimpaired glucose toleranceA staggering 138 million people are living withdiabetes in the Western Pacific, more than inany other IDF Region. With 19.8 million peopleaffected, Africa has the smallest diabetes popu-

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160

140

120

100

80

60

40

20

0

200 400 600 800 1,000 1,200 1,400 1,600 1,800

N u m b e r o f p e o p l e w i t h d

i a b e t e s ( m i l l i o n s )

Population (millions)

Pacific Region spent only USD 88 billion, despitehaving the largest number of people with diabetes.The South and Central America, and Middle Eastand North Africa Regions each dedicated to

diabetes less than 5% of global diabetes healthexpenditure, while the South-East Asia and AfricaRegions spent less than 1%.

Health expenditureThe disparities between the Regions can be seenclearly in healthcare spending on diabetes. TheNorth America and Caribbean Region spentan estimated USD 263 billion – 48% of global

health expenditure on diabetes. Europe spentUSD 147 billion. The spending of each of theseRegions on diabetes healthcare was greater thanthat of the other Regions combined. The Western

Table 3.0 Regional estimates for diabetes (20-79 years), 2013 and 2035

Figure 3.0 Number of people with diabetes by population (20-79 years) by IDF Region, 2013

2013 2035 Increasein the

number ofpeople with

diabetes%

IDFREGION

PopulationMILLIONS

Number ofpeople with

diabetesMILLIONS

Comparativediabetes

prevalence%

PopulationMILLIONS

Number ofpeople with

diabetesMILLIONS

Comparativediabetes

prevalence%

AFR 407.9 19.8 5.7 775.5 41.5 6.0 109.6

EUR 658.7 56.3 6.8 668.7 68.9 7.1 22.4

MENA 374.5 34.6 10.9 583.7 67.9 11.3 96.2

NAC 334.9 36.8 9.6 404.5 50.4 9.9 37.3

SACA 300.5 24.1 8.2 394.2 38.5 8.2 59.8

SEA 883.2 72.1 8.7 1,216.9 123.0 9.4 70.6

WP 1,613.2 138.2 8.1 1,818.2 201.8 8.4 46.0

World 4,572.9 381.8 8.3 5,861.8 591.9 8.8 55.0

AFRSACA

MENA

EUR

NAC

Bubble size indicates the projected

increase in the number of people

with diabetes from 2013 to 2035WP

SEA

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MortalityAlthough only 8.6% of all deaths in the AfricaRegion can be attributed to diabetes, in 2013 astaggering 76.4% of those deaths occurred inpeople under the age of 60. Furthermore, there

were more than 50% more deaths from diabetes inwomen compared to men. This is in part becausemen are more likely to die from other causes, suchas armed conflict, and because in many caseswomen have poor access to healthcare.

Health expenditureAccording to estimates for the Africa Region, atleast USD 4 billion was spent on diabetes health-care in 2013, and this spending is expected toincrease around 58% by 2035. In the same period,the prevalence of diabetes is projected to almostdouble. With its health expenditure on diabetesthe lowest of any of the IDF Regions, a two-foldincrease in diabetes prevalence without a corre-sponding increase in spending will almost certainlyhave a very negative impact on rates of complica-tions and death for people with diabetes in Africa.

Data sourcesThe number of data sources examining theprevalence of diabetes in adults in the Regionhas increased substantially in recent years. For

this edition of the IDF Diabetes Atlas , 69 sourcesfrom 29 countries were considered, and a totalof 21 sources from 19 countries were selected.How

Documents

2013 IDF.pdf