Diabetes Atlas 3rd Edition

DIABETES ATLAS
THIRD EDITION
The mission of the International Diabetes Federation is to

promote diabetes care, prevention and a cure worldwide.
DIABETES ATLAS COMMITTEE
Jean-Claude Mbanya (co-chair)

Delice Gan (co-chair)
Bjørnar Allgot
Karel Bakker
Jonathan Betz Brown
Ambady Ramachandran
Gojka Roglic
Jonathan Shaw
Martin Silink
Linda Siminerio
Gyula Soltèsz
Rhys Williams
Paul Zimmet
Editor and project manager: Delice Gan

Project coordinator: Olivier Jacqmain
Diabetes Atlas, third edition, and other IDF publications are available from:
International Diabetes Federation
Executive Office
19 Avenue Emile de Mot
B-1000 Brussels
Belgium
Tel +32 2 538 5511
Fax +32 2 538 5114
idf@idf.org
www.idf.org
Online version of Diabetes Atlas: www.eatlas.idf.org

© International Diabetes Federation, 2006
No part of this publication may be reproduced or transmitted in
any form or by any means without the prior written permission of
the International Diabetes Federation.
First published, 2000

Second edition, 2003
Third edition, 2006
Permission has been obtained from the United Nations, Population 7HITEHOUSE3TATION.*53!
Division to use data from the World Population Prospects: The 2004 Revision.
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ACKNOWLEDGEMENTS CONTRIBUTIONS
The International Diabetes Federation (IDF) would like to express its CHAPTER 1
thanks to its partners for their generous support in making the 1.1 Richard Sicree, Jonathan Shaw, Paul Zimmet
Diabetes Atlas, third edition, possible: 1.2 Richard Sicree, Jonathan Shaw, Paul Zimmet
1.3 Robyn Tapp, Richard Sicree, Jonathan Shaw, Paul Zimmet
World Diabetes Foundation
Sanofi-Aventis Groupe CHAPTER 2
Merck and Co, Inc 2.1 Gyula Soltész, Chris Patterson, Gisela Dahlquist
Roche Diagnostics 2.2 Ravinder Singh, Jonathan Shaw, Paul Zimmet
Novartis
Bristol Myers-Squibb CHAPTER 3
Astra Zeneca Boyd Metzger
A publication such as this would not have been possible without CHAPTER 4
the commitment and contribution of many people around the Gojka Roglic
world. IDF would like to thank and express its deep appreciation of
the contributions of the following authors: CHAPTER 5
Jonathan Betz Brown, Dorte Vistisen, Richard Sicree,
Jonathan Shaw, Gregory Nichols, Ping Zhang
CHAPTER 6
6.1 Richard Sicree, Jonathan Shaw, Paul Zimmet
6.2 David Beran, John Yudkin
CHAPTER 7
Ravinder Singh, Jonathan Shaw, Paul Zimmet
CHAPTER 8
Paul Zimmet, KGMM Alberti, Jonathan Shaw
CHAPTER 9
Rhys Williams, Jonathan Shaw
CHAPTER 10
Martin Silink
IN TOUCH WITH
Sylvia Brunoldi, Marguerite de Clerk, Fatema Jawad,
Ambady Ramachandran
Special thanks to Shirley Murray for coordinating the work at the

International Diabetes Institute, and to Morten Agergaard for the
design of this publication.
Special thanks also to the IDF Regional Chairs for assistance: Morsi
Arab, Gordon Bunyan, Susana Feria de Campanella, Debbie Jones,
Kaushik Ramaiya, Wim Wientjens, Mahen Wijesuriya
_
ACKNOWLEDGEMENTS
IDF also gratefully acknowledges the help of the following for their
contribution to the publication:
IDF member associations
Zulfiqarali G Abbas, Carlos A Aguilar-Salinas, Nizar Albache,

Mansour M Al-Nozha, Maha Al-Till, Karolina Antonov, Fereidoun
Azizi, Michael Barry, Lee-Ming Chuang, Aynina Cisse, Kirsten
Coppell, Max de Courten, Wendy Davis, John Day, Anne Fagot-
Campagna, Juan Jose Gagliardino, Geoff Gill, Dan Hackam, Markolf
Hanefeld, Hans Hauner, Günther Heller, Lex Herreburgh, Julia
Hippisley-Cox, Akhtar Hussain, Tazeen Jafar, Jak Jervell, Harry Keen,
Hilary King, Ross Lawrenson, Warren Lee, Theodoros G Loizou, Berit
Lundman, Rachid Malek, Jaana Martakainen, Arne Melander, V
Mohan, Errol Morrison, Henrietta Mulnier, Bruce Neal, Annemette
Nielsen, Cynthia Perez, Catherine Regniers, Antti Reunanen,
Shaukat M Sadikot, Helmut Schröder, Ulrich Schwabe, Laidon
Shapo, Claudia P Sánchez-Castillo, Mohammed Tazi, Lesley Tilson,
Tom Walley, Peter Watkins, Kumudu Wijewardene
CONTENTS

Foreword 1
Introduction 3
Executive Summary 5
What is Diabetes? 7
PART 1 THE GLOBAL BURDEN OF DIABETES

Diabetes and Impaired Glucose Tolerance 10
CHAPTER 1
1.1 Prevalence and Projections 15
1.2 Known and Newly Diagnosed Diabetes 105
1.3 Complications of Diabetes 111
Diabetes in the Young: a Global Perspective

CHAPTER 2
2.1 Global Trends in Childhood Type 1 Diabetes 153
2.2 Type 2 Diabetes in the Young 193

CHAPTER 3 Gestational Diabetes Mellitus 211
CHAPTER 4 Diabetes Mortality 219
CHAPTER 5 The Economic Impacts of Diabetes 237
PART 2 THE CHALLENGES

Access to Insulin, Medication and Diabetes Supplies 267
CHAPTER 6 6.1 Diabetes Medication Use: International Prescription Patterns 271
6.2 Managing Insulin-Requiring Diabetes in Sub-Saharan Africa 288
CHAPTER 7 Mental Health, Antipsychotic Drugs and Hyperglycaemia 299
CHAPTER 8 The Metabolic Syndrome 307
PART 3 PREVENTION AND ACTION

Prevention and action 313
CHAPTER 9 Prevention and Diabetes: Possibilities for Success and Consequences of Inaction 317
From Vision to Action

CHAPTER 10 329

APPENDICES
Appendix 1.1 Methodology for Chapter 1.1 335
Appendix 1.2 Methodology for Chapter 1.3 339
Appendix 2 Methodology for Chapter 2.1 341
Appendix 3 Methodology for Chapter 5 343
Glossary 350
Acronyms 352
References 354
World Diabetes Foundation 376
_
FOREWORD
D iabetes is no longer an epidemic that can be ignored.

Each new edition of the Diabetes Atlas, strengthened by
the latest prevalence studies, confirms the fact that diabetes
these issues and challenges. It is now up to us to take up the
challenge and find cost-effective ways to tackle one of the
largest health problems we now face. We must unite –
is increasing – and increasing rapidly – in every part of the governments, organizations, individuals – to prevent
world. At the same time, there is now good evidence diabetes, to improve diabetes care for the millions affected
showing that type 2 diabetes can be prevented in many and to, ultimately, find a cure.
cases, and that there are cost-effective measures for
preventing diabetic complications. I would like to express my appreciation and thanks to the
many colleagues around the world whose invaluable
The third edition of the Diabetes Atlas firmly confounds what contribution has made this edition of the Diabetes Atlas
many have believed for so long. Once thought of as a disease possible. I would also like thank our sponsoring partners who
of affluent countries, type 2 diabetes is now a growing have given their support in so many ways. The Diabetes Atlas
burden on developing economies. More than 80% of the 246 will be a significant resource for all of us who are working to
million people with diabetes live in low- and middle-income improve the lives of millions touched by diabetes.
countries, where health resources are needed to combat
both contagious and chronic diseases. Once thought of as a
disease of the elderly, people in younger age groups now
form the bulk of those with diabetes. Some 46% of adults
with diabetes are in the 40–59 age group. Once thought of
‘as a touch of sugar’, studies show that diabetes at any age, if
not properly managed, will lead to serious outcomes, and, in
some cases, death. It is estimated that 3.8 million men and Pierre Lefèbvre
women will die from diabetes in 2007, more than 6% of total IDF President
world mortality. 2003 - 2006
If left unchecked, the number of people with diabetes will

reach 380 million in less than 20 years. This is more than the
current adult population of the African Region or of the
North American Region. This will mean that 1 out of 14 adults
worldwide will have diabetes in the year 2025. The loss of
earnings and lives because of diabetes will be hard to bear.
This edition of the Diabetes Atlas brings us face to face with
FOREWORD
INTRODUCTION
C hronic diseases account for a large proportion of the

global burden of disease and are the major cause of
death in almost all countries. It is estimated that diabetes,
The world has also been slow to recognize that there are
interventions that have been proven cost-effective in chronic
disease prevention and control. Many of these interventions
cardiovascular disease, cancer and other chronic, are feasible and inexpensive, even in the poorest countries.
noncommunicable diseases caused 35 million deaths in The World Health Organization is developing a framework
2005. Total deaths from infectious diseases, maternal and for assisting diverse countries in developing, implementing
perinatal conditions and nutritional deficiencies are and evaluating national policies and programmes for the
projected to decline by 3% by 2015. At the same time, prevention and control of chronic diseases. It supports an
deaths due to chronic diseases are projected to increase integrated, comprehensive, stepwise and multisectoral
by 17%. According to the recent report from the World approach focused on the common risk factors. An integrated
Health Organization, Preventing Chronic Disease: a vital approach to public health prevention and control of chronic
investment, each year at least 4.9 million people die as a disease is necessary to achieve the global goal of reducing
result of tobacco use, 2.6 million people die as a result of death rates by 2% per year over the next 10 years;
being overweight or obese, 4.4 million die as a result of achievement of this goal will prevent 36 million premature
raised total cholesterol levels and 7.1 million die as a result deaths by 2015.
of raised blood pressure.
Diabetes presents major challenges to patients, health
The same report stresses that common and modifiable systems and national economies. The World Health
risk factors that underlie the major chronic diseases are Organization together with the International Diabetes
widespread, and that the global response to address them Federation is working to raise awareness of diabetes
is inadequate. The inadequate response is in large part worldwide along with improving the quality of care. This
due to misconceptions regarding the major chronic latest edition of the Diabetes Atlas is a welcome update of the
diseases and their shared risk factors. Chronic diseases do trends in the global burden of diabetes and its related
not affect only rich people. In all but the least-developed economic implications. It also spotlights recently-
countries, poor people are more likely to develop chronic documented dimensions of the disease — such as the
diseases and more likely to die from them. Chronic increase in diabetes in children and the often underestimated
diseases are increasingly affecting younger people. mortality attributable to diabetes. I am confident that the
Childhood obesity is a growing problem even in poor Diabetes Atlas will continue to be a valuable resource for
countries and the incidence of type 2 diabetes in children advocates, policy-makers, researchers and healthcare
and adolescents is increasing. providers.
Although we have been extremely vigilant towards the

spread of infectious diseases, such as SARS and avian Robert Beaglehole
influenza in recent years, we have failed to keep in check the Director
‘silent killers’ like diabetes, cardiovascular disease and cancer. Department of Chronic Diseases and Health Promotion
These are widely perceived to be the result of voluntary Noncommunicable Diseases and Mental Health Cluster
choice of an unhealthy lifestyle. However, the choice of World Health Organization
lifestyle is very limited among the young and the poor, and Geneva
government action is needed to improve every person’s
access to a healthy life.
INTRODUCTION

EXECUTIVE SUMMARY
Global projections for the number of people with diabetes (20-79 age group), 2007-2025 (millions)
53.2
64.1
28.3 +21%
40.5
+43% 67.0
99.4
+48%
46.5
24.5
80.3
44.5
+73%
+81%
10.4
18.7
16.2 +80%
32.7
+102%
Africa
Eastern Mediterranean and Middle East World
Europe
North America 2007: 246
South and Central America 2025: 380
South-East Asia Increase: +55%
Western Pacific
T he third edition of the Diabetes Atlas confirms beyond all

doubt that the diabetes epidemic is real and that its
magnitude is larger than previous projections had anticipated.
around the world. There is also a closer examination of type
1 and type 2 diabetes in the young, as well as gestational
diabetes mellitus.
It reveals that the major burden of diabetes falls on the
developing world where it threatens not only to subvert the Data are provided for 215 countries and territories for the years
gains of economic development but also the gains brought 2007 and 2025. Estimates show that there will be some 246
about by international humanitarian programmes addressing million people with diabetes in 2007. This figure already
the UN Millennium Development Goals. outstrips an estimate made in 1994 in which it was predicted
that there would be 239 million people with diabetes in the
The third edition of the Diabetes Atlas has been structured year 2010. New studies have allowed us to revise the estimate
on four key messages: for 2025 from the second edition of the Atlas. If action is not
taken to put preventive measures in place, some 380 million
• Diabetes is common and getting commoner people are expected to have diabetes in 2025. This would be
• Diabetes is a life-threatening condition more than the current adult population of the African region.
• A full and healthy life is possible with diabetes
• In many cases, type 2 diabetes may be prevented Two sets of prevalence estimates have been provided in this
edition: national or regional prevalence, and comparative
The book is thus divided into three parts: the global burden, prevalence. The national or regional prevalence rate is ideal
the challenges, and prevention and action. Part 1 of the for assessing the burden of diabetes for each country or
Diabetes Atlas looks at the global burden of diabetes. It region, while the comparative prevalence is ideal for making
describes the diabetes pandemic and shows the evidence comparisons between countries or regions.
that is hard to ignore. It points out the consequences of
inaction by revealing the mortality caused by diabetes as The data underline once again that the burden of diabetes
well as the mounting health expenditures in countries is greatest in the developing world, where some 80% of
EXECUTIVE SUMMARY
those with diabetes live. The world is expected to spend at public health strategies to improve nutrition, prevent
least USD232 billion in 2007 to treat and prevent diabetes overweight and obesity, increase physical activity and reduce
and its complications. However, estimates in the Diabetes smoking, as these strategies will prevent not only diabetes
Atlas show that more than 80% of expenditures for medical but many of the chronic diseases.
care for diabetes are made in the world’s economically
richest countries, not in the low- and middle-income Part three also describes IDF’s lead to put diabetes on the
countries. In the world’s poorest countries, not enough is global agenda through its Unite for Diabetes campaign and
spent to provide even the least expensive lifesaving diabetes World Diabetes Day. It reinforces the message that the
drugs. epidemic of diabetes is one of the most serious challenges
facing the modern world. Diabetes is largely a hidden, silent
For the first time, country by country estimates of mortality epidemic causing much hardship, but it has not as yet
attributable to diabetes are presented in the Diabetes Atlas. received serious consideration from the world community.
It is estimated that there will be 3.8 million deaths attributable Prevention of diabetes is essential, as millions, especially in
to diabetes in 2007, similar in magnitude to those reported low- and middle-income countries, develop the disease each
for HIV/AIDS in the year 2002. The number of deaths year. To do nothing is not an option and is morally
attributable to diabetes calculated here is three to four times indefensible.
greater than those given in the conventional international
statistical reports largely based on diabetes given as an
underlying cause on death certificates. Although these
mortality estimates may not be accurate, given the
assumptions on which the calculations are based, they do
provide a more realistic estimate of diabetes-attributable
mortality than currently exist.
Part two focuses on some of the major challenges facing

people with diabetes. It examines the access to insulin,
medication and diabetes supplies, as well the association
between mental health, antipsychotic drugs and
hyperglycaemia. The issue of the metabolic syndrome is also
addressed here.
Access to insulin, medication and diabetes supplies remains

a major challenge for millions of people with diabetes around
the world. Part two provides a description of the pattern of
use of diabetes therapies, both pharmacological and dietary,
in as many countries as data are available. Describing the use
of hypoglycaemic treatments is valuable in gaining an
understanding of how therapies are actually used in practice,
as against the advice given in various published guidelines.
This edition of the Atlas also takes a closer look at the access
to diabetes care in three sub-Saharan countries as examples
of where solutions for better access could be found for
people with diabetes in the poorer countries.
Part three is a call for action. It provides the evidence that

much of type 2 diabetes can be prevented, and underlines
the need to implement cost-effective strategies to reduce or
prevent diabetic complications. Governments are
encouraged to take stock of the evidence and to implement
EXECUTIVE SUMMARY DIABETES ATLAS THIRD EDITION

WHAT IS DIABETES ?
D iabetes is recognized as a group of heterogeneous

disorders with the common elements of hyperglycaemia
and glucose intolerance, due to insulin deficiency, impaired
need injections of insulin every day in order to control the
levels of glucose in their blood. Without insulin, people with
type 1 diabetes will die.
effectiveness of insulin action, or both1. Diabetes mellitus is
classified on the basis of aetiology and clinical presentation The onset of type 1 diabetes is often sudden and dramatic
of the disorder into four types: and can include symptoms such as:
• type 1 diabetes • abnormal thirst and a dry mouth

• type 2 diabetes • frequent urination
• gestational diabetes mellitus (GDM) • extreme tiredness/lack of energy
• other specific types • constant hunger
• sudden weight loss
Type 1 diabetes • slow-healing wounds
• recurrent infections
Type 1 diabetes is sometimes called insulin-dependent, • blurred vision
immune-mediated or juvenile-onset diabetes. It is caused by
an auto-immune reaction, where the body’s defence system Studies now show that while incidence is on the increase
attacks the insulin-producing cells. The beta cells of the among children, it is not increasing among young adults.
pancreas therefore produce little or no insulin, the hormone This indicates a shift to a younger age at onset. The causes of
that allows glucose to enter body cells. The reason why this the changes over time are unknown and although migration
occurs is not fully understood. might slowly change the genetic background within a
population, the rapid changes in incidence rate reported to
The disease can affect people of any age, but usually occurs occur within comparatively short time spans are more likely
in children or young adults. People with this form of diabetes to be due to changes in environmental risk factors. These
WHAT IS DIABETES ?
environmental risk factors may initiate autoimmunity or Type 2 diabetes is often, but not always, associated with
accelerate and precipitate an already ongoing beta cell obesity, which itself can cause insulin resistance and lead to
destruction2. These risk factors include: elevated blood sugar levels. It is strongly familial, but major
susceptibility genes have not yet been identified. There are
Early events several possible factors in the development of type 2
Potential risk factors which may initiate the autoimmune diabetes. These include:
process include early fetal events e.g. blood group
incompatibility; maternal viral infections during pregnancy; • ethnicity
and early exposure to cow’s milk components and other • obesity, diet and inactivity
nutritional factors. • insulin resistance
• family history
Population-based case-control studies have identified some • intrauterine environment
protective factors, including a long duration of breast feeding3,
early vitamin D supplementation4, pre-school day care (as a In contrast to type 1 diabetes, persons with type 2 diabetes
proxy measure of infections)5 and atopic diseases6. are not dependent on exogenous insulin and are not ketosis-
prone, but may require insulin for control of hyperglycaemia
Lifestyle if this is not achieved with diet alone or with oral
Since type 1 diabetes in childhood is associated with hypoglycaemic agents.
estimates of general wealth such as GDP, it has been
suggested that lifestyle habits related to welfare might be Type 2 diabetes constitutes about 85 to 95% of all diabetes
responsible for the changes in trend. Wealth is a well-known in developed countries, and accounts for an even higher
determinant of birth weight and childhood growth. percentage in developing countries.
Weight and growth Gestational diabetes

Different estimates of child growth such as high birth weight,
an increased height, weight, weight for height and body Gestational diabetes mellitus (GDM) is a carbohydrate
mass index (BMI) have repeatedly been shown to be risk intolerance of varying degrees of severity which starts or is
factors for childhood onset diabetes7-11. Rapid growth is first recognized during pregnancy. The definition applies
associated with high growth hormone levels and an increased regardless of whether insulin is used for treatment or if the
number of fat cells both leading to insulin resistance and condition persists after pregnancy. It does not exclude the
thereby an overloading of the beta cell. Although possibility that unrecognized glucose intolerance may have
autoimmune mechanisms are responsible for the beta cell antedated the pregnancy.
destruction leading to type 1 diabetes, overload factors may
accelerate this process. Increased maternal glucose (blood sugar) levels are
associated with an increased rate of complications in the
Type 2 diabetes baby, including large size at birth, birth trauma, hypoglycaemia
(low blood sugar), and jaundice. Maintaining control of blood
Type 2 diabetes is characterized by insulin resistance and sugar levels significantly reduces the risk to the baby.
relative insulin deficiency, either of which may be present at
the time that diabetes becomes clinically manifest. The Women who have had GDM have an increased risk of
specific reasons for the development of these abnormalities developing type 2 diabetes in later years. GDM is also
are not yet known. associated with increased risk of obesity and abnormal
glucose metabolism during childhood and adult life in the
The diagnosis of type 2 diabetes usually occurs after the age of offspring.
40 years but could occur earlier, especially in populations with
a high diabetes prevalence. Type 2 diabetes can remain Impaired glucose tolerance
undetected, i.e. asymptomatic, for many years and the diagnosis
is often made from associated complications or incidentally Impaired glucose tolerance (IGT) is an asymptomatic condition
through an abnormal blood or urine glucose test. defined by elevated (though not diabetic) levels of blood
DIABETES ATLAS THIRD EDITION

Insulin production and action
Raises High
Blood Blood
Sugar Sugar
Promotes
insulin
release
Glucagon
Stimulates
Liver breakdown
of glycogen
Glycogen Glycose
Pancreas
Stimulates
formation
of glycogen
Insulin
Stimulates glucose
uptake from blood
Tissue Cells Promotes

(muscle, brain, fat, etc) glucagon
release
Insulin is a hormone produced by the pancreas that is necessary for cells to be able
Lowers Low
Blood Blood to use blood sugar. In response to high levels of glucose in the blood, the insulin-
Sugar Sugar producing cells in the pancreas secrete the hormone insulin. Type I diabetes occurs
when these cells are destroyed by the body’s own immune system. People with
type 2 diabetes produce insulin but cannot use it effectively.
glucose two hours after a 75g oral glucose challenge. Along survival. Insulin may also be used by people with type 2
with impaired fasting glucose (IFG), it is now recognized as diabetes. In type 2 diabetes, the body needs more insulin
being a stage in the transition from normality to diabetes. than it can produce.
Thus, individuals with IGT are at high risk of progressing to Since the landmark discovery of insulin by Frederick Banting
type 2 diabetes, although such progression is not inevitable, and Charles Best in 1921, huge steps forward have been
and probably over 30% of individuals with IGT will return to made in research and development in creating genetically
normal glucose tolerance over a period of several years. Not engineered human insulin. Until recently insulin was derived
surprisingly, IGT shares many characteristics with type 2 from a limited resource of the pancreas of cattle and pigs.
diabetes, being associated with obesity, advancing age,
insulin resistance and an insulin secretory defect.
Insulin
Insulin is the internal secretion of the pancreas formed by

groups of beta cells in the islets of Langerhans in this organ.
It is the hormone needed to enable glucose to enter the cells
and provide energy. Insulin is also important in keeping
blood glucose levels within the acceptable limits.
Insulin is injected into the body by people with type 1

diabetes in whom the cells that produce insulin have been
destroyed. This is the most common form of diabetes in
children and young adults, and they depend on insulin for
WHAT IS DIABETES ?
PART 1
THE GLOBAL BURDEN
It is now recognized that it is the developing countries that

presently face the greatest burden of diabetes. However,
many governments and public health planners still remain
largely unaware of the current magnitude, or, more
importantly, the future potential for increases in diabetes
and its serious complications in their own countries.
D iabetes is now one of the most common non-

communicable diseases globally. It is the fourth or fifth
leading cause of death in most developed countries and
problem, both because of its association with diabetes
incidence and its own association with an increased risk of
the development of cardiovascular disease.
there is substantial evidence that it is epidemic in many
developing and newly industrialized nations. Complications Part 1 of the Diabetes Atlas looks at the global burden of
from diabetes, such as coronary artery and peripheral diabetes. It describes the diabetes pandemic and shows the
vascular disease, stroke, diabetic neuropathy, amputations, evidence that is hard to ignore. It points out the consequences
renal failure and blindness are resulting in increasing of inaction by revealing the mortality caused by diabetes as
disability, reduced life expectancy and enormous health well as the mounting health expenditures in countries
costs for virtually every society. Diabetes is certain to be one around the world.
of the most challenging health problems in the 21st
century. Chapter 1 presents estimates of the prevalence of diabetes
mellitus and IGT for 215 countries and territories for the years
The number of studies describing the epidemiology of 2007 and 2025, which should provide some concept of the
diabetes over the last 20 years has been extraordinary. It is current and likely future burden. This chapter also provides a
now recognized that it is the developing countries that review of studies which allow an estimate of the proportion
presently face the greatest burden of diabetes. However, of cases of diabetes that are undiagnosed. Data are also
many governments and public health planners still remain provided on the prevalence of many of the complications of
largely unaware of the current magnitude, or, more diabetes, which illustrate the seriousness of the disease.
importantly, the future potential for increases in diabetes and
its serious complications in their own countries. Chapter 2 looks at the global trends in childhood type 1
diabetes and provides estimates for type 1 diabetes in
In addition to diabetes, the condition of impaired glucose children and adolescents. This chapter also reviews the
tolerance (IGT ) also constitutes a major public health available epidemiological data on type 2 diabetes in the
10 PART 1 DIABETES ATLAS THIRD EDITION

young from around the world. By focusing on such data it is
hoped that deficiencies in our knowledge of the disease will
be highlighted, and that strategies to deal with it will be
developed.
Chapter 3 highlights the rising trend of gestational diabetes

and the increased risk of developing type 2 diabetes in later
years in both the mother and the offspring.
Chapter 4 provides estimates of mortality attributable to

diabetes for 193 countries for the year 2007, which underlines
the need for preventive measures for diabetes and its
complications worldwide.
Chapter 5 examines the economic impact of diabetes and

estimates national health expenditures to treat and prevent
diabetes and its complications in 193 countries and territories
for the years 2007 and 2025. The results show that more than
80% of expenditures for medical care for diabetes are made
in the world’s economically richest countries, not in the low-
and middle-income countries where 80% of persons with
diabetes will soon live. In the world’s poorest countries, not
enough is spent to provide even the least expensive lifesaving
diabetes drugs.
THE
GLOBAL BURDEN PART 1 11
CHAPTER 1
DIABETES AND IMPAIRED GLUCOSE TOLERANCE

The number of people with
diabetes in Tanzania is expected
to increase by 50% within the
next 20 years.
14 CHAPTER 1 DIABETES ATLAS THIRD EDITION

1.0
DIABETES AND IMPAIRED GLUCOSE TOLERANCE
With the forces of globalization and industrialization

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

disorders with the common elements of hyperglycaemia
and glucose intolerance, due to insulin deficiency, impaired
should be used when interpreting data and their limitations
will be discussed further throughout the text.
effectiveness of insulin action, or both. Diabetes mellitus is Comparison of country, regional, and even global rates from
classified on the basis of aetiology and clinical presentation one report to the next can be misleading and should be
of the disorder into four types: type 1 diabetes, type 2 performed with extreme caution. Large changes in the
diabetes, gestational diabetes, and other specific types. prevalence or numbers of people with diabetes from one
edition of the Diabetes Atlas to another are usually due to the
Impaired glucose tolerance (IGT ) is an asymptomatic use of a more recent study rather than a genuine change in
condition defined by elevated (though not diabetic) levels the profile of diabetes within that country. Thus, the inclusion
of blood glucose two hours after a 75g oral glucose challenge. of recent, and more reliable research brings us closer to the
Along with impaired fasting glucose, it is now recognized as actual rates of diabetes, but also brings with it dangers in
being a stage in the transition from normality to diabetes. comparing global reports and estimates over time. These
Thus, individuals with IGT are at high risk of progressing to limitations need to always be considered, and the reader
type 2 diabetes, although such progression is not inevitable, must realize that the key purpose of reports such as these is
and probably over 30% of individuals with IGT will return to to stimulate action in the form of preventive and management
normal glucose tolerance over a period of several years. programmes, as well as further research.
The data presented in this chapter should be cautiously

interpreted as general indicators of diabetes frequency, and
the estimates will need to be revised as new and better
epidemiological information becomes available. When
reporting data in this form, various assumptions need to be
made that give rise to a number of limitations. Caution
DIABETES AND IMPAIRED GLUCOSE TOLERANCE CHAPTER 1 15

1.1
PREVALENCE AND PROJECTIONS
This report should act as a stimulus for intervention.

Perhaps the most essential aspect of research is the action
taken as a result of findings. Diabetes requires culturally
appropriate intervention in order to reduce the enormous
personal suffering and economic burden that grows with this
epidemic.
Introduction and other unhealthy lifestyle and behavioural patterns 1.
D iabetes mellitus and lesser forms of glucose intolerance,

particularly impaired glucose tolerance (IGT), can now
be found in almost every population in the world and
Figure 1.1 highlights the large range of type 2 diabetes
prevalences even within the same or similar ethnic groups,
when living under different conditions. Clearly, many of the
epidemiological evidence suggests that, without effective differences between these rates reflect underlying
prevention and control programmes, diabetes will likely behavioural, environmental and social risk factors, such as
continue to increase globally1. diet, level of obesity and physical activity.
Type 1 diabetes usually accounts for only a minority of the Within ethnic groups, high rates of type 2 diabetes are
total burden of diabetes in a population; it is the predominant usually found in migrant or urbanized populations that may
form of the disease in younger age groups in most developed have experienced a greater degree of lifestyle change. The
countries. Type 1 diabetes is increasing in incidence in both lowest rates are generally found in rural communities where
developing and developed countries, and there is an people have lifestyles incorporating high levels of physical
indication of a shift towards type 1 diabetes developing in activity.
children at earlier ages (see Chapter 2).
The incidence and prevalence of type 2 diabetes is also
Type 2 diabetes constitutes about 85 to 95% of all diabetes reported to be increasing in children. Studies from America
in developed countries1, and accounts for an even higher and Japan have demonstrated an increasing incidence2,3,
percentage in developing countries. Type 2 diabetes is while other ethnic groups with high adult diabetes
now a common and serious global health problem, which, prevalence such as the Pima Indians4 are also reporting
for most countries, has evolved in association with rapid increasing adolescent prevalences (see Chapter 2). The
cultural and social changes, ageing populations, increasing importance of this problem and the need for further research
urbanization, dietary changes, reduced physical activity are emphasized by the authors of this chapter.

Figure 1.1
Differences in the prevalence of type 2 diabetes among selected ethnic groups, 2007
Rural Bangladesh
Asian Indian
Singapore Indian
Rural Tunisia
Arab
United Arab Emirates
Rural Colombia
Hispanic
Urban Mexican
China
Chinese
Singapore Chinese
Rural Tanzania
African
African Jamaican
Rural Fiji
Oceania
Nauru
Prevalence (%) 0 5 10 15 20 25 30 35 40 45
2007 Prevalence rates are age standardized to

2025 Segi’s World Population for ages 30-64 year
In addition to estimating the prevalence of diabetes for the change recommended is the lowering of the diagnostic
years 2007 and 2025, data on case numbers and national value of the fasting plasma glucose concentration to 7.0
prevalence of impaired glucose tolerance (IGT) are presented mmol/l. For glucose tested in whole blood, the new
for both years. The decision to include data on IGT was based recommended threshold is 6.1 mmol/l12.
on two major factors associated with its presence: it greatly
increases the risk of developing diabetes5, and it is associated In many population studies, individuals have been categorized
with the development of cardiovascular disease6,7. as having diabetes mellitus based on blood glucose values
measured after an overnight fast and/or two hours after a 75g
Classification criteria and reporting oral glucose load. Whilst WHO still recommends the oral
standards glucose tolerance test (OGTT) as being the single best choice,
they also state that “if it is not possible to perform the OGTT
Standardization of methods and reporting in diabetes (e.g. for logistical or economic reasons), the fasting plasma
epidemiology promotes comparison between studies and glucose alone may be used for epidemiological purposes” 12.
may permit the pooling of results from different studies8,9.
Standardized criteria for detecting and reporting glucose It is important to realize that different screening and
intolerance have evolved greatly since the 1960s10. diagnostic criteria may have been used for different studies
in this report. The impact that the recent diagnostic cut-off
In the late 1970s both the US National Diabetes Data Group level changes have on prevalence estimates seems to vary
(NDDG) and the World Health Organization (WHO) produced from country to country13. In this section, the criteria used
new criteria on which to diagnose diabetes mellitus. In 1985, will be reported when they are known.
WHO modified their criteria to be more consistent with
NDDG values. More recently, the American Diabetes Global estimates of diabetes
Association (ADA) 11 and WHO 12 have produced new
recommendations for the diagnosis of diabetes. The major The global burden of diabetes has been estimated several
PREVALENCE
AND PROJECTIONS CHAPTER 1 17
Estimates for 2025 Why two prevalence estimates?
The estimates for 2025 of this edition are slightly Prevalences have been calculated for each country and
different to those published most recently in 2003. region in two ways:
There are two main reasons for this. Most importantly
30 new studies, applied to 70 countries, have been 1. National or regional prevalence
used. New studies were only used when it was felt that 2. Comparative prevalence
they improved the assessment of prevalence.
National or regional prevalence
Secondly, the 2004 edition of the United Nations The national or regional prevalence indicates the
Population Prospects, rather than the 2000 edition for percentage of each country’s or region’s population that
the population of each country, was used. This has only has diabetes. It is ideal for assessing the burden of
very marginally changed the estimate of world adult diabetes for each country or region. However, because
population for 2025, but for individual countries the the prevalence of diabetes increases with age, it cannot
changes are occasionally important. For example, the be used for comparing prevalences between countries
population estimate (age 20–79 years) for Bangladesh or regions which have different age structures. For
has been reduced by nine million, while that for example, the national prevalence of diabetes is higher in
Ethiopia has increased by seven million. Japan (7.2%) than in Samoa (6.5%), but we cannot tell if
this is just because Japan has an older population or
because Japanese are more prone to develop diabetes
than are Samoans.
times14-17. In 1994, the International Diabetes Federation (IDF) obtaining age-specific prevalences for those countries with
Directory14 included type 1 and type 2 diabetes estimates adequate data are given.
supplied by member nations. Using these data IDF estimated
that over 100 million people worldwide had diabetes. Also The principal aspects of the determination of prevalence
in 1994, McCarty et al15 used data from population-based were:
epidemiological studies and estimated that the global
burden of diabetes was 110 million in 1994 and that it would 1. Identification of studies through a detailed literature
likely more than double to 239 million by 2010. search, and contact with IDF member organizations.
WHO16 also produced a report using epidemiological 2. Employing the methodology indicated in Appendix 1.1 to
information and estimated the global burden at 135 million create smoothed curves for prevalence (with respect to
in 1995, with the number reaching 299 million by the year age).
2025. In 1997, Amos et al17 estimated the global burden of
diabetes to be 124 million people, and projected that this 3. Applying the prevalence rates to the population
would increase to 221 million people by the year 2010. distribution of that country, and where no data for those
Despite using different methodologies, and at times showing countries were available, to those other countries of similar
large differences in country-specific estimates, these reports ethnicity and economic circumstances, for which no local
have arrived at remarkably similar global figures of data were available.
diabetes.
4. Assuming an urban/rural prevalence ratio of 2:1 for
Methodology diabetes (but not IGT ), except in those countries
classified by WHO16 as market economies, or former
The principal details of the methodology are provided in socialist economies. The urban proportion of the
Appendix 1.1, where details of the rationale and process of population was derived from UN estimates18.

At a glance

2007 2025
Comparative prevalence Total world population (billions) 6.6 7.9
The comparative prevalence has been calculated by Adult population (age 20-79, billions) 4.1 5.2
assuming that every country and region has the same age
profile (the age profile of the world population has been WORLD DIABETES AND IGT (20-79 age group)
used). This removes the differences of age between
countries and regions, and makes this figure ideal for Diabetes
making comparisons, for example, the comparative Comparative prevalence (%) 6.0 7.3
prevalence shows that Samoans (7.5%) are in fact more Number of people with diabetes (millions) 246 380
prone to have diabetes than are Japanese (4.9%). The
comparative prevalence should not be used for assessing IGT
the proportion of people within a country or region who Comparative prevalence (%) 7.5 8.0
have diabetes. Number of people with IGT (millions) 308 418
5. The data for diabetes rates include both type 1 and type 2 Results
diabetes, with a separate chapter providing estimates on
type 1 diabetes in children and adolescents (see Chapter 2). The main aim of this section is to estimate the prevalence
of diabetes mellitus and IGT for each country for the years
6. The prevalence of diabetes throughout the Diabetes Atlas 2007 and 2025. Data are provided for 215 countries and
includes both undiagnosed and previously diagnosed territories, which have been allocated mostly on a
diabetes. geographical basis into one of the seven IDF regions: Africa
(AFR), Eastern Mediterranean and Middle East (EMME),
This section contains prevalence estimates of diabetes and IGT Europe (EUR), North America (NA), South and Central
for the years 2007 and 2025, and although the Tables contain America (SACA), South-East Asia (SEA), and the Western
data listed to one decimal point, it should not be inferred that Pacific (WP).
this indicates the degree of precision, but rather to facilitate
calculations and the appearance of the Tables. In general, no The prevalence of diabetes and IGT has been calculated in
predictions of diabetes or IGT numbers should be taken as two ways:
having reliability of more than one significant figure.
1. National prevalence: the age and sex structure of each
The consequence of applying current age and gender specific country has been used to provide an accurate
specific prevalence rates to estimate prevalences and estimate of the percentage of adults affected within each
number of cases for the year 2025 is that only changes in country.
the age and urban/rural distribution of the population will
affect the estimates. Since it is likely that the age specific 2. Comparative prevalence: the age and sex structure of the
prevalence rates (the prevalence at any given age) will rise world population has been used to provide a prevalence
due to increasing obesity, the figures are probably estimate for each country that can readily be compared
underestimates. to other countries.
PREVALENCE
MAP 1.1
Prevalence estimates of diabetes, 2007
>20%
14% - 20%
10% - 14%
8% - 10%
6% - 8%
4% - 6%
<4%
MAP 1.2
Prevalence estimates of diabetes, 2025
>20%
14% - 20%
10% - 14%
8% - 10%
6% - 8%
4% - 6%
<4%

MAP 1.3
Prevalence estimates of impaired glucose tolerance, 2007
>20%
14% - 20%
10% - 14%
8% - 10%
6% - 8%
4% - 6%
<4%
MAP 1.4
Prevalence estimates of impaired glucose tolerance, 2025
>20%
14% - 20%
10% - 14%
8% - 10%
6% - 8%
4% - 6%
<4%
PREVALENCE AND PROJECTIONS CHAPTER 1 21

Figure 1.2 Figure 1.3
World population (20-79 age group) by region, 2007 and 2025 Prevalence of diabetes* (20- 79 age group) by region, 2007 and 2025
Millions Prevalence (%)

12
2,000
10
1,600
1,200
800
4
400
2
0 0
AFR EMME EUR NA SACA SEA WP AFR EMME EUR NA SACA SEA WP
2007
2007 *Comparative prevalence
2025 2025
The data presented are for all diabetes combined, i.e. type 1 million, or 7.1% of the adult population, by 2025 (see Table
and 2 diabetes, and for IGT. Only adults aged from 20 to 79 1.1). The largest increases will take place in the regions
years of age are considered because the majority of all dominated by developing economies.
people who have diabetes and IGT are adults. Type 1 and
type 2 diabetes in children and adolescents are addressed The Western Pacific Region with 67 million and the
separately in Chapter 2. It should be noted that column European Region with 53 million will have the highest
numbers in the Tables may not always exactly be the sum of number of people with diabetes in 2007. However the
the components because of rounding effects. comparative prevalence rate (adjusted to the world
population) of 4.4% for the Western Pacific Region is
Demography significantly lower than 9.2% for the Eastern Mediterranean
and Middle East Region, and 8.4% in the North American
The total populations of the regions and the population Region (see Figure 1.3).
aged from 20-79 years are shown in Figure 1.2. It is clear that
the Western Pacific Region, which includes China, and the By 2025 the diabetes prevalence of the South and Central
South-East Asian Region, which has India as a member, have America Region is expected to be nearly as high (9.3%) as
the greatest numbers of people. that of the North American Region (9.7%). The Eastern
Mediterranean and Middle East Region will continue to have
Diabetes the highest rate of prevalence with 10.4% of its adult
population affected by diabetes.
Prevalence
It is estimated that approximately 246 million people, or The age structure of the population has a large effect on the
5.9%, in the age group 20-79 will have diabetes worldwide relative prevalences. The European and North American
in 2007. Some 80% of these live in the developing countries. Regions have considerably older populations, so that without
The worldwide estimate is expected to increase to some 380 reference to an age-standardized population, the European

Number of people with diabetes (20-79 age group) by region, 2007
and 2025 Number of people with diabetes in age groups by region, 2007
Millions Millions
100 40
90
35
80
30
70
25
60
50 20
40
15
30
10
20
5
10
0 0
2007 20 - 39 40 - 59 60 - 79
2025
Region has the second highest prevalence, for both years (see there are expected to be two million more women than men
Tables 1.17 and 1.18). When adjusting to the same population with diabetes (124 million women vs 122 million men), with
structure, the European Region has the third highest this difference expected to be about four million by 2025
prevalence for 2007, and the fourth for 2025 (see Table 1.1). (192 million vs 188 million).
It is the Western Pacific Region, however, which will have the Urban/rural distribution
highest number of people with diabetes, with some 100 In 2007 the expected number of people with diabetes in
million, representing an almost 50% increase from 2007 (see urban areas will be 86 million, compared to 66 million in rural
Figure 1.4). areas in countries not considered to be established market
economies or former socialist economies. By 2025 it is
Age distribution expected that this discrepancy will increase to 179 million
The 40-59 year age group currently has the greatest number urban and 81 million rural persons with diabetes.
of persons with diabetes with some 113 million, of which
more than 70% live in developing countries (see Figure 1.5). Impaired Glucose Tolerance
By 2025, because of the ageing of the world’s population, Prevalence

there will be 166 million with diabetes aged 40-59, over 80% It is estimated that approximately 308 million, or 7.5% in the
of which will be in newly developed or developing countries. age group 20 – 79, will have IGT in 2007, of which more than
There will be almost as many in the 60-79 age group, 80% live in developing countries. By 2025 the number of
approximately 164 million (see Figure 1.6). people with IGT is projected to increase to 418 million, or
8.1%, in the adult population (see Table 1.2).
Gender distribution
The estimates for both 2007 and 2025 showed little gender The Western Pacific Region is expected to have the greatest
difference in the number of persons with diabetes. For 2007 number of people with IGT in 2007 with some 112 million,
PREVALENCE
Prevalence of impaired glucose tolerance* (20-79 age group) by
Number of people with diabetes by age group, 2007 and 2025 region, 2007 and 2025

200 12
175
10
150
8
125
100 6
75
4
50
2
25
0 0
Age group 20 - 39 40 - 59 60 - 79 AFR EMME EUR NA SACA SEA WP

2007 2007 *Comparative prevalence
2025 2025

Number of people with impaired glucose tolerance (20-79 age group) Prevalence of diabetes and impaired glucose tolerance* (20-79 age
by region, 2007 and 2025 group) by region, 2007 and 2025

160 25
140
20
120
100
15
80
10
60
40
5
20
0 0

2007 Diabetes 2007 *Comparative prevalence
2025 IGT 2025

Number of people with diabetes and impaired glucose tolerance (20- Number of people with impaired glucose tolerance by age group,
79 age group) by region, 2007 and 2025 2007 and 2025
Millions Millions
300 175
150
250
125
200
100
150
75
100
50
50
25
0 0
AFR EMME EUR NA SACA SEA WP Age group 20-39 40-59 60-79
Diabetes 2007 2007

IGT 2025 2025
although the European Region has the highest prevalence Regional overview
rate with 9.1% of the adult population affected by IGT (see
Figure 1.7). By 2025, absolute numbers of persons with IGT Africa
are generally likely to increase by 30-70% in many regions,
with the greatest increases in Africa, and the Eastern Diabetes exerts a considerable toll on the health resources
Mediterranean and Middle East (see Figure 1.8). of the developing countries of sub-Saharan Africa. The
chronicity of the disease and diabetic complications places
The prevalence of IGT is generally similar to that of diabetes, an immense burden on people with diabetes and their
but somewhat higher for the African and Western Pacific families.
Regions, but slightly lower than of diabetes in the North
American Region (see Figure 1.9). The landscape of sub-Saharan Africa is dominated by the
twin disasters of poverty and HIV infection. While HIV
Figure 1.10 highlights the large increases in absolute numbers infection and consequent AIDS so dominate the health
of both diabetes and IGT over the 18-year period. needs for sub-Saharan Africa, there is only a small proportion
of the population reaching ages at which type 2 diabetes
Age distribution becomes a major health concern. In 2007 only 9.9% of the
As with diabetes, the 40-59 year age group is expected to have population will be 50 years of age or older, and this is
the greatest number of persons with IGT for 2007 with some expected to increase to only 10.5% by 2025. Thus the effects
122 million, and this will remain true in 2025 with 164 million as of HIV and malnutrition combine to greatly reduce the size
shown in Figure 1.11. It is also of note that one-third of all those of groups most at risk for type 2 diabetes.
who will have IGT for 2007 are in the 20-39 year age group.
Diabetes and IGT prevalence
It is estimated that there will be 10.4 million people with
diabetes, or 3.1% of the adult population, in the African
PREVALENCE
AFRICA At a glance
2007 2025
Total population (millions) 747 1,088
Adult population (millions) (20-79 years) 336 537
Diabetes and IGT (20-79 age group)
Diabetes
Regional prevalence (%) 3.1 3.5
Comparative prevalence (%) 3.6 4.5
Number of people with diabetes (millions) 10.4 18.7
IGT
Number of people with IGT (millions) 24.2 40.3
Region in 2007 (see Table 1.7). There are marked discrepancies prevalence. Notwithstanding that Cameroon and Ghana are
between the rates of diabetes prevalence among different about 1,000 kilometres apart, and classified by the United
communities in sub-Saharan Africa. The highest prevalences Nations (UN)31 as being in different parts of Africa (central
are among the ethnic Indian population of Tanzania19 and and western, respectively), it was decided to use the average
South Africa20. The studies from Tanzania21,22 (urban:rural ratio of the results of the two studies to apply to the other African
of 5:1) and Cameroon23 (ratio of 2:1) both confirm the marked countries in the region.
urban/rural discrepancy in diabetes prevalence, with the
consequent likely increases in numbers with diabetes as That the data should need to be extrapolated to such distant
more people move to urban areas. and probably dissimilar countries and populations indicates
the great need for further epidemiological investigation in
The availability of prevalence data for sub-Saharan Africa is the region. Such a need can also be linked with the high
very limited, and nearly all the data here were derived from proportion of diabetes that has not been previously detected,
studies from South Africa 24-27, Tanzania 21,22, Ghana 28, but found only at the time of surveying. Undiagnosed
Cameroon23,29 and Sudan30. This meant that data from these diabetes accounted for 80% of those with the condition in
studies were applied to populations living up to several Cameroon29, 70% in Ghana28 and over 80% of the 2002
thousand kilometres from where the study was undertaken. Tanzania survey22 (See Chapter 1.2).
In the three years since the last edition of the Diabetes Atlas
(2003), only two further unpublished studies27,29 have been The impact of type 2 diabetes is bound to continue if nothing is
made available for this report. done to curb the rising prevalence of impaired glucose tolerance,
which now varies between 0.9% and 16.5% (see Table 1.9).
Whereas the previously used Cameroon data23 indicated a
much lower prevalence of urban diabetes than the Ghana Eastern Mediterranean and Middle East
data, the new data from Cameroon29 indicate a very similar
diabetes prevalence to that for Ghana, but much lower IGT Studies performed in six countries of the Eastern

Eastern Mediterranean and Middle East
At a glance
2007 2025
Total population (millions) 592 814
Diabetes
IGT
Mediterranean and Middle East Region – Bahrain32, Egypt33,34, people, or 7.7% of the adult population, will have diabetes in
Kuwait35, Oman36, Saudi Arabia37-40 and United Arab Emirates41 2007 (see Table 1.12), with the number of those with diabetes
– have shown their current diabetes prevalence to be among expected to nearly double by 2025. Similarly the number of
the world’s 10 highest, and a similar situation applies for the persons with IGT is expected to also rise markedly by 2025,
IGT prevalences of some of these countries (see Tables 1.3 increasing the likelihood of further increases in the prevalence
and 1.5). The ageing of populations, together with socio- of diabetes as the century proceeds.
economic changes and westernization, has resulted in the
dramatic increase in the diabetes prevalence. The comparative prevalences for 2007, when applied to a
world standard population distribution rather than the
Over the past three decades major social and economic young population distribution common in the region, are as
changes have occurred in the majority of these nations. high as 20% in the United Arab Emirates41, 15% in Bahrain
These include progressive urbanization, decreasing infant and Qatar32, but even in much less affluent Pakistan the
mortality and increasing life expectancy. Rapid economic prevalence is 9.6%47-49.
development, especially among the more wealthy oil-
producing countries, has been associated with tremendous In contrast to Africa, there is a large number of studies reporting
changes in lifestyle towards the westernized pattern reflected diabetes prevalence, so that of the 22 countries of the Region,
by changes in nutrition, less physical activity, tendency to 18 have data available, from which national prevalence
increased obesity and more smoking42-46. estimates could be derived (see Table 1.16). Since the second
edition of the Diabetes Atlas, new data have been included for
Diabetes and IGT prevalence Algeria50, Iran51, Morocco52, Occupied Palestinian Territory53,54,
The explosion of diabetes in the EMME Region is mainly due Saudi Arabia38-40, Syrian Arab Republic55 and Yemen56. These
to type 2 diabetes. As with many other countries with high new studies have led to an increase in estimated prevalence
diabetes prevalence, the onset of type 2 diabetes tends to for all of these populations, except Yemen, for which data from
occur at a relatively young age. An estimated 24.5 million Oman had previously been used36.
PREVALENCE
EUROPE At a glance
2007 2025
Diabetes
IGT
Europe diabetes currently, and such high levels of IGT that the diabetes
prevalence will almost certainly increase by 2025 to levels
There exists a great diversity of populations and affluence above those indicated in Table 1.18, as these took no account
among the 53 countries and territories in the European of the higher incidence of diabetes among those with IGT.
Region, with gross domestic product (GDP) varying from
over USD60,000 per capita for Luxembourg to less than Surprisingly there is a paucity of good data from many of the
USD2,000 for several of the former socialist republics57. more affluent western countries of the region. Much of the
data for Europe is based on surveys establishing the prevalence
Diabetes and IGT prevalence of ‘known diabetes’. This applied to reports from France62,
The number of people with diabetes in this vast region is Germany63-65, Israel66, Italy67, Netherlands68 and Norway69. The
expected to reach 53.2 million, or 8.4% of the adult population prevalence rates of these reports were doubled to estimated
in 2007. National prevalence rates for diabetes show a wide total diabetes, based on other European data70-73.
variation from 2.0% in Iceland to 11.8% in Germany (see Table
1.17). Abnormal glucose tolerance in this region shows little In comparison with the second edition of the Diabetes Atlas,
association with affluence, and there was no evidence that national data from several countries – Albania, Cyprus,
any difference in urban/rural prevalence existed except in Denmark, France and Norway – have been used, which has
Turkey58, and the Central Asian Republics of Kazakhstan, reduced the need to extrapolate from other countries.
Kyrgyzstan, Tajikistan and Turkmenistan (for which data were Nonetheless, there remains a marked lack of data for eastern
extrapolated from neighbouring Uzbekistan59). Europe, so that survey results from Poland were used for 12
other countries.
The lack of data from several of the former socialist republics
required that data for many countries be extrapolated from To a large degree the high prevalence of abnormal glucose
two studies from Poland - urban Krakow60, and the urban and tolerance is a consequence of the relatively old population
rural areas near Lublin61. These data suggested high levels of of the European Region, such that currently a third of the

North America At a glance
2007 2025
Diabetes
IGT
population is over 50 years of age, and is expected to increase Diabetes and IGT prevalence
to over 40% by 2025. Thus the number of persons with The high prevalence of abnormal glucose tolerance for Canada
diabetes and IGT will increase, although the total regional and the USA are very much a consequence of their older age
population will have decreased. This will place an increasing distribution, such that 30% of their population are over 50
financial burden on the declining working-age population years of age, and expected to be 36% by 202531. This is in
to provide resources for the health consequences of rising contrast to 16% of those over 50 years of age increasing to
diabetes prevalence in the older population. The region has 26% for Mexico, and 20% increasing to 28% for the Caribbean.
the resources to be at the forefront of efforts to amend
lifestyle factors contributing to the prevalence of diabetes. The data published in Tables 1.24 and 1.25 indicate the
expected number of persons with impaired fasting glucose
North America (IFG) for Canada and the USA, based on the data from the
National Health and Nutrition Examination Survey (NHANES)
The North American Region has the highest prevalence of 1999-200074, which based assessment on the fasting glucose.
diabetes among the IDF regions with 9.2%, or 28.3 million NHANES III data75 suggested that IGT prevalence was about
persons with diabetes in the adult population, for 2007 (see 50% higher than for IFG, on which basis about 18 million
Table 1.22). The region is expected to continue to have the Americans are likely to affected by IGT in 2007 (9%
highest prevalence in 2025 when 10.8% of adults are prevalence), and nearly 25 million in 2025.
anticipated to have diabetes.
As all the Caribbean islands other than Barbados, Guadeloupe
Although the region comprises 24 countries and territories, and Martinique had their estimates extrapolated from
68% of the adult population reside in the United States of Jamaican data76, the differences in prevalence are a
America (USA), with a further 21% living in Mexico and 8% in consequence only of different age distributions for the islands.
Canada, so that only 3% of the region’s adult population
reside in the other 21 smaller nations. There were new studies of diabetes prevalence used for
PREVALENCE
South and Central America At a glance
2007 2025
Diabetes
IGT
USA77 and Mexico78,79, which hardly affected the USA estimate, 25% by 2025. Thus the region has a markedly younger age
but somewhat increased that for Mexico. distribution than most of North America. The likelihood is
that diabetes will become a more major health priority for
South and Central America the region given the decreasing difference in age distribution
between this region and North America, and with the
The South and Central American Region encompasses 22 continuing momentum for urbanization.
countries and territories, most of which are still developing
economically. It is estimated that 16.2 million persons, or South-East Asia
6.0% of the adult population, will have diabetes in 2007 (see
Table 1.27). In the next 18 years, the number of people with The South-East Asian Region comprises only seven countries.
diabetes is expected to rise dramatically to 32.7 million. The adult population of India accounts for 85% of that of the
region. Mauritius has the highest per capita GDP at USD13,300,
Diabetes and IGT prevalence while the other countries all have per capita GDPs of less than
Considerable extrapolation was required in this region as 15 USD5,000, although India with a current annual growth of 7.1%
countries did not have any epidemiological data from which is experiencing economic development at a faster pace than
prevalence estimates could be derived. New studies in almost anywhere in the world except its neighbour, China57.
Mexico78,79 were used to extrapolate prevalence estimates for
several countries in the region. New studies were also used Diabetes and IGT prevalence
for Argentina80, Brazil81 and Chile82, all of which were of There will be an estimated 46.5 million people, or 6.0% of the adult
specific regional populations. population, with diabetes in the region in 2007 (see Table 1.32).
Economic progress is inevitably associated with increasing
South America and Central America have similar age urbanization, and it appears that features of urban life tend to increase
distribution profiles. Currently about 17% of the population the prevalence of diabetes among persons of Indian ethnic
is older than 50 years, with this figure likely to increase to background to a greater extent than for other populations83.

South-East Asia At a glance
2007 2025
Total population (millions) 1,336 1,656
Adult population (millions) (20-79 years) 770 1,083
Diabetes
IGT
The second edition of the Diabetes Atlas used data from a single With regard to IGT, the same nationwide study indicated the
report84, based on a population-based survey from the six largest same pattern as for diabetes, suggesting large cities to have
Indian cities, and extrapolated these results nationwide, applying twice the prevalence of smaller cities, for which the
a 4:1 urban:rural ratio from these findings for diabetes prevalence prevalence is twice those of rural areas. As India is a
(the majority of the Indian population is classified as rural). For predominantly rural country, this has led to a marked
this report, two additional reports of population data collected reduction in the overall IGT numbers projected for 2007 and
on a nationwide basis85,86 were used, which suggest that 2025 (see Tables 1.34 and 1.35), such that both are about half
diabetes prevalence in smaller urban centres (100,000 – those previously projected in the second edition of the
1,000,000 inhabitants) tends to be about half of the larger cities, Diabetes Atlas.
but still twice that of rural areas (less than 100,000 persons). This
has led to a 30% reduction in expected urban diabetes cases, Mauritius, the second smallest country of the region,
but no change to rural diabetes estimates. highlights the extent to which persons of Indian ethnicity
appear predisposed to diabetes, when exposed to more
The anticipated increase in regional diabetes prevalence affluent economic circumstances. This island has the world’s
from 6.0% to 7.4% in 2025 is very much a consequence of eighth highest diabetes prevalence (of countries with
the increasing life expectancy in India, where the proportion representative prevalence data); currently 11% and expected
of the population over 50 years is expected to increase from to be 13% by 2025, and a similarly high IGT prevalence of
16% to 22% between 2007 and 202531, and the urban 16%, likely to rise to nearly 18%.
proportion from 31% to 43%87 (see Table 1.33). Evidence
suggests that in more affluent parts of the country, the rural Additional data have also become available for Nepal89,90,
prevalence is higher than less affluent rural areas88, indicating Bangladesh 91 and Sri Lanka 92. These additional studies
that increasing economic growth will increase diabetes have not markedly affected the Bangladeshi or Nepali
prevalence in India even more than these possibly estimates, but have markedly increased those for Sri
conservative estimates have indicated. Lanka.
PREVALENCE
Western Pacific At a glance
2007 2025
Total population (millions) 2,168 2,397
Adult population (millions) (20-79 years) 1,469 1,732
Diabetes
IGT
Comparative prevalence 7.5 7.8
Western Pacific new surveys from South Korea96, Viet Nam97, Singapore98 and
China99. The age specific prevalence estimates of these studies
The world’s most populous region contains 39 disparate were also applied to several other countries of the region.
countries and territories with populations ranging from 1.3
billion for China to less than 5,000 in the smallest Pacific The use of these studies led to higher prevalence estimates
island nations of Niue and Tokelau. Similarly the economic for all of the countries in which they were performed, except
profile varies from per capita GDPs of over USD30,000 for Singapore. For Cambodia, this was a doubling in national
Australia, Hong Kong, Japan and Singapore to less than prevalence, for the Philippines a tripling, and for Thailand
USD3,000 in one-third of the other countries. more than tripling; all of these countries had prevalence
estimates previously based on a 1996 report from Thailand100.
The less economically advanced countries struggle with the For Viet Nam, the estimates based on the Ho Chi Minh City
double burden of managing infectious diseases and the survey of 2001 are twice those from the survey a decade
diabetes epidemic with limited resources. Many also face the previously from Hanoi101. For South Korea, the new survey96
lack of government awareness of the seriousness of the showed a 25% higher prevalence than of that used
diabetes threat to their populations. previously102. The new Singapore data led to slightly lower
overall prevalence than the 1998 data103.
Diabetes and IGT prevalence
Not surprisingly there is a great diversity in the prevalence of The new Chinese data have the largest impact on overall
diabetes, with the world’s highest found in the Micronesian prevalence and case number estimates, as 60% of the region’s
population of Nauru (30.7% of the adult population). population live there. The national prevalence estimate is
60% higher than that derived from the previously used
Several new studies have been included since the second survey104. Whereas that survey from 1994 was OGTT-based,
edition of the Diabetes Atlas, incorporating data from urban with classification based on 1985 WHO criteria105, the current
and rural areas of Cambodia93, Philippines94 and Thailand95, and report based diagnosis (of diabetes, or IFG) on fasting glucose

Figure 1.12
Top 10: Prevalence of diabetes* (20-79 age group) in 2007 (with 2025 prevalence)
COUNTRY
Nauru
Saudi Arabia
Bahrain
Kuwait
Oman
Tonga
Mauritius
Egypt
Mexico
Prevalence (%) 0 5 10 15 20 25 30 35 40

2025
levels106 as well as self-report. The current report is also more the prevalence of diabetes, a number of assumptions needed
nationally representative, albeit with fewer participants. In to be made, and therefore the results are subject to a number
addition to the fasting criterion indicating a higher diabetes of limitations. In addition to those highlighted in the
prevalence than previously estimated, the Chinese IFG Methodology section in Appendix 1.1, some of these are
prevalence of 6.9% is double that of the previous IGT that:
estimate. There was no evident urban/rural IFG gradient, but
diabetes prevalence was about 50% higher in urban areas. • The studies included in this section often used differing
Only 25% of diabetes had been previously diagnosed. screening techniques. The majority of studies used an
OGTT to screen for diabetes. However, some studies used
The diabetes epidemic has the greatest potential to explode a fasting blood glucose (FBG), some a two-hour blood
in China, simply because of its population size. Although the glucose (2BG), some a random blood glucose (RBG), and
current national prevalence there of 4.3% is among the some based their data on self-report (SR). It is difficult to
region’s lowest, the high prevalence among Chinese control for this unless, for example, only those studies
populations in the more urbanized and affluent cities of that used an OGTT were included. This would also have
Hong Kong and Singapore indicate what may develop as the effect of excluding findings from countries lacking
China rapidly urbanizes and expands economically. The data OGTT data, which would result in data for those countries
indicated for 2025 in Table 1.38 are likely to represent an being extrapolated from another country. The other
underestimate of China’s diabetes problem if it continues to consequence of incorporating studies that had no OGTT
develop economically faster than almost any other country data is that impaired fasting glucose (IFG) rather than IGT
in the world. represented the non-diabetic, but abnormal, glucose
metabolism.
Discussion
• There were inconsistencies in the diagnostic criteria
In order to make national, regional and global predictions for adopted, resulting from the updating of the diagnostic
PREVALENCE
Figure 1.13
Top 10: Prevalence of impaired glucose tolerance* (20-79 age group) in 2007 (with 2025 prevalence)
COUNTRY
Nauru
Bahrain
Kuwait
Singapore
Kiribati
Mauritius
Poland
Tonga
Denmark
Prevalence (%) 0 5 10 15 20 25 30 35 40

2025
criteria in 199711. The use of a lower fasting diagnostic With the forces of globalization and industrialization
criterion for diabetes will tend to result in a higher proceeding at an increasing rate, the prevalence of diabetes
prevalence of diabetes and lower prevalence of IGT. The is predicted to increase dramatically over the next few
diagnostic criteria used for each country are indicated in decades. The resulting burden of complications and
the Tables on data sources. premature mortality will continue to present itself as a major
and growing public health problem for most countries.
• Studies from several countries (Canada, France, Germany,
Israel, Italy, Netherlands, New Zealand, Norway) only It is hoped that this report will assist in monitoring the trends
provided data on self-reported diabetes. To account for of diabetes prevalence over time, by adopting the same
undiagnosed diabetes, the prevalence of diabetes for methodology for future reports. A report such as this should
Canada was multiplied by a factor of 1.5, in accordance also be an indicator of a country’s and region’s ‘database’ of
with findings from the USA75, and for the other countries research. It should stimulate research in those countries
doubled, based on data from a number of countries70-73,107. lacking data, as well as encourage further and improved
research in those countries where available data may not be
• If a country lacked data, it was assumed that their age and representative of national rates.
sex-specific prevalence rates of diabetes mellitus were the
same as those rates in another socio-economically, Finally, this report should act as a stimulus for intervention.
ethnically and geographically similar country. Perhaps the most essential aspect of research is the action
taken as a result of findings. Diabetes requires culturally
• Some of the studies were performed more than a decade appropriate intervention in order to reduce the enormous
ago, and thus may not reflect current prevalence rates. personal suffering and economic burden that grows with
The prevalences and numbers of persons predicted this epidemic.
based on such studies are likely to be conservative
estimates.

Table 1.1
Regional estimates for diabetes (20-79 age group), 2007 and 2025
2007 2025 2007/2025

No. of No. of Increase in the
Population people with Diabetes Population people with Diabetes no. of people
(20-79) Diabetes prevalence* (20-79) diabetes prevalence* with diabetes
Region millions millions % millions millions % %

AFR 336 10.4 3.6 537 18.7 4.5 80.1
EMME 318 24.5 9.2 492 44.5 10.4 81.4
EUR 634 53.2 6.6 653 64.1 7.8 20.6
NA 306 28.3 8.4 376 40.5 9.7 43.4
SACA 272 16.2 6.3 364 32.7 9.3 101.7
SEA 770 46.5 6.5 1,083 80.3 8.0 72.6
WP 1,469 67.0 4.4 1,732 99.4 5.1 48.4
Total 4,107 246.1 5.9 5,237 380.3 7.1 54.5
*comparative prevalence
Table 1.2
Regional estimates for IGT (20-79 age group), 2007 and 2025
2007 2025 2007/2025

No. of No. of Increase in the
Population people with IGT Population people with IGT no. of people
(20-79) IGT prevalence* (20-79) IGT prevalence* with IGT
Region millions millions % millions millions % %

AFR 336 24.2 8.2 537 40.3 9.2 66.9
EMME 318 22.4 8.1 492 38.6 8.8 72.4
EUR 634 65.3 9.1 653 71.2 9.6 9.0
NA 306 19.6 5.8 376 27.5 6.7 40.3
SACA 272 19.8 7.5 364 27.6 7.9 39.4
SEA 770 45.2 6.0 1,083 70.5 6.7 56.1
WP 1,469 111.9 7.5 1,732 142.7 7.8 27.5
Total 4,107 308.3 7.5 5,237 418.4 8.1 35.7

Table 1.3
Top 10: Prevalence of diabetes* (20-79 age group), 2007 and 2025
2007 2025
Country Prevalence (%) Country Prevalence (%)
1 Nauru 30.7 1 Nauru 32.3

2 United Arab Emirates 19.5 2 United Arab Emirates 21.9
3 Saudi Arabia 16.7 3 Saudi Arabia 18.4
4 Bahrain 15.2 4 Bahrain 17.0
5 Kuwait 14.4 5 Kuwait 16.4
6 Oman 13.1 6 Tonga 15.2
7 Tonga 12.9 7 Oman 14.7
8 Mauritius 11.1 8 Mauritius 13.4
9 Egypt 11.0 9 Egypt 13.4
10 Mexico 10.6 10 Mexico 12.4
Includes only countries where surveys with glucose testing were undertaken for that country

Table 1.4
Top 10: Number of people with diabetes (20-79 age group), 2007 and 2025
2007 2025
Country Persons (millions) Country Persons (millions)
1 India 40.9 1 India 69.9

2 China 39.8 2 China 59.3
3 United States of America 19.2 3 United States of America 25.4
4 Russian Federation 9.6 4 Brazil 17.6
5 Germany 7.4 5 Pakistan 11.5
6 Japan 7.0 6 Mexico 10.8
7 Pakistan 6.9 7 Russian Federation 10.3
8 Brazil 6.9 8 Germany 8.1
9 Mexico 6.1 9 Egypt 7.6
10 Egypt 4.4 10 Bangladesh 7.4

Table 1.5
Top 10: Prevalence of impaired glucose tolerance* (20-79 age group), 2007 and 2025
2007 2025
Country Prevalence (%) Country Prevalence (%)
1 Nauru 20.4 1 Nauru 21.2

2 United Arab Emirates 18.7 2 Bahrain 19.9
3 Bahrain 18.7 3 United Arab Emirates 19.9
4 Kuwait 18.7 4 Kuwait 19.9
5 Singapore 18.7 5 Singapore 19.7
6 Kiribati 17.3 6 Kiribati 18.1
7 Mauritius 16.3 7 Mauritius 17.0
8 Poland 15.2 8 Poland 16.3
9 Tonga 13.0 9 Ghana 15.0
10 Denmark 12.4 10 Tonga 13.8
Includes only countries where surveys with glucose testing were undertaken for that country
Table 1.6
Top 10: Number of people with impaired glucose tolerance (20-79 age group), 2007 and 2025
2007 2025
Country Persons (millions) Country Persons (millions)
1 China 64.3 1 China 79.1

2 India 35.9 2 India 56.2
3 Russian Federation 17.8 3 Indonesia 20.6
4 Indonesia 14.1 4 Russian Federation 17.8
5 Japan 12.9 5 United States of America 16.5
6 United States of America 12.4 6 Japan 12.7
7 Brazil 8.4 7 Brazil 11.5
8 Bangladesh 6.8 8 Pakistan 11.0
9 Pakistan 6.4 9 Bangladesh 10.6
10 Ukraine 6.0 10 Mexico 7.7

Table 1.7
Prevalence estimates of diabetes mellitus (DM), 2007 - African Region

DM prevalence (%) N
Country/territory Population (20-79) (000’s) National Comparative* R
Angola 7,159 2.7 3.3

Benin 4,047 3.8 4.4
Botswana 872 4.2 5.2
Burkina Faso 5,823 3.0 3.7
Burundi 3,536 1.3 1.7
Cameroon 8,027 4.3 3.7
Cape Verde 260 4.2 5.1
Central African Republic 1,877 3.8 4.4
Chad 4,275 2.7 3.6
Comoros 401 2.6 3.2
Congo 1,754 4.2 5.0
Congo, Democratic Republic of 25,387 2.4 3.0
Côte d’Ivoire 8,790 4.0 4.6
Djibouti 393 4.1 5.2
Equatorial Guinea 232 4.2 4.7
Eritrea 2,086 1.8 2.3
Ethiopia 36,121 1.9 2.3
Gabon 695 4.3 4.9
Gambia 793 3.7 4.1
Ghana 11,531 3.5 4.2
Guinea 4,469 3.7 4.1
Guinea-Bissau 697 3.3 3.8
Kenya 16,266 2.6 3.3
Lesotho 854 4.0 3.8
Liberia 1,435 3.8 4.6
Madagascar 8,896 2.6 3.0
Malawi 5,578 1.7 2.1
Mali 5,822 3.3 4.1
Mauritania 1,510 3.6 4.6
Mozambique 9,178 3.1 3.7
Namibia 971 4.0 4.2
Niger 6,004 3.1 3.7
Nigeria 61,213 3.8 4.5
a
Réunion 510 12.7 13.5
Rwanda 4,197 1.1 1.5
b
Sao Tome and Principe 81 3.7 4.6
Senegal 5,654 3.8 4.6
a,b
Seychelles 51 12.6 12.6
Sierra Leone 2,696 3.8 4.3
Somalia 3,982 2.4 2.8
South Africa 27,085 4.5 4.4
Swaziland 463 3.8 4.0
Tanzania, United Republic of 18,316 2.4 2.9
Togo 2,948 3.5 4.1
Uganda 11,788 1.6 2.0
Western Sahara 212 5.0 5.6
Zambia 5,068 3.0 3.8
Zimbabwe 6,207 3.6 4.0

AFR Total 336,211 3.1 3.6
a. Réunion and the Seychelles were deemed as having the same ethnicity distribution as Mauritius
b. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2007
* All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

Number of people with DM (000’s) in the 20-79 age group
Rural Urban Male Female 20-39 40-59 60-79 TotaL
37.5 153.4 101.4 89.5 67.2 85.3 38.3 190.8

56.2 95.9 81.7 70.4 57.4 62.6 32.0 152.0
5.4 31.5 13.0 23.8 5.5 18.6 12.8 36.9
113.1 61.1 92.6 81.7 73.8 60.7 39.8 174.3
26.3 20.8 24.4 22.6 16.6 18.9 11.6 47.1
107.2 239.0 178.6 167.6 154.7 114.9 76.7 346.2
2.1 8.9 5.2 5.8 4.3 4.2 2.5 11.0
28.1 43.7 36.7 35.1 25.1 27.0 19.7 71.8
68.2 47.3 44.7 70.7 14.2 62.4 38.8 115.4
2.1 8.3 5.7 4.8 3.7 4.6 2.1 10.5
15.3 58.7 38.8 35.1 29.1 27.6 17.3 74.0
146.0 473.2 331.4 287.7 218.0 262.3 138.8 619.1
117.2 231.3 198.1 150.4 124.5 137.6 86.3 348.5
1.3 14.6 6.4 9.6 2.0 9.0 5.0 15.9
2.9 6.8 5.2 4.6 3.3 3.9 2.6 9.7
13.4 24.0 19.2 18.2 14.3 15.0 8.2 37.4
253.3 428.4 371.0 310.7 226.4 287.5 167.8 681.7
7.6 22.3 16.1 13.8 10.4 12.0 7.5 29.9
14.0 15.7 15.9 13.7 9.8 12.4 7.4 29.6
166.4 233.6 225.9 174.1 107.9 181.2 110.8 400.0
77.3 88.3 91.3 74.3 57.0 65.3 43.3 165.6
13.4 9.5 12.1 10.9 8.5 8.9 5.5 22.9
84.2 333.2 227.7 189.7 154.1 179.9 83.4 417.4
20.2 13.7 12.3 21.6 6.5 15.3 12.1 33.9
17.5 36.4 28.7 25.2 21.7 21.6 10.6 53.9
53.1 174.2 123.6 103.6 74.4 102.2 50.6 227.3
40.7 56.1 52.4 44.5 32.4 38.0 23.0 96.9
95.7 96.0 97.9 93.8 79.5 67.9 44.3 191.7
12.4 41.9 20.8 33.5 6.8 29.2 18.3 54.3
45.1 244.0 147.2 141.9 94.4 126.9 67.9 289.1
18.9 20.2 16.1 23.0 8.2 19.4 11.4 39.1
114.2 69.2 99.9 83.5 74.8 74.7 33.8 183.4
819.6 1,526.8 1,263.3 1,083.0 875.9 926.5 543.9 2,346.3
9.9 54.8 32.3 32.4 10.8 32.5 21.4 64.6
31.6 15.6 25.1 22.2 17.4 17.4 12.3 47.2
1.0 2.0 1.5 1.5 1.2 1.0 0.7 3.0
71.4 144.7 110.1 106.0 83.5 83.0 49.6 216.1
1.5 4.9 3.1 3.2 1.1 3.2 2.1 6.4
43.9 58.8 54.4 48.3 34.6 42.8 25.3 102.8
23.8 69.9 50.4 43.2 32.5 42.2 18.9 93.6
502.4 710.4 481.6 731.2 213.4 631.1 368.4 1,212.9
9.2 8.2 6.8 10.6 3.6 8.2 5.7 17.4
111.3 334.7 239.9 206.1 148.6 188.1 109.3 446.0
48.5 55.0 54.4 49.1 39.0 40.6 24.0 103.5
81.7 101.5 100.3 82.9 71.1 65.5 46.6 183.2
0.2 10.4 5.0 5.6 1.0 6.6 3.0 10.6
23.4 130.2 83.5 70.1 55.4 61.9 36.3 153.6
122.0 99.4 94.4 127.0 52.6 100.5 68.3 221.4

3,678 6,728 5,348 5,058 3,428 4,408 2,566 10,406

Table 1.8
Prevalence estimates of diabetes mellitus (DM), 2025 - African Region

DM prevalence (%) N
Angola 12,108 3.4 4.4

Benin 7,206 4.2 5.3
Burundi 5,902 1.9 2.5
Cameroon 12,033 4.7 4.3
Chad 7,206 2.7 3.1
Comoros 693 3.6 4.3
Congo 3,159 4.3 5.8
Congo. Democratic Republic of 43,720 3.1 4.1
Côte d’Ivoire 13,691 4.2 5.3
Eritrea 3,689 2.5 3.3
Ethiopia 59,447 2.6 3.3
Gabon 1,021 4.7 5.6
Gambia 1,276 4.2 4.9
Ghana 17,951 4.1 5.0
Guinea 7,415 4.0 4.9
Guinea-Bissau 1,207 3.5 4.6
Kenya 27,659 3.5 4.5
Lesotho 869 3.2 4.8
Liberia 2,435 4.0 5.4
Malawi 9,001 2.2 3.1
Mali 10,657 3.6 4.9
Namibia 1,394 3.4 5.3
Niger 11,296 3.4 4.5
Nigeria 97,842 4.2 5.3
a
Réunion 659 16.4 15.7
Rwanda 6,824 1.5 2.0
b
Sao Tome and Principe 131 4.4 5.4
Senegal 9,532 4.3 5.4
a.b
Seychelles 58 14.9 14.9
Somalia 6,797 3.2 3.9
Tanzania. United Republic of 28,548 3.2 4.1
Togo 5,108 3.9 4.9
Uganda 23.,910 2.1 2.9
Zambia 7,726 3.5 4.9
Zimbabwe 7,689 3.0 5.0

AFR Total 537,116 3.5 4.5

Rural Urban Male Female 20-39 40-59 60-79 TotaL
56.7 350.9 217.7 189.9 149.3 182.4 75.9 407.6

79.2 225.4 167.3 137.3 110.0 122.9 71.6 304.6
1.8 32.0 13.1 20.7 5.8 9.5 18.5 33.8
173.0 176.2 189.7 159.6 144.7 140.1 64.5 349.2
45.8 65.8 59.8 51.8 41.8 46.2 23.7 111.6
123.1 438.8 296.2 265.7 250.8 193.9 117.2 561.9
2.8 18.9 11.4 10.4 7.0 9.6 5.2 21.7
29.7 74.9 55.2 49.4 43.1 35.2 26.3 104.6
89.2 106.9 77.0 119.1 27.6 107.0 61.6 196.1
3.6 21.4 13.6 11.3 7.7 12.4 4.9 25.0
20.3 115.5 72.6 63.2 56.4 51.8 27.6 135.8
221.6 1,131.1 732.0 620.7 502.3 602.1 248.3 1,352.8
139.9 441.3 322.8 258.5 220.5 219.7 141.1 581.3
1.7 25.2 11.0 16.0 3.2 15.1 8.7 27.0
3.9 9.0 6.9 5.9 5.1 4.2 3.5 12.8
23.4 69.5 49.2 43.8 33.5 44.2 15.2 92.9
397.1 1,121.5 829.6 689.1 538.1 653.1 327.5 1,518.7
8.2 39.4 26.1 21.5 16.9 17.4 13.4 47.6
18.4 35.3 29.0 24.7 17.1 22.0 14.5 53.6
218.3 511.7 417.9 312.1 181.7 339.6 208.7 730.0
100.4 195.7 165.3 130.8 107.0 115.1 74.1 296.1
18.7 23.2 22.2 19.6 16.9 16.0 9.0 41.8
132.8 841.1 543.2 430.6 340.7 449.8 183.4 973.8
10.4 17.4 8.9 19.0 4.4 8.4 15.0 27.8
22.6 74.3 52.4 44.5 40.9 36.6 19.5 96.9
83.4 425.7 277.5 231.6 167.6 230.6 110.9 509.1
59.1 137.4 108.2 88.2 80.0 73.7 42.8 196.5
139.6 243.9 203.2 180.3 159.7 153.2 70.6 383.5
16.2 85.8 40.7 61.3 11.5 58.4 32.0 101.9
56.3 444.2 265.0 235.5 185.3 206.6 108.6 500.5
12.3 35.4 17.9 29.7 7.8 18.8 21.1 47.7
181.4 200.7 212.2 169.9 154.9 151.9 75.2 382.1
987.6 3,077.7 2,240.1 1,825.2 1,579.8 1,566.1 919.3 4,065.3
11.9 96.1 50.3 57.7 13.2 49.0 45.7 108.0
57.1 48.6 55.6 50.1 40.6 43.5 21.5 105.7
1.4 4.4 3.1 2.7 1.9 2.6 1.2 5.8
96.5 314.3 216.2 194.6 148.3 171.3 91.2 410.9
1.4 7.3 4.2 4.5 1.2 4.1 3.4 8.7
51.8 116.5 89.4 78.9 60.6 67.5 40.1 168.2
39.0 176.3 116.1 99.2 69.1 102.9 43.3 215.3
302.2 976.7 460.7 818.2 141.7 485.4 651.8 1,278.9
3.9 8.8 4.5 8.2 2.8 3.1 6.8 12.7
155.1 754.5 501.3 408.3 323.0 394.2 192.3 909.6
68.9 132.4 107.2 94.0 73.9 79.6 47.7 201.2
158.2 343.9 274.1 228.0 203.1 218.4 80.6 502.1
0.2 22.8 10.1 12.8 2.3.0 12.7 8.0 23.0
29.9 237.0 149.9 117.0 111.4 106.1 49.4 266.9
72.6 158.4 89.7 141.4 41.6 89.0 100.5 231.1

4,529 14,211 9,887 8,852 6,454 7,743 4,543 18,740

Table 1.9
Prevalence estimates of impaired glucose tolerance (IGT), 2007 - African Region

IGT prevalence (%) N
Country/territory Population (20-79) (000’s) National Comparative* M
Angola 7,159 7.4 8.5

Benin 4,,047 6.7 7.6
Burkina Faso 5,,823 6.6 7.6
Burundi 3,536 7.4 8.5
Cameroon 8,027 0.9 1.1
Chad 4,275 2.2 2.8
Comoros 401 7.4 8.5
Congo 1,754 6.7 7.6
Côte d’Ivoire 8,790 6.8 7.6
Eritrea 2,086 6.0 8.5
Ethiopia 36,121 7.6 8.5
Gabon 695 6.9 7.6
Gambia 793 7.0 7.6
Ghana 11,531 12.7 14.0
Guinea 4,469 7.0 7.6
Guinea-Bissau 697 6.8 7.6
Kenya 16,266 7.2 8.5
Lesotho 854 8.6 9.6
Liberia 1,435 6.5 7.6
Malawi 5,578 7.6 8.5
Mali 5,822 6.6 7.6
Namibia 971 7.7 9.6
Niger 6,004 6.5 7.6
Nigeria 61,213 6.7 7.6
Réuniona 510 16.5 16.3
Rwanda 4,197 7.3 8.5
Sao Tome and Principeb 81 6.6 7.6
Senegal 5,654 6.7 7.6
Seychellesa.b 51 16.2 16.3
Somalia 3,982 7.5 8.5
Togo 2,948 6.7 7.6
Uganda 11,788 7.2 8.5
Zambia 5,068 7.4 8.5
Zimbabwe 6,207 7.6 9.6

AFR Total 336,211 7.2 8.2

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

Male Female 20-39 40-59 60-79 Total
224.7 304.6 246.3 183.5 99.5 529.3

128.7 141.8 126.1 91.8 52.7 270.5
41.6 22.1 18.0 17.1 28.6 63.7
181.4 200.1 195.1 108.5 77.9 381.5
106.5 153.4 121.4 89.6 49.0 259.9
31.7 43.5 28.2 28.3 18.6 75.1
7.4 10.1 8.2 5.6 3.8 17.6
59.0 71.8 56.6 40.8 33.3 130.7
34.2 61.2 24.5 43.7 27.2 95.4
12.8 16.7 13.9 10.1 5.5 29.5
54.7 62.6 56.3 36.0 25.1 117.4
809.3 1,076.5 876.4 621.7 387.7 1,885.8
300.3 296.9 269.1 193.9 134.3 597.2
3.3 5.6 2.3 4.3 2.3 8.9
7.6 8.7 6.8 5.4 4.1 16.3
62.2 62.2 62.2 62.2 62.2 124.4
1,183.1 1,547.7 1,208.8 946.8 575.1 2,730.7
22.8 25.5 20.8 16.1 11.3 48.3
26.1 29.5 23.0 19.6 12.9 55.5
712.9 754.4 664.4 475.5 327.5 1,467.3
151.5 159.4 133.2 102.4 75.2 310.8
22.0 25.3 21.7 15.3 10.4 47.4
520.0 657.0 573 384.2 219.9 1,177.0
45.9 27.9 16.4 14.6 42.8 73.8
44.5 49.3 46.3 30.9 16.7 93.8
294.1 382.9 294.7 240.9 141.3 677.0
182.5 238.7 188.8 137.0 95.4 421.2
175.4 208.2 192.1 111.2 80.2 383.6
12.4 22.3 8.8 15.9 9.9 34.6
288.3 418.8 307.2 238.7 161.2 707.1
50.2 24.3 19.5 19.6 35.4 74.5
190.0 199.9 194.4 130.3 65.2 389.9
1,969.0 2,152.3 1,903.7 1,343.4 874.1 4,121.3
32.7 51.8 28.9 38.7 16.8 84.4
125.7 178.8 148.5 99.6 56.3 304.5
2.5 2.9 2.7 1.5 1.2 5.4
171.5 207.5 178.5 120.8 79.7 379.0
3.3 4.9 3.0 3.5 1.8 8.2
87.2 100.5 78.7 66.0 43.0 187.7
127.3 170.4 135.9 106.9 54.9 297.8
1,426.6 726.8 501.2 635.0 1,017.2 2,153.4
23.5 12.4 9.6 8.0 18.3 35.9
599.1 785.1 614.8 457.9 311.5 1,384.2
92.5 106.3 92.0 64.4 42.3 198.7
372.9 477.7 430.8 246.8 173.0 850.6
2.2 3.0 1.1 2.9 1.3 5.2
165.6 207.8 177.6 111.3 84.5 373.4
316.1 153.0 136.0 104.1 229.0 469.1

11,505 12,650 10,467 7,852 5,897 24,154

Table 1.10
Prevalence estimates of impaired glucose tolerance (IGT), 2025 - African Region

Angola 12,108 7.4 9.2

Benin 7,206 7.5 9.1
Botswana 887 8.5 11.3
Burundi 5,902 7.5 9.2
Cameroon 12,033 2.2 3.2
Chad 7,206 2.1 3.1
Comoros 693 7.8 9.2
Congo 3,159 7.1 9.1
Côte d’Ivoire 13,691 7.4 9.1
Eritrea 3,689 7.4 9.2
Ethiopia 59,447 7.6 9.2
Gabon 1,021 7.7 9.1
Gambia 1,276 7.9 9.1
Ghana 17,951 13.2 15.0
Guinea 7,415 7.5 9.1
Guinea-Bissau 1,207 7.2 9.1
Kenya 27,659 7.5 9.2
Lesotho 869 8.4 11.3
Liberia 2,435 7.0 9.1
Malawi 9,001 7.2 9.2
Mali 10,657 7.0 9.1
Namibia 1,394 8.0 11.3
Niger 11,296 7.1 9.1
Nigeria 97,842 7.3 9.1
Réuniona 659 17.4 17.0
Rwanda 6,824 7.5 9.2
Sao Tome and Principeb 131 7.6 9.1
Senegal 9,532 7.5 9.1
Seychellesa.b 58 17.0 17.0
Somalia 6,797 7.7 9.2
South Africa 29,250 9.7 11.3
Togo 5,108 7.5 9.1
Uganda 23,910 7.1 9.2
Zambia 7,726 7.1 8.5
Zimbabwe 7,689 7.6 9.2
AFR Total 537,116 7.5 9.2


383.3 511.2 422.1 302.1 170.3 894.5

278.9 261.4 219.5 197.9 122.9 540.3
49.7 25.6 21.2 11.1 42.9 75.2
383.6 361.2 344.4 267.7 132.6 744.8
188.1 252.3 204.3 146.9 89.1 440.4
179.9 89.7 43.6 148.5 77.4 269.6
16.7 17.6 12.3 13.9 8.1 34.3
95.8 96.8 88.0 57.8 46.8 192.6
55.8 95.9 43.4 69.0 39.4 151.7
23.4 30.4 21.8 20.9 11.2 53.8
113.2 110.4 103.7 76.2 43.6 223.5
1,392.5 1,803.1 1,531.4 1,068.3 595.9 3,195.6
530.7 485.6 431.4 347.8 237.1 1,016.3
5.5 9.2 3.6 7.1 4.0 14.6
12.2 11.8 10.8 7.0 6.3 24.0
113.9 157.7 125.5 101.1 45.1 271.6
1,972.9 2,516.9 2,026.0 1,497.6 966.2 4,489.8
40.4 38.3 31.2 26.1 21.4 78.6
50.7 50.0 36.3 37.8 26.6 100.7
1,155.1 1,207.3 975.0 816.5 570.9 2,362.5
293.7 265.7 227.8 196.6 135.0 559.4
43.4 43.0 39.0 29.7 17.7 86.4
926.6 1,147.0 935.1 725.9 412.6 2,073.6
43.8 28.9 19.3 10.9 42.6 72.8
87.7 83.4 80.6 57.7 32.8 171.1
516.1 660.9 503.3 409.3 264.4 1,177.0
289.1 356.4 329.0 180.0 136.4 645.5
376.8 372.0 347.8 268.3 132.7 748.7
22.1 38.1 14.1 29.8 16.2 60.1
440.6 582.5 480.4 311.5 231.2 1,023.2
74.8 36.2 30.7 23.6 56.7 111.0
422.2 379.4 365.6 286.1 149.8 801.6
3,721.0 3,434.7 3,113.0 2,486.8 1,555.9 7,155.7
45.1 69.5 32.9 47.0 34.6 114.6
212.0 297.0 238.1 176.3 94.6 508.9
5.0 5.0 3.7 4.2 2.0 10.0
353.4 361.9 288.4 271.9 155.0 715.3
4.1 5.9 3.1 4.1 2.7 9.9
154.9 155.9 125.7 113.2 71.8 310.7
224.9 296.5 219.7 194.0 107.7 521.4
1,838.1 1,000.3 561.2 593.6 1,683.6 2,838.5
23.0 13.1 12.6 4.3 19.3 36.2
955.6 1,197.6 975.4 703.5 474.4 2,153.3
191.1 190.7 157.0 136.9 87.9 381.8
743.5 953.0 864.4 568.9 263.2 1,696.5
4.6 6.8 2.3 5.7 3.5 11.5
250.6 297.2 288.6 153.9 105.3 547.8
397.4 188.8 175.1 119.6 291.5 586.2
19,704 20,600 17,129 13,335 9,839 40,303

Table 1.11
Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT)
Country/territory Data used S
Angolaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22

Beninb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Botswanac,d South Africa (Omar et al, 1993; Levitt et al 1993; Erasmus et al, 2001; Motala, 2006)24-27
Burkina Fasob Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Burundia Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Cameroon Cameroon (Mbanya, 2006)29
Cape Verdeb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Central African Republicb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Chad Sudan (Elbagir et al, 1996)30
Comorosa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Congob Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Congo, Democratic Republic of a Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Côte d’Ivoireb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Djibouti Sudan (Elbagir et al, 1996)30
Equatorial Guineab Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Eritreaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Ethiopiaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Gabonb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Gambiab Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Ghana Ghana (Amoah et al, 2002)28
Guineab Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Guinea-Bissaub Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Kenyaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Lesothoc,d South Africa (Omar et al, 1993; Levitt et al 1993; Erasmus et al, 2001 and Motala, 2006)24-27
Liberiab Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Madagascara Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Malawia Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Malib Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Mauritania Sudan (Elbagir et al, 1996)30
Mozambiquea Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Namibiac,d South Africa (Omar et al, 1993; Levitt et al 1993; Erasmus et al, 2001 and Motala, 2006)24-27
Nigerb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Nigeriab Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Réunion Mauritius (Dowse et al, 1990)109
Rwandaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Sao Tome and Principeb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Senegalb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Seychelles Mauritius (Dowse et al, 1990)109
Sierra Leoneb Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Somaliaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
South Africac,d South Africa (Omar et al, 1993; Levitt et al 1993; Erasmus et al, 2001; Motala, 2006)24-27
Swazilandc,d South Africa (Omar et al, 1993; Levitt et al 1993; Erasmus et al, 2001 and Motala, 2006)24-27
Tanzania, United Republic of a Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Togob Cameroon (Mbanya, 2006)29 and Ghana (Amoah et al, 2002)28
Ugandaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Western Sahara Sudan (Elbagir et al, 1996)30
Zambiaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)21,22
Zimbabwec,d South Africa (Omar et al, 1993; Levitt et al 1993; Erasmus et al, 2001 and Motala, 2006)24-27
a. The prevalence was calculated after the combination of the data of the two studies, notwithstanding the different criteria. IGT figures were calculated from the McLarty
data, as the Aspray study only used FBG criteria
b. The prevalence was calculated as the average of the two studies as their sample sizes differed considerably
c. The prevalence was calculated after the combination of the data of the four studies
d. IGT figures were based only on the study of Omar et al26

- African Region
d Screening method Diagnostic criteria Sample size Age (yrs)
OGTT/FBG WHO - 1985, 1999 7,781 15+

OGTT WHO - 1999 14,110 15+
OGTT WHO - 1985, 1999 3,780 15+
OGTT WHO - 1999 14,110 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1999 9,377 15+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1999 14,110 15+
2hBG WHO - 1985 1,284 25-84
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1999 14,110 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1999 14,110 15+
2hBG WHO - 1985 1,284 25-84
OGTT WHO - 1999 14,110 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1999 4,733 25+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1999 14,110 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1985, 1999 3,780 15+
OGTT WHO - 1999 14,110 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1999 14,110 15+
2hBG WHO - 1985 1,284 25-84
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1985, 1999 3,780 15+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1985 4,929 25-74
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1999 14,110 15+
OGTT WHO - 1985 4,929 25-74
OGTT WHO - 1999 14,110 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1985, 1999 3,780 15+
OGTT WHO - 1985, 1999 3,780 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1999 14,110 15+
OGTT/FBG WHO - 1985, 1999 7,781 15+
2hBG WHO - 1985 1,284 25-84
OGTT/FBG WHO - 1985, 1999 7,781 15+
OGTT WHO - 1985, 1999 3,780 15+

Table 1.12
Prevalence estimates of diabetes mellitus (DM), 2007 - Eastern Mediterranean and Middle East Region

DM prevalence (%) N
Afghanistan 13,825 8.0 9.7

Algeria 20,346 7.3 8.4
Armenia 2,056 8.7 7.7
Bahrain 491 14.3 15.2
Egypt 43,071 10.1 11.0
Iran, Islamic Republic of 42,984 6.0 7.8
Iraq 14,699 7.5 10.0
Jordan 3,169 7.3 9.8
Kuwait 1,953 10.1 14.4
Lebanon 2,262 7.4 7.7
Libyan Arab Jamahiriya 3,659 3.7 4.4
Morocco 19,125 7.1 8.1
Occupied Palestinian Territory 1,719 6.4 8.4
Oman 1,482 10.7 13.1
Pakistan 83,527 8.3 9.6
Qatar 622 12.7 15.2
Saudi Arabia 13,730 13.5 16.7
Sudan 19,056 3.2 4.0
Syrian Arab Republic 10,473 8.1 10.6
Tunisia 6,639 4.8 5.2
United Arab Emirates 3,377 13.0 19.5
Yemen 9,456 2.5 2.9

EMME Total 317,720 7.7 9.2

Rural Urban Male Female 20-39 40-59 60-79 Total
858.2 254.2 606.6 505.8 288.0 581.3 243.2 1,112.4

553.9 921.2 730.1 744.9 480.6 650.1 344.4 1,475.1
40.1 139.5 66.0 113.7 13.1 89.8 76.8 179.6
2.4 68.1 43.9 26.6 14.4 46.6 9.5 70.5
1,455.3 2,901.8 1,920.8 2,436.2 1,064.1 2,144.4 1,148.6 4,357.1
560.5 2,005.0 1,091.6 1,473.9 328.9 1,330.5 906.2 2,565.5
131.5 974.9 547.6 558.8 186.9 622.5 297.1 1,106.5
30.9 201.6 121.5 111.0 43.1 122.7 66.8 232.6
2.1 195.9 127.7 70.2 62.6 102.5 32.9 197.9
7.7 159.3 79.7 87.3 7.4 72.9 86.7 167.0
7.9 127.6 56.7 78.9 45.6 49.7 40.3 135.5
355.2 1,005.0 647.7 712.5 327.5 706.1 326.6 1,360.2
13.0 96.2 46.2 63.0 9.8 66.1 33.3 109.2
9.4 149.7 99.0 60.1 57.1 75.9 26.1 159.1
4,279.6 2,649.9 3,700.6 3,229.0 1,631.6 3,774.7 1,523.2 6,929.5
2.8 76.4 60.5 18.6 21.4 51.5 6.3 79.2
140.3 1,714.6 1,016.4 838.5 520.9 986.2 347.8 1,854.9
255.9 351.6 244.5 363.0 71.6 334.3 201.6 607.5
233.5 616.6 422.4 427.7 290.9 311.3 247.9 850.1
57.4 259.8 135.0 182.2 72.7 158.6 86.0 317.2
29.9 409.6 320.9 118.6 181.7 228.9 28.9 439.5
94.3 137.8 115.4 116.7 95.7 100.7 35.7 232.1

9,122 15,416 12,201 12,337 5,815 12,607 6,116 24,538

Table 1.13
Prevalence estimates of diabetes mellitus (DM), 2025 - Eastern Mediterranean and Middle East Region

DM prevalence (%) N

Algeria 28,553 8.9 9.2
Armenia 2,155 10.3 9.0
Bahrain 715 17.0 17.0
Egypt 62,958 12.2 13.4
Iraq 25,477 9.0 11.6
Jordan 5,128 9.8 11.5
Kuwait 2,893 15.4 16.4
Lebanon 2,947 9.1 9.3
Morocco 26,372 9.1 9.5
Occupied Palestinian Territorya 3,365 6.7 9.8
Oman 2,379 13.3 14.7
Pakistan 135,664 8.5 9.9
Qatar 808 17.1 16.9
Saudi Arabia 23,007 15.7 18.4
Sudan 29,494 3.8 5.0
Tunisia 8,633 6.2 6.1
Yemen 18,267 2.8 3.4

EMME Total 492,202 9.0 10.4
a. Occupied Palestinian Territory assigned urban/rural distribution of Jordan



1,290.6 691.6 1,059.9 922.2 534.8 1,042.5 404.9 1,982.1

716.1 1,812.5 1,261.3 1,267.2 555.5 1,234.8 738.2 2,528.5
37.2 184.8 77.4 144.7 17.5 82.9 121.7 222.1
2.8 118.8 69.4 52.2 16.6 65.4 39.6 121.6
1,842.1 5,807.5 3,295.4 4,354.2 1,619.1 3,583.7 2,446.8 7,649.6
804.8 4,310.1 2,164.8 2,950.1 513.7 2,566.0 2,035.2 5,114.9
199.4 2,082.4 1,128.3 1,153.4 313.8 1,307.1 660.8 2,281.7
48.5 451.9 260.7 239.7 58.2 302.7 139.5 500.4
3.7 441.3 278.9 166.1 58.9 247.9 138.2 445.0
9.0 258.3 125.1 142.2 9.0 115.6 142.7 267.3
10.5 225.7 94.8 141.4 51.0 101.7 83.5 236.2
441.9 1,953.6 1,156.6 1,238.9 412.1 1,253.7 729.7 2,395.6
13.0 213.4 99.5 126.8 18.4 133.4 74.6 226.4
10.4 305.7 185.8 130.3 77.3 164.5 74.3 316.1
5,433.1 6,104.6 5,612.4 5,925.3 2,712.2 6,242.3 2,583.2 11,537.6
3.6 134.5 93.5 44.6 18.7 95.0 24.5 138.2
171.5 3,438.6 1,876.2 1,733.9 786.9 1,958.9 864.3 3,610.0
329.8 799.6 464.9 664.4 117.2 623.8 388.4 1,129.4
352.5 1,426.8 882.7 896.6 438 735.3 605.9 1,779.3
65.1 469,9 224.4 310.6 82.3 272..5 180.2 535.0
50.7 930.8 673.6 308.0 194.1 625.7 161.8 981.6
145.7 360.0 251.4 254.3 208.4 211.6 85.8 505.7

11,982 32,522 21,337 23,167 8,814 22,967 12,724 44,504

Table 1.14
Prevalence estimates of impaired glucose tolerance (IGT), 2007

IGT prevalence (%)

Algeria 20,346 5.7 6.4
Armenia 2,056 7.4 6.7
Bahrain 491 17.0 18.7
Egypt 43,071 4.6 5.1
Iraq 14,699 7.2 8.6
Jordan 3,169 7.2 8.6
Kuwait 1,953 15.5 18.7
Lebanon 2,262 3.9 4.1
Morocco 19,125 6.0 6.4
Oman 1,482 9.1 10.8
Pakistan 83,527 7.7 8.7
Qatar 622 15.1 18.7
Saudi Arabia 13,730 11.0 11.7
Sudan 19,056 2.3 2.8
Tunisia 6,639 6.1 6.4
Yemen 9,456 2.8 4.0

EMME Total 317,720 7.0 8.1
*All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

- Eastern Mediterranean and Middle East Region

344.2 687.0 407.0 403.2 221.0 1,031.2

387.5 780.8 454.9 516.8 196.5 1,168.3
46.5 105.9 30.4 70.6 51.4 152.4
42.8 40.6 32.6 40.5 10.4 83.5
988.2 988.2 988.2 988.2 988.2 1,976.5
1,762.8 2,351.9 1,322.7 1,918.6 873.4 4,114.7
527.3 529.7 352.8 513.9 190.3 1,057.0
119.5 107.7 80.3 103.5 43.3 227.2
165.8 136.0 156.2 118.0 27.6 301.8
37.1 51.7 11.7 39.4 37.8 88.8
73.3 132.7 82.4 87.7 35.9 206.0
363.4 781.0 414.0 525.3 205.0 1,144.4
61.5 61.6 40.5 59.8 22.8 123.1
66.3 68.1 60.9 57.6 15.9 134.4
2,186.5 4,235.9 2,340.1 2,621.2 1,461.1 6,422.4
61.8 32.2 45.0 42.5 6.5 94.0
874.6 638.1 782.9 567.7 162.1 1,512.70
164.2 278.2 108.6 208.8 125.0 442.4
423.7 541.7 225.4 412.0 328.0 965.4
132.5 271.7 138.1 187.3 78.8 404.2
314.9 156.4 279.0 170.0 22.3 471.2
131.8 136.4 53.2 133.5 81.5 268.2

9,276 13,114 8,407 9,786 5,185 22,390

Table 1.15
Prevalence estimates of impaired glucose tolerance (IGT), 2025


Algeria 28,553 6.7 6.8
Armenia 2,155 8.1 7.3
Bahrain 715 19.3 19.9
Egypt 62,958 4.9 5.5
Iraq 25,477 7.9 9.3
Jordan 5,128 8.4 9.3
Kuwait 2,893 18.6 19.9
Lebanon 2,947 4.6 4.7
Morocco 26,372 6.7 6.8
Oman 2,379 10.7 11.4
Pakistan 135,664 8.1 9.4
Qatar 808 17.9 19.9
Saudi Arabia 23,007 11.5 12.1
Sudan 29,494 2.5 3.1
Tunisia 8,633 7.0 6.8
Yemen 18,267 3.0 4.6

EMME Total 492,202 7.8 8.8
*All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population


614.7 1,247.7 757.4 726.8 378.2 1,862.4

641.9 1,278.5 522.2 974.3 423.9 1,920.4
53.0 122.1 32.7 64.2 78.3 175.1
69.8 68.5 40.3 55.7 42.3 138.3
1,552.9 1,552.9 1,552.9 1,552.9 1,552.9 3,105.8
3,117.5 4,018.0 1,696.8 3,575.9 1,862.9 7,135.5
1,000.1 1,008.4 567.7 1,029.4 411.4 2,008.5
224.1 207.3 105.6 238.1 87.7 431.4
287.3 252.0 155.3 268.7 115.4 539.3
57.6 78.3 13.6 60.3 62.0 135.9
116.8 227.4 92.6 179.6 72.0 344.1
568.2 1,198.1 477.2 863.9 425.2 1,766.3
127.3 123.4 77.6 120.7 52.4 250.7
118.4 135.3 84.0 125.1 44.6 253.7
3,867.4 7,144.0 3,749.7 4,446.0 2,815.7 11,011.4
85.2 59.2 40.9 78.0 25.6 144.4
1,443.1 1,199.8 1,162.4 1,078.4 402.2 2,642.9
276.1 457.1 160.2 352.8 220.1 733.2
902.1 1,103.8 332.0 916.9 757.0 2,005.9
198.9 404.9 146.4 299.3 158.2 603.8
529.3 328.3 294.9 446.7 116.0 857.6
265.3 277.8 110.5 253.4 179.3 543.1

16,117 22,493 12,172 17,707 10,283 38,610

Table 1.16

Afghanistana Pakistan (Shera et al, 1995, 1999a, 1999b)47-49

Algeria Algeria (Malek et al, 2001)50
Armenia Turkey (Satman et al, 2002)58
Bahrainb Bahrain (Al-Mahroos et al, 1998)32
Egyptc Egypt (Herman et al, 1995 and Arab, 1997)33,43
Iran, Islamic Republic of Iran (Azizi et al, 2003)51
Iraq Jordan (Ajlouni et al, 1998)110
Jordan Jordan (Ajlouni et al, 1998)110
Kuwaitb Kuwait (Abdella et al, 1998)35
Lebanon Lebanon (Salti et al, 1997)111
Libyan Arab Jamahiriya Libyan Arab Jamahiriya (Kadiki et al, 1999)112
Moroccod Morocco (Tazi et al, 2003)52
Occupied Palestinian Territorye Occupied Palestinian Territory (Abdul-Rahim et al, 2001 and Husseini, 2000)53,54
Omanf Oman (Al-Lawati et al, 2002)36
Pakistana Pakistan (Shera et al, 1995, 1999a, 1999b)47-49
Qatarb Bahrain (Al-Mahroos et al, 1998)32
Saudi Arabiaa,b Saudi Arabia (El-Hazmi et al, 1998; Al-Nozha et al, 2004 and Al-Nuaim 1997)38,39,113
Sudan Sudan (Elbagir et al, 1996)30
Syrian Arab Republic Syrian Arab Republic (Albache, 2006)55
Tunisiac,e Tunisia (Papoz et al, 1988 and Ghannem et al, 1997)114,115
United Arab Emirates UAE (Malik et al, 2005)41
Yemen Yemen (Al-Habori, 2004)56
a. The prevalence was obtained by combining the data from the three studies
b. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from UAE data
c. The prevalences were calculated as the average of the two cited studies as their sample sizes differed considerably
d. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from Libyan data
e. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from Jordanian data
f. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from other Oman data (Asfour et al, 1995)116


OGTT WHO - 1985 3,409 25+

FBG/ SR ADA - 1997 1,457 30-64
2hBG WHO - 1999 24,788 20+
OGTT WHO - 1985 2,128 40-69
OGTT/Post prandial GT WHO - 1985 5,251 20+
OGTT WHO - 1999 10,368 20+
OGTT WHO - 1985 2,776 25-79
OGTT WHO - 1985 2,776 25-79
OGTT WHO - 1985 3,003 20+
OGTT WHO - 1985 2,518 30+
Registration N/A 15,912 20+
FBG/ SR WHO - 1980 6,570 20+
OGTT WHO - 1985 992 30-65
OGTT WHO - 1999 5,731 20-79
OGTT WHO - 1985 3,409 25+
OGTT WHO - 1985 2,128 40-69
OGTT WHO - 1985, ADA 1997 47,573 14+
2hBG WHO - 1985 1,284 25-84
OGTT WHO - 1999 1,700 20+
FBG/ SR WHO - 1980 6,570 20+
OGTT WHO - 1999 6,612 19+
OGTT WHO - 1999 498 20-69

Table 1.17
Prevalence estimates of diabetes mellitus (DM), 2007 - European Region

DM prevalence (%) N
Albania 1,995 4.8 4.5

Andorraa 52 7.8 5.7
Austria 6,129 11.1 7.9
Azerbaijan 5,474 6.9 7.3
Belarus 7,241 9.2 7.6
Belgium 7,600 7.9 5.2
Bosnia and Herzegovina 2,972 9.0 7.0
Bulgaria 5,880 10.1 7.6
Channel Islands 112 3.9 2.9
Croatia 3,445 9.5 7.1
Cyprus 604 10.3 8.9
Czech Republic 7,792 9.7 7.6
Denmark 3,889 7.5 5.5
Estonia 983 9.9 7.6
Finland 3,837 8.4 5.9
France 43,116 8.4 5.9
Georgia 3,130 9.1 7.4
Germany 62,580 11.8 7.9
Greece 8,554 8.6 5.9
Hungary 7,543 9.8 7.6
Iceland 204 2.0 1.6
Ireland 3,017 5.6 5.1
Israel 4,302 7.8 6.9
Italy 44,006 8.7 5.8
Kazakhstan 9,846 5.6 5.6
Kyrgyzstan 3,106 4.3 5.1
Latvia 1,707 10.0 7.6
Liechtensteina 25 10.7 7.9
Lithuania 2,481 9.7 7.6
Luxembourg 344 6.9 5.2
Macedonia, the Former Yugoslav Republic of 1,465 8.2 7.1
Malta 296 9.7 6.7
Moldova 3,026 8.3 7.6
Monacoa 24 8.1 5.9
Netherlands 11,883 7.3 5.2
Norway 3,242 4.7 3.6
Poland 28,686 9.1 7.6
Portugal 7,922 8.2 5.7
Romania 16,212 9.4 7.6
Russian Federation 106,481 9.0 7.6
San Marinoa 22 7.8 5.8
Serbia and Montenegrob 7,625 8.9 7.1
Slovakia 4,014 8.8 7.6
Slovenia 1,518 9.8 7.6
Spain 33,181 7.5 5.7
Sweden 6,456 7.2 5.2
Switzerland 5,336 11.2 7.9
Tajikistan 3,280 3.5 4.9
Turkey 46,513 7.1 7.8
Turkmenistan 2,857 4.0 5.2
Ukraine 34,309 9.8 7.6
United Kingdom 42,771 4.0 2.9
Uzbekistan 15,293 4.0 5.1
EUR Total 634,373 8.4 6.6
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of developed world population from 2005 to
2007 b. Estimates made prior to the establishment of Serbia and Montenegro as independent countries * All comparisons between countries should be done using the

46.2 49.6 19.1 36.8 40.0 95.8

2.0 2.1 0.1 1.4 2.6 4.1
327.7 354.7 32.3 215.6 434.5 682.3
123.4 257.0 152.0 228.4 45.1 195.2 140.1 380.4
306.5 362.7 61.3 259.1 348.7 669.2
296.7 302.1 9.9 166.5 422.4 598.8
110.8 155.7 20.3 108.2 138.0 266.5
129.4 466.3 239.1 356.7 39.5 246.8 309.4 595.7
2.2 2.2 0.2 1.7 2.4 4.3
135.2 193.6 21.7 134.5 172.5 328.7
41.4 20.7 6.6 29.0 26.6 62.1
379.6 377.2 69.8 282.6 404.4 756.8
153.3 137.3 20.0 115.1 155.5 290.6
43.4 53.8 8.2 33.7 55.4 97.3
173.6 148.1 21.6 105.2 195.0 321.7
1,695.0 1,921.6 128.2 1,231.5 2,256.9 3,616.6
83.7 202.4 110.8 175.4 21.1 125.2 139.8 286.2
3,563.3 3,815.9 305.9 2,189.0 4,884.3 7,379.2
345.8 390.9 38.9 191.4 506.5 736.7
352.2 389.4 67.8 269.5 404.3 741.5
2.3 1.8 0.2 1.3 2.6 4.1
87.0 82.6 33.2 65.9 70.5 169.7
176.2 160.9 13.9 119.5 203.7 337.1
1,967.3 1,882.8 123.8 1,197.6 2,528.8 3,850.2
140.7 410.0 295.8 254.9 35.7 303.3 211.7 550.7
59.6 72.6 76.1 56.1 9.7 75.3 47.2 132.2
76.0 94.3 14.1 57.3 98.9 170.3
1.2 1.4 0.1 0.9 1.6 2.7
109.5 130.4 21.1 83.0 135.8 239.9
11.8 11.8 0.5 7.2 15.9 23.6
51.8 68.5 10.9 53.7 55.8 120.3
11.9 16.8 0.3 9.5 18.9 28.6
122.1 127.9 28.0 106.6 115.3 250.0
0.9 1.0 0.1 0.7 1.2 1.9
442.5 429.5 16.6 270.2 585.1 872.0
88.7 63.7 14.2 52.6 85.6 152.4
1,295.2 1,312.6 253.8 1,071.7 1,282.2 2,607.7
317 331.3 15.4 193.6 439.3 648.3
759.0 765.5 155.9 539.6 829.0 1,524.5
4,392.6 5,239.0 910.5 3,937.5 4,783.7 9,631.6
0.9 0.8 0.1 0.6 1.0 1.7
287.8 387.3 52.7 288.2 334.2 675.1
175.6 177.7 37.5 144.6 171.2 353.3
75.3 73.6 13.0 56.8 79.1 148.9
1,249.7 1,248.1 73.6 757.5 1,666.7 2,497.8
214.2 253.3 36.8 137.3 293.3 467.5
283.9 313.2 27.1 198.9 371.1 597.1
123.4 257.0 69.5 46.1 9.2 66.1 40.3 115.6
497.7 2,789.1 1,386.1 1,900.8 431.3 1,672.6 1,183.0 3,286.9
45.8 69.6 67.0 48.4 10.1 67.4 37.9 115.4
1,498.7 1,848.5 279.0 1,197.0 1,871.3 3,347.3
839.4 869.9 85.3 598.0 1,026.1 1,709.4
256.9 348.7 360.7 244.9 51.5 351.7 202.4 605.6
• • 25,270 27,884 3,703 19,621 29,830 53,154
comparative prevalence, which is adjusted to the world population.

Table 1.18
Prevalence estimates of diabetes mellitus (DM), 2025 - European Region

DM prevalence (%) N
Albania 2,400 7.5 6.9

Andorraa 62 9.3 7.1
Austria 6,293 13.2 9.4
Belarus 6,698 10.5 8.7
Belgium 7,787 9.7 6.6
Bulgaria 5,155 11.5 8.9
Croatia 3,247 10.6 8.1
Cyprus 745 11.3 10.1
Denmark 4,107 11.4 8.5
Estonia 922 10.8 8.7
Finland 3,949 10.0 6.9
France 45,455 10.4 7.3
Georgia 2,972 10.6 8.7
Germany 60,962 13.3 9.4
Greece 8,587 9.7 7.0
Hungary 7,255 11.2 8.7
Iceland 242 2.5 1.9
Ireland 3,700 6.4 5.9
Israel 5,783 8.5 7.6
Italy 42,240 10.4 6.9
Latvia 1,545 11.0 8.7
Lithuania 2,368 10.7 8.7
Malta 319 11.6 8.2
Moldova 3,074 9.9 8.7
Monacoa 26 9.5 7.3
Norway 3,651 5.4 4.1
Poland 28,716 11.0 8.7
Portugal 8,219 9.8 7.1
Romania 15,451 10.7 8.7
Slovakia 4,132 10.8 8.7
Slovenia 1,467 11.8 8.7
Spain 33,222 9.7 7.1
Sweden 6,847 8.1 6.0
Turkey 61,913 8.9 9.1
Ukraine 28,853 10.9 8.7
EUR Total 653,394 9.8 7.7
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of developed world population from 2005
to 2025. b. Estimates made prior to the establishment of Serbia and Montenegro as independent countries. * All comparisons between countries should be done using

93.6 87.6 9.7 56.9 116.6 181.2

2.9 3.0 2.1 1.6 4.1 5.8
418.5 416.9 27.8 234.9 572.7 835.5
144.8 465.5 234.2 376.1 58.4 264.9 287.0 610.3
322.4 386.7 57.1 237.8 416.1 709.1
396.9 359.8 8.8 158.3 589.6 756.7
138.8 207.5 18.3 141.4 186.5 346.3
97.3 498.9 240.1 356.1 30.9 237.3 328.0 596.2
3.0 2.6 2.2 1.6 3.8 5.6
145.7 198.3 20.6 121.9 203.4 344.0
55.4 29.3 10.3 34.8 41.5 84.7
436.7 441.6 53.9 291.2 535.3 878.4
174.0 297.6 30.9 1.2 328.6 471.6
45.7 54.4 9.5 32.8 59.9 100.2
218.1 178.4 21.4 88.5 286.5 396.5
2,397.1 2,369.0 117.0 1,188.7 3,460.4 4,766.1
68.4 249.3 120.0 197.7 21.0 118.3 178.4 317.7
3,995.7 4,149.2 276.6 2,191.0 5,677.3 8,144.9
402.2 430.5 31.5 231.2 572.0 832.7
391.0 421.3 54.5 277.1 482.7 812.3
3.4 2.7 0.2 1.5 4.4 6.1
135.0 102.1 30.0 87.6 121.5 237.1
242.3 252.3 26.2 133.3 337.2 494.6
2,302.6 2,122.9 85.2 1,299.1 3,043.2 4,425.5
141.6 596.5 383.7 354.3 46.3 339.6 352.2 738.0
80.8 154.2 131.9 103.2 15.9 115.3 103.9 235.0
79.5 91.0 14.4 55.7 102.4 170.5
1.7 1.9 0.1 1.0 2.5 3.7
119.5 136 21.8 84.0 151.6 255.5
18.5 16.7 0.6 8.9 25.8 35.3
64.3 82.9 12.2 59.4 77.5 147.2
16.3 21.0 2.3 8.5 28.5 37.3
148.8 157.6 29.6 106.6 172.2 306.4
1.1 1.3 0.1 0.7 1.7 2.5
641.4 580.8 14.4 267.2 940.6 1,222.1
115.8 83.4 14.5 54.5 130.3 199.2
1,555.2 1,615.4 220.9 1,021.9 1,929.0 3,170.5
446.9 361.8 13.4 222.7 574.6 808.8
820.2 838.2 121.7 622.3 916.4 1,658.5
4,556.9 5,769.2 788.1 3,360.2 6,179.8 10,326.2
0.7 0.8 0.1 0.5 0.9 1.5
323.2 419.4 51.0 287.7 405.9 742.6
221.2 227.1 33.5 154.1 262.6 448.3
87.8 85.5 11.8 55.3 108.1 173.3
1,775.7 1,466.0 44.8 947.3 2,251.6 3,241.7
248.6 305.8 37.7 138.0 378.6 554.4
347.2 382.5 25.6 186.3 517.8 729.7
95.3 139.5 133.9 101.0 20.8 117.8 96.2 234.8
539.8 4,981.5 2,325.2 3,196.0 481.3 2,734.1 2,305.8 5,521.2
68.7 157.3 126.7 99.3 16.9 117.5 91.6 226.0
1,387.6 1,783.1 228.6 1,009.6 1,934.5 3,170.7
1,099.0 1,061.5 80.1 622.1 1,458.4 2,160.6
393.5 822.8 700.5 515.8 92.4 625.3 498.6 1,216.3
• • 30,794 33,302 3,445 20,868 39,837 64,096
the comparative prevalence, which is adjusted to the world population.

Table 1.19
Prevalence estimates of impaired glucose tolerance (IGT), 2007 - European Region

Albania 1,995 2.5 2.4

Andorraa 52 9.9 8.9
Austria 6,129 6.0 4.0
Belarus 7,241 16.9 15.2
Belgium 7,600 6.4 4.8
Bulgaria 5,880 7.7 6.3
Croatia 3,445 7.1 5.8
Cyprus 604 6.7 5.9
Denmark 3,889 14.8 12.4
Estonia 983 17.5 15.2
Finland 3,837 6.9 4.2
France 43,116 7.5 6.6
Georgia 3,130 7.1 6.1
Germany 62,580 6.4 4.0
Greece 8,554 7.3 5.9
Hungary 7,543 17.4 15.2
Iceland 204 5.5 4.8
Ireland 3,017 1.9 1.6
Israel 4,302 5.4 5.1
Italy 44,006 5.9 4.7
Latvia 1,707 17.6 15.2
Lithuania 2,481 17.3 15.2
Malta 296 7.8 6.0
Moldova 3,026 16.0 15.2
Monacoa 24 7.4 6.6
Netherlands 11,883 6.1 4,8
Norway 3,242 8.5 7.2
Poland 28,686 16.4 15.2
Portugal 7,922 10.1 8.9
Romania 16,212 16.9 15.2
Slovakia 4,014 16.4 15.2
Slovenia 1,518 17.3 15.2
Spain 33,181 9.8 8.9
Sweden 6,456 9.0 7.2
Turkey 46,513 6.1 6.5
Ukraine 34,309 17.4 15.2
EUR Total 634,373 10.3 9.1
2007. b. Estimates made prior to the establishment of Serbia and Montenegro as independent countries * All comparisons between countries should be done using the

16.2 34.6 13.0 17.8 22.0 50.8

2.1 3.1 3.3 1.9 2.0 5.2
176.2 191.9 0.6 87.1 280.4 368.1
113.1 210.9 82.0 152.0 90.0 324.0
483.8 740.5 282.7 507.3 436.3 1,224.3
242.8 245.6 52.8 150.9 284.8 488.5
78.3 123.5 33.1 81.9 86.8 201.7
166.5 286.1 70.6 180.1 201.9 452.6
3.5 2.1 3.4 2.6 1.6 5.6
94.6 151.2 36.2 100.4 109.2 245.8
18.6 21.7 9.0 16.1 17.2 40.3
581.2 762.9 308.1 528.4 509.6 1,344.1
263.8 313.5 106.2 197.1 276.0 577.4
66.9 105.0 39.2 65.1 69.6 171.8
111.5 154.5 2.5 44.2 221.4 266.1
2,245.5 996.0 603.2 1,552.8 1,087.5 3,241.4
78.5 144.5 38.4 94.4 90.3 223.0
1,951.8 2,083.1 5.6 877.6 3,151.7 4,034.9
286.8 335.4 97.8 216.8 307.7 622.3
541.8 770.6 297.9 507.8 508.8 1,312.5
6.0 5.3 3.6 3.9 5.8 11.3
28.4 28.5 3.6 22.6 32.7 56.9
143.3 91.1 49.2 94.4 92.8 234.4
1,081.4 1,532.5 434.4 844.7 1,336.7 2,613.9
270.5 431.0 155.8 296.6 249.1 701.5
80.6 119.2 55.6 82.8 61.4 199.8
116.9 182.7 65.6 111.7 124.3 299.7
0.7 0.8 0.0 0.4 1.1 1.4
169.7 259.3 96.7 163.9 170.5 429.0
10.3 9.8 2.6 6.7 10.7 20.0
37.1 56.9 18.3 40.4 35.3 94.0
11.1 11.8 3.4 11.0 10.6 23.0
197.5 285.6 132.4 207.6 145.1 483.1
1.2 0.5 0.3 0.8 0.6 1.8
368.4 352.2 86.7 245.1 390.7 720.6
90.3 185.8 53.6 87.5 135.0 276.1
2,029.9 2,675.6 1,091.8 1,952.2 1,581.8 4,705.5
324.0 475.3 203.4 273.2 324.7 799.4
1,169.8 1,574.8 686.9 1,025.8 1,034.0 2,744.6
6,981.7 10,858.4 4,206.6 7,634.9 6,000.6 17,840.0
0.5 0.7 2.2 0.4 0.5 1.2
203.7 311.3 90.6 214.6 211.8 515.0
279.0 380.8 170.4 275.8 215.6 659.9
115.0 148.2 58.6 107.8 98.8 263.2
1,328.0 1,922.3 917.9 1,098.5 1,236.0 3,250.4
188.4 390.0 101.4 167.3 309.7 578.4
152.3 171.0 0.5 82.8 240.0 323.3
79.2 113.3 63.0 78.3 51.2 192.5
1,019.4 1,818.7 812.1 1,252.4 773.7 2,838.2
69.7 104.2 53.6 73.7 46.7 173.9
2,310.6 3,658.8 1,290.6 2,332.6 2,348.3 5,969.4
1,363.8 808.9 571.3 919.8 683.5 2,172.7
383.0 544.3 287.5 386.7 253.1 927.3
28,135 37,186 13,856 25,479 25,967 65,322
comparative prevalence, which is adjusted to the world population .

Table 1.20
Prevalence estimates of impaired glucose tolerance (IGT), 2025 - European Region

Albania 2,400 2.8 2.7

Andorraa 62 10.6 9.4
Austria 6,293 7.6 5.0
Belarus 6,698 18.2 16.3
Belgium 7,787 7.3 5.5
Bulgaria 5,155 8.6 7.1
Croatia 3,247 8.1 6.5
Cyprus 745 7.4 6.5
Denmark 4,107 16.2 13.5
Estonia 922 18.4 16.3
Finland 3,949 9.2 5.4
France 45,455 7.9 7.1
Georgia 2,972 8.0 6.9
Germany 60,962 7.7 5.0
Greece 8,587 8.0 6.5
Hungary 7,255 18.7 16.3
Iceland 242 6.6 5.5
Ireland 3,700 2.4 2.0
Israel 5,783 5.9 5.7
Italy 42,240 6.6 5.1
Latvia 1,545 19.0 16.3
Lithuania 2,368 18.3 16.3
Malta 319 8.6 6.9
Moldova 3,074 17.6 16.3
Monacoa 26 7.8 7.1
Norway 3,651 9.6 7.9
Poland 28,716 17.3 16.3
Portugal 8,219 10.8 9.4
Romania 15,451 18.3 16.3
Slovakia 4,132 18.4 16.3
Slovenia 1,467 19.1 16.3
Spain 33,222 10.7 9.4
Sweden 6,847 9.8 7.9
Turkey 61,913 7.1 7.3
Ukraine 28,853 18.6 16.3
EUR Total 653,394 10.9 9.6
2025 b. Estimates made prior to the establishment of Serbia and Montenegro as independent countries * All comparisons between countries should be done using the

20.6 47.4 14.4 19.7 35.9 68.0

2.8 3.8 3.4 2.2 3.0 6.6
239.9 238.3 0.5 106.9 370.8 478.2
165.3 314.2 97.6 198.6 183.4 479.5
488.4 733.5 2.2 4.4 527.9 1,221.9
279.4 288.2 48.8 142.1 376.7 567.6
87.3 135.2 28.5 86.3 107.6 222.5
164.3 277.4 52.5 173.4 215.8 441.6
3.5 2.3 1.4 2.5 1.9 2.9
117.2 145.3 29.1 87.3 146.0 262.5
25.0 29.8 10.1 19.5 27.1 54.8
630.9 807.1 221.3 554.4 664.4 1,438.0
303.1 361.2 107.7 190.5 368.0 664.3
68.6 101.3 33.1 63.5 75.3 169.9
162.5 201.3 2.5 36.4 326.9 363.8
2,451.2 1,127.0 567.4 1,469.1 1,543.7 3,578.2
83.1 155.4 35.2 87.8 115.5 238.5
2,319.9 2,396.0 4.9 1,004.3 3,706.7 4,715.9
316.3 366.8 73.7 257.0 352.5 683.1
575.4 778.1 226.8 527.6 601.3 1,353.6
8.2 7.8 3.7 4.3 9.9 15.9
44.9 45.4 3.4 34.3 54.5 90.3
214.9 129.1 59.6 124.3 162.0 344.0
1,190.4 1,587.2 317.5 857.6 1,604.5 2,777.6
325.9 520.0 156.4 315.7 373.9 846.0
122.9 179.2 69.8 116.3 116.0 302.1
125.3 168.8 52.9 107.2 136.0 294.2
1.4 1.6 0.2 0.8 1.9 2.9
178.9 255.6 84.4 160.4 191.7 434.5
13.8 13.5 2.9 8.6 15.8 27.4
53.1 60.8 16.0 42.7 55.2 113.9
13.5 13.8 3.5 10.4 15.5 27.3
227.6 314.3 116.6 210.2 217.1 541.9
1.4 0.6 0.3 0.9 0.8 2.0
452.7 465.6 84.0 235.7 600.5 918.3
114.3 235.2 56.2 90.0 203.3 349.5
2,291.5 2,675.6 1,091.8 1,952.2 1,581.8 4,967.1
381.7 503.2 160.9 311.4 414.6 884.9
1,220.3 1,604.9 503.7 1,181.2 1,142.4 2,825.2
6,894.7 10,864.6 3,329.5 6,614.7 7,817.2 17,759.3
0.7 1.0 2.3 0.5 0.9 1.7
266.7 308.6 79.3 207.1 291.0 575.3
328.1 430.9 134.7 297.5 328.7 759
125.9 154.8 43.4 104.6 134.7 280.7
1,571.9 1,984.7 596.7 1,368.2 1,593.6 3,556.5
216.4 451.7 102.4 166.8 398.9 668.1
200.9 215.8 0.4 85.0 331.1 416.6
134.8 201.4 103.6 126.7 105.8 336.2
1,615.8 2.807.1 910.9 2,005.9 1,506.1 4,422.9
114.3 170.9 69.7 116.3 99.1 285.2
2,070.7 3,306.2 960.1 1,974.3 2,444.4 5,376.8
1,504.8 896.2 592.7 914.5 895.8 2,401.0
644.6 911.5 391.5 624.2 540.5 1,556.2
31,178 39,997 11,892 25,864 33,136 71,175
comparative prevalence, which is adjusted to the world population

Table 1.21

Albania Albania (Shapo et al, 2003)117

Andorra Spain (Castell et al, 1999)118
Austriaa,b Germany (Rathmann et al, 2003; Thefeld et al, 1999 and Meisinger et al, 2004 )64,65,71
Germany (Hauner et al, 2003)63
Azerbaijan Turkey (Satman et al, 2002)58
Belarusb Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Belgium The Netherlands (Mooy et al, 1995)72
Bosnia and Herzegovina Turkey (Satman et al, 2002)58
Bulgaria Turkey (Satman et al, 2002)58
Channel Islandsb United Kingdom (Unwin et al, 1997 and Yudkin et al, 1993)119,120
Croatiac Turkey (Satman et al, 2002)58
Cyprus Cyprus (Loizou et al, 2006)121
Czech Republicb Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Denmark Denmark (Glumer et al, 2003)122
Estoniab Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Finlandb Finland (Tuomilehto et al, 1986 and Yliharsila et al, 2005)123,124
Franceb France (Gourdy et al, 2001 and Ricordeau et al, 2000)62,70
Georgia Turkey (Satman et al, 2002)58
Germanya,b Germany (Rathmann et al, 2003; Thefeld et al, 1999 and Meisinger et al, 2004 )64,65,71
Greecec Greece (Panagiotakos et al, 2005)125
Hungaryb Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Icelandd Iceland (Vilbergsson et al, 1997)126
Irelandb Ireland (Smith et al, 2003)127
Israele Israel (Bar-On et al, 1992 and Stern et al, 1999)128,129
Israel (Chodick et al, 2003)66
Italyf Italy (Cricelli et al, 2003)67
Kazakhstanb Uzbekistan (King et al, 1998 and 2002)130,131
Kyrgyzstanb Uzbekistan (King et al, 1998 and 2002)130,131
Latviab Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Liechtenstein Germany (Rathmann et al, 2003; Thefeld et al, 1999 and Meisinger et al, 2004 )64,65,71
Lithuaniab Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Luxembourg The Netherlands (Mooy et al, 1995)72
Macedonia, the Former Yugoslav Republic of c Turkey (Satman et al, 2002)58
Malta Malta (Schranz, 1989)132
Moldovab Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Monacob France (Gourdy et al, 2001 and Ricordeau et al, 2000)62,70
Netherlands The Netherlands (Ubink-Veltmaat et al, 2003)68
Norway Norway (Stene et al, 2004)69
Polandb Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Portugal Spain (Castell et al, 1999)118
Romaniab Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Russian Federationb Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
San Marinob Italy (Cricelli et al, 2003)67
Serbia and Montenegroc Turkey (Satman et al, 2002)58
Slovakiab Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Sloveniab Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
Spain Spain (Castell et al, 1999)118
Sweden Sweden (Eliasson et al, 2002)133
Switzerlanda,b Germany (Rathmann et al, 2003; Thefeld et al, 1999 and Meisinger et al, 2004 )64,65,71
Tajikistanb Uzbekistan (King et al, 1998 and 2002)130,131
Turkey Turkey (Satman et al, 2002)58

- European Region

OGTT WHO - 1985 1,120 25+

OGTT WHO - 1985 3,839 30-79
SR/OGTT WHO - 1999 12,732 18-79
SR Known diabetes 300,000 20+
2hBG WHO - 1999 24,788 20+
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985 2,540 50-74
2hBG WHO - 1999 24,788 20+
2hBG WHO - 1999 24,788 20+
OGTT WHO - 1985 2,529 25-75
2hBG WHO - 1999 24,788 20+
OGTT WHO - 1999 1,200 20-79
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1999 6,784 30-60
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985, 1999 2,775 45-84
SR and FBG Known diabetes, ADA 1997 3,508 35-64
2hBG WHO - 1999 24,788 20+
SR/OGTT WHO - 1999 12,732 18-79
SR Known diabetes 300,000 20
FBG ADA - 1997 3,032 20+
OGTT WHO - 1985 6,842 35+
OGTT (50-100g) WHO - 1985 18,887 30-79
OGTT WHO - 1999 3,821 40+
OGTT WHO – 1980,1985 6,918 25-64
SR Known diabetes 1,600,000 25+
2hBG WHO - 1994, 1999 2,865 35+
2hBG WHO - 1994, 1999 2,865 35+
OGTT WHO - 1985 6,842 35+
SR/OGTT WHO - 1999 12,732 18-79
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985 2,540 50-74
2hBG WHO - 1999 24,788 20+
OGTT WHO - 1985 1,422 35+
OGTT WHO - 1985 6,842 35+
SR and FBG Known diabetes, ADA 1997 3,508 35-64
SR Known diabetes 155,574 50-74
SR Known diabetes combination 30+
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985 3,839 30-79
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985 6,842 35+
2hBG WHO - 1999 24,788 20+
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985 3,839 30-79
OGTT WHO - 1999 6,952 25-74
SR/OGTT WHO - 1999 12,732 18-79
2hBG WHO - 1994, 1999 2,865 35+
2hBG WHO - 1999 24,788 20+

Table 1.21
Turkmenistanb Uzbekistan (King et al, 1998 and 2002)130,131

Ukraineb Poland (Szurkowska et al and Lopatynski et al, 2001)60,61
United Kingdomb United Kingdom (Unwin et al, 1997 and Yudkin et al, 1993)119,120
Uzbekistanb Uzbekistan (King et al, 1998 and 2002)130,131
a. IGT prevalences were derived from the data of Rathmann et al

b. The prevalences were obtained by combining the data from the two (or more) studies
c. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Cyprus data
d. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Netherlands data (Mooy et al)
e. IGT prevalence for Israel was derived only from the data in Bar-On et al
f. IGT prevalence for Italy were derived from other reports: Garancini et al, 1995134, Verillo et al135

- European Region
2hBG WHO - 1994, 1999 2,865 35+

OGTT WHO - 1985 6,842 35+
OGTT WHO - 1985 2,529 25-75
2hBG WHO - 1994, 1999 2,865 35+

Table 1.22
Prevalence estimates of diabetes mellitus (DM), 2007 - North American Region

DM prevalence (%) N
Anguillaa 8 5.7 5.7

Antigua and Barbudaa 43 7.0 7.0
Arubaa 45 10.1 10.1
Bahamas 207 9.8 10.2
Barbados 194 8.4 7.7
Belize 148 7.6 9.6
Bermudaa 41 10.1 10.1
British Virgin Islandsa 15 10.1 10.1
Canada 23,879 9.3 7.4
Cayman Islandsa 29 10.1 10.1
Dominicaa 42 11.2 11.2
Grenadaa 56 9.1 9.1
Guadeloupe 299 10.2 8.8
Guyana 463 8.1 9.2
Haiti 4,441 7.1 9.0
Jamaica 1,536 9.9 10.3
Martinique 272 10.6 8.6
Mexico 64,939 9.4 10.6
Saint Kitts and Nevisa 24 8.8 8.8
Saint Lucia 98 8.4 9.0
Saint Vincent and the Grenadinesa 72 8.2 8.1
Trinidad and Tobago 901 11.4 11.5
United States of America 208,667 9.2 7.8
US Virgin Islands 74 12.4 9.6

NA Total 306,493 9.2 8.4
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of the world population from 2005 to 2007

0.4 0.1 0.2 0.3 0.1 0.2 0.2 0.5

1.3 1.7 1.3 1.7 0.3 1.5 1.2 3.0
2.0 2.5 0.5 2.2 1.8 4.5
8.5 11.7 2.4 10.2 7.6 20.2
5.0 11.3 6.7 9.6 1.6 8.6 6.1 16.3
4.0 7.2 4.4 6.8 2.2 6.2 2.7 11.2
1.8 2.3 0.5 2.0 1.6 4.1
0.6 0.8 0.2 0.7 0.6 1.5
1,207.2 1,008.4 154.9 953.0 1,107.8 2,215.6
1.3 1.6 0.3 1.4 1.2 2.9
0.8 4.0 1.8 3.0 0.7 2.6 1.5 4.8
2.1 2.9 1.9 3.2 0.7 2.8 1.6 5.1
0.0 30.5 12.9 17.6 3.0 15.7 11.8 30.5
15.5 22.0 13.0 24.6 6.7 21.0 9.9 37.6
140.7 173.4 109.0 205.0 59.5 163.7 90.9 314.1
39.6 112.0 56.0 95.7 22.7 82.3 46.6 151.7
0.6 28.1 11.7 17.0 2.3 14.4 12.0 28.7
854.9 5,260.7 2,413.4 3,702.3 1,123.0 2,762.3 2,230.4 6,115.7
1.0 1.1 0.8 1.3 0.3 1.2 0.7 2.1
3.6 4.7 3.1 5.2 1.3 4.6 2.4 8.3
1.5 4.4 2.6 3.3 0.7 2.9 2.3 5.9
13.9 88.6 37.9 64.6 13.4 58.6 30.6 102.5
10,389.5 8,767.5 1,945.0 8,375.6 8,836.4 19,157.0
3.2 6.0 3.2 6.0 0.7 4.8 3.7 9.2

1,088 5,759 14,291 13,962 3,343 12,498 12,411 28,253

Table 1.23
Prevalence estimates of diabetes mellitus (DM), 2025 - North American Region

DM prevalence (%) N
Anguillaa 12 7.1 7.1

Arubaa 52 11.6 11.6
Bahamas 274 12.0 11.8
Barbados 212 11.9 9.5
Belize 231 9.7 11.4
Bermudaa 49 11.6 11.6
Canada 28,132 11.1 8.6
Grenadaa 61 11.1 11.1
Guyana 499 11.8 11.2
Haiti 6,281 8.6 11.0
Jamaica 1,823 11.8 12.2
Mexico 88,723 12.2 12.4
United States of America 247,747 10.3 8.8

NA Total 376,180 10.8 9.7
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of the world population from 2005 to 2025

0.6 0.3 0.4 0.5 0.1 0.4 0.4 0.9

1.4 3.1 2.0 2.5 0.4 2.0 2.1 4.5
2.6 3.4 0.5 2.7 2.7 6.0
13.5 19.3 2.7 14.8 15.3 32.8
5.6 19.7 10.7 14.6 1.4 10.3 13.6 25.3
6.2 16.3 8.5 13.9 3.5 12.5 6.5 22.4
2.5 3.2 0.5 2.6 2.6 5.7
0.3 2.0 1.0 1.3 0.2 1.0 1.0 2.3
1,714.6 1,404.4 172.6 971.1 1,977.3 3,119.0
2.5 3.2 0.5 2.6 2.6 5.7
0.7 5.0 2.1 3.5 0.6 2.9 2.1 5.6
2.1 4.8 2.5 4.3 0.8 3.5 2.5 6.8
17.7 25.1 2.7 18.5 21.6 42.8
17.4 41.3 20.4 38.3 5.7 32.4 20.6 58.7
174.3 364.9 201.1 338.1 99.6 291.3 148.2 539.2
40.6 173.7 75.9 138.4 26.8 106.6 80.9 214.3
0.6 37.1 15.2 22.4 2.1 15.0 20.6 37.7
1,159.3 9,651.6 4,206.5 6,604.5 1,272.5 4,910.5 4,627.9 10,810.9
1.1 1.8 1.1 1.8 0.3 1.5 1.1 2.9
4.4 8.9 4.9 8.4 1.6 7.0 4.6 13.3
1.4 7.1 3.8 4.7 0.8 4.0 3.7 8.5
14.0 127.0 49.9 91.1 13.6 69.0 58.4 141.0
13,625.2 11,786.7 2,222.7 8,330.1 14,859.2 25,411.9
2.5 7.2 2.9 6.8 0.9 3.5 5.3 9.7

1,432 10,472 19,987 20,540 3,833 14,816 21,881 40,528

Table 1.24
Prevalence estimates of impaired glucose tolerance (IGT), 2007 - North American Region


Arubaa 45 11.4 11.4
Bahamas 207 11.3 11.4
Barbados 194 12.0 11.4
Belize 148 9.9 11.4
Bermudaa 41 11.4 11.4
Canadab 23,879 6.1 5.0
Grenadaa 56 11.4 11.4
Guyana 463 10.4 11.4
Haiti 4,441 9.8 11.4
Jamaica 1,536 11.3 11.4
Mexico 64,939 7.4 8.0
United States of America b 208,667 5.9 5.0

NA Total 306,493 6.4 5.8
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2007
b. Prevalence figures are for IFG (not IGT) as only fasting specimens were measured for the majority of NHANES III participants

0.4 0.6 0.3 0.4 0.3 1.0

2.0 2.9 1.3 2.1 1.6 4.9
2.1 3.0 1.4 2.1 1.6 5.1
8.9 14.4 6.6 10.0 6.8 23.3
9.2 14.2 5.4 10.9 7.1 23.4
5.7 8.9 5.4 5.7 3.5 14.6
1.9 2.8 1.2 2.0 1.5 4.7
0.7 1.0 0.4 0.7 0.5 1.7
915.2 548.6 158.9 638.2 666.7 1,463.8
1.3 2.0 0.9 1.4 1.0 3.3
2.0 2.9 1.3 2.0 1.5 4.9
2.6 3.8 1.7 2.7 2.0 6.4
15.4 22.6 8.2 16.8 13.1 38.0
17.1 31.1 16.3 19.8 12.1 48.2
154.2 281.3 162.6 158.0 114.8 435.5
69.1 104.6 48.7 69.9 55.0 173.7
14.4 21.5 6.6 15.7 13.6 35.9
1,871.1 2,909.7 1,491.3 1,788.7 1,500.7 4,780.7
1.1 1.6 0.7 1.2 0.9 2.8
4.2 6.6 3.2 4.4 3.2 10.8
3.0 4.6 2.5 2.8 2.3 7.6
40.5 61.5 26.9 44.4 30.8 102.1
7,621.2 4,754.3 1,445.8 5,413.2 5,517.4 12,375.4
4.2 6.0 1.6 4.3 4.3 10.2

10,768 8,810 3,399 8,217 7,962 19,578

Table 1.25
Prevalence estimates of impaired glucose tolerance (IGT), 2025 - North American Region


Arubaa 52 12.5 12.5
Bahamas 274 12.8 12.5
Barbados 212 14.6 12.5
Belize 231 11.0 12.5
Bermudaa 49 12.5 12.5
Canadab 28,132 7.2 5.7
Grenadaa 61 12.5 12.5
Guyana 499 12.6 12.5
Haiti 6,281 10.4 12.5
Jamaica 1,823 12.2 12.5
Mexico 88,723 8.6 8.8
United States of America b 247,747 6.7 5.7

NA Total 376,180 7.3 6.7
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2025
b. Prevalence figures are for IFG (not IGT) as only fasting specimens were measured for the majority of NHANES III participants

0.7 0.9 0.3 0.6 0.6 1.6

2.7 3.6 1.4 2.5 2.4 6.4
2.8 3.7 1.4 2.6 2.5 6.5
14.2 20.9 7.3 14.1 13.7 35.1
13.8 17.2 4.3 11.8 15.0 31.1
10.2 15.3 7.4 10.6 7.4 25.5
2.6 3.5 1.3 2.4 2.4 6.1
1.2 1.6 0.6 1.1 1.1 2.8
1,262.9 751.1 173.7 648.2 1,192.2 2,014
2.6 3.5 1.3 2.5 2.4 6.2
2.3 3.1 1.2 2.2 2.1 5.4
3.3 4.4 1.7 3.1 2.9 7.7
21.7 29.0 7.8 19.0 23.9 50.7
24.8 38.0 12.4 27.9 22.5 62.7
245.7 404.6 219.9 259.4 171.0 650.3
91.7 130.9 52.9 83.9 85.8 222.7
19.0 25.3 5.8 15.6 22.9 44.3
3,201.4 4,456.9 1,606.4 3,044.9 3,007.0 7,658.3
1.5 2.0 0.8 1.4 1.3 3.5
6.3 8.9 3.5 6.2 5.4 15.2
4.5 6.1 2.3 4.5 3.8 10.6
55.5 75.0 22.7 50.6 57.2 130.5
10,177.0 6,314.7 1,681.6 5,439.2 9,371.9 16,491.7
4.4 6.3 1.8 2.9 6.0 10.7

15,173 12,327 3,820 9,657 14,023 27,499

Table 1.26

Anguillaa Barbados (Hennis et al, 2002)136

Antigua and Barbudaa Barbados (Hennis et al, 2002)136
Arubaa Barbados (Hennis et al, 2002)136
Bahamas Barbados (Hennis et al, 2002)136
Barbadosa Barbados (Hennis et al, 2002)136
Belize Jamaica (Wilks et al, 1999)76
Bermudaa Barbados (Hennis et al, 2002)136
British Virgin Islandsa Barbados (Hennis et al, 2002)136
Canadab Canada (Hux et al, 2003)137
Cayman Islandsa Barbados (Hennis et al, 2002)136
Dominica Jamaica (Wilks et al, 1999)76
Grenada Jamaica (Wilks et al, 1999)76
Guadeloupea Guadeloupe (Costagliola et al, 1991)138
Guyana Jamaica (Wilks et al, 1999)76
Haiti Jamaica (Wilks et al, 1999)76
Jamaica Jamaica (Wilks et al, 1999)76
Martiniquea Guadeloupe (Costagliola et al, 1991)138
Mexicoc Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79
Saint Kitts and Nevis Jamaica (Wilks et al, 1999)76
Saint Lucia Jamaica (Wilks et al, 1999)76
Saint Vincent and the Grenadinesa Barbados (Hennis et al, 2002)136
Trinidad and Tobago Jamaica (Wilks et al, 1999)76
United States of America USA (Cowie et al, 2006)77
US Virgin Islands Jamaica (Wilks et al, 1999)76
a. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Jamaican data
b. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from USA data
c. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from Brazilian data81,139,140
N/A Not available

- North American Region

SR or HBA1c > 10% Known diabetes 4,104 40-79

OGTT WHO - 1980 1,303 25-74
Registry Known diabetes N/A 20+
OGTT WHO - 1980 1,303 25-74
OGTT WHO - 1980 1,303 25-74
SR or FPG > 8.0 WHO - 1980 1,036 18+
OGTT WHO - 1980 1,303 25-74
OGTT WHO - 1980 1,303 25-74
OGTT WHO - 1980 1,303 25-74
SR or FPG > 8.0 WHO - 1980 1,036 18+
OGTT/FBG ADA - 1997 84,054 20+
OGTT WHO - 1980 1,303 25-74
OGTT WHO - 1980 1,303 25-74
OGTT WHO - 1980 1,303 25-74
FBG ADA - 1997 4,761 20+
OGTT WHO - 1980 1,303 25-74

Table 1.27
Prevalence estimates of diabetes mellitus (DM), 2007 - South and Central American Region

DM prevalence (%)
Argentina 24,952 6.0 5.6

Bolivia 4,910 5.1 5.8
Brazil 119,519 5.8 6.2
Chile 10,883 5.9 5.6
Colombia 27,860 4.6 5.0
Costa Rica 2,746 8.5 9.3
Cuba 8,117 10.4 9.3
Dominican Republic 5,219 7.3 8.7
Ecuador 7,792 5.2 5.7
El Salvador 3,980 7.7 9.0
French Guiana 111 11.5 11.8
Guatemala 6,034 7.2 8.6
Honduras 3,764 7.1 9.1
Netherlands Antilles 126 13.7 11.3
Nicaragua 2,870 7.6 10.1
Panama 2,002 9.0 9.7
Paraguay 3,344 4.0 4.8
Peru 16,642 5.4 6.0
Puerto Rico 2,704 12.8 10.7
Suriname 274 9.7 10.2
Uruguay 2,280 6.4 5.6
Venezuela 16,297 4.9 5.4

SACA Total 272,427 6.0 6.3


143.1 1,344.7 695.9 791.9 121.7 736.1 629.9 1,487.8

46.4 201.7 113.9 134.2 36.3 126.3 85.6 248.1
620.4 6,292.9 3,101.0 3,812.3 919.5 3,245.7 2,748.1 6,913.3
73.9 571.6 310.4 335.1 80.4 349.1 216.0 645.5
166.6 1,111.2 571.5 706.3 122.7 729.7 425.3 1,277.8
68.6 165.2 98.4 135.3 37.5 114.0 82.3 233.8
95.2 749.5 309.9 534.8 100.8 447.3 296.6 844.7
72.8 310.7 147.4 236.1 66.3 219.5 97.7 383.5
84.3 320.6 191.1 213.7 55.1 209.1 140.6 404.8
106.4 201.3 119.5 188.3 59.6 130.2 117.9 307.7
1.4 11.3 5.6 7.2 2.5 7.6 2.7 12.8
176.1 259.7 171.3 264.5 82.6 183.6 169.6 435.8
89.1 178.6 110.7 157.1 56.2 119.1 92.5 267.8
2.8 14.4 6.3 10.9 2.0 10.0 5.2 17.2
42.8 174.0 87.6 129.2 48.5 99.3 69.0 216.8
45.1 135.4 75.8 104.7 29.8 82.3 68.4 180.4
33.9 98.8 59.5 73.2 24.1 69.1 39.5 132.7
130.2 763.8 425.0 469.0 126.8 464.0 303.2 894.0
45.0 300.3 129.2 216.1 35.3 140.6 169.4 345.3
7.7 19.0 10.6 16.0 5.3 14.3 7.1 26.7
11.5 134.9 67.5 78.9 10.7 69.0 66.7 146.4
48.1 746.9 371.6 423.3 74.2 440.6 280.1 795.0

2,111 14,106 7,180 9,038 2,098 8,007 6,113 16,218

Table 1.28
Prevalence estimates of diabetes mellitus (DM), 2025 - South and Central American Region

DM prevalence (%) N
Argentina 31,093 6.4 6.4

Bolivia 7,490 5.7 7.0
Brazil 154,392 11.4 11.5
Chile 13,639 6.9 6.4
Colombia 38,483 5.9 6.0
Costa Rica 3,866 11.3 11.4
Cuba 8,467 12.9 10.6
Ecuador 10,946 6.4 6.9
El Salvador 5,766 9.7 11.0
Guatemala 10,227 7.9 10.6
Honduras 6,151 8.7 11.1
Nicaragua 4,686 9.4 12.1
Panama 2,810 11.4 11.7
Paraguay 5,389 4.8 5.7
Peru 23,552 6.6 7.1
Puerto Rico 3,031 14.5 12.6
Suriname 323 12.2 11.9
Uruguay 2,627 6.8 6.4
Venezuela 23,232 6.0 6.3

SACA Total 363,651 9.0 9.3


143.3 1,852.4 944.0 1,051.8 149.2 975.6 871.0 1,995.7

55.7 375.0 199.2 231.4 56.6 217.0 157.0 430.6
1,111.2 16,516.3 9,588.6 8,038.8 2,166.8 7,837.6 7,623.0 17,627.5
82.0 863.3 457.4 487.9 93.1 434.1 418.1 945.3
215.2 2,036.1 1,014.6 1,236.7 153.0 1,117.4 980.8 2,251.3
91.9 345.7 183.6 254.0 51.7 180.3 205.5 437.6
90.0 1,006.2 393.9 702.3 78.6 537.9 479.7 1,096.2
89.5 576.2 244.8 421.0 86.9 360.9 218.0 665.8
103.0 599.1 326.6 375.5 74.7 341.5 285.9 702.1
142.8 416.7 217.2 342.3 77.6 264.6 217.2 559.4
1.8 20.9 9.3 13.3 4.0 11.1 7.6 22.6
239.2 572.2 303.1 508.3 154.3 351.7 305.4 811.4
127.7 409.1 223.1 313.7 94.3 243.0 199.5 536.8
2.5 18.3 8.2 12.6 3.9 6.1 10.8 20.8
63.2 378.5 178.7 263.0 78.1 206.9 156.6 441.7
57.8 262.3 132.3 187.9 37.5 138.4 144.3 320.1
46.3 210.6 110.2 146.7 40.4 119.9 96.6 256.9
165.1 1,378.9 724.3 819.6 169.8 778.5 595.7 1,544.0
42.1 396.3 162.6 275.8 38.4 160.1 239.9 438.4
8.1 31.3 15.7 23.7 5.7 20.1 13.6 39.4
10.8 168.2 84.8 94.2 11.6 84.3 83.0 179.0
61.5 1,326.1 648.1 739.6 101.3 680.3 606.0 1,387.6

2,951 29,759 16,170 16,540 3,728 15,067 13,915 32,710

Table 1.29
Prevalence estimates of impaired glucose tolerance (IGT), 2007 - South and Central American Region

Argentina 24,952 9.9 9.6

Bolivia 4,910 7.2 8.0
Brazil 119,519 7.0 7.3
Chile 10,883 10.1 9.6
Colombia 27,860 4.3 4.4
Costa Rica 2,746 6.9 7.3
Cuba 8,117 12.5 11.4
Ecuador 7,792 7.5 8.0
Guatemala 6,034 6.6 7.3
Honduras 3,764 6.3 7.3
Nicaragua 2,870 6.2 7.3
Panama 2,002 7.0 7.3
Paraguay 3,344 8.6 9.6
Peru 16,642 7.3 8.0
Puerto Rico 2,704 8.1 7.3
Suriname 274 7.5 7.6
Uruguay 2,280 10.4 9.6
Venezuela 16,297 4.8 5.0

SACA Total 272,427 7.3 7.5


837.3 1,627.9 528.3 1,244.7 692.2 2,465.2

141.2 214.6 110.9 130.6 114.2 355.7
3,427.4 4,932.2 2,582.8 3,527.5 2,249.3 8,359.5
380.7 714.3 230.1 606.3 258.7 1,095.0
464.2 723.1 446.5 479.6 261.1 1,187.3
81.9 106.7 59.0 81.5 48.1 188.7
432.5 584.2 221.0 423.1 372.5 1,016.7
208.6 324.7 180.3 222.5 130.5 533.3
242.2 341.4 168.5 219.6 195.5 583.6
108.8 156.8 97.2 96.9 71.5 265.6
2.9 5.4 2.9 4.0 1.4 8.3
162.3 234.2 146.8 142.0 107.8 396.5
103.1 134.5 93.7 88.2 55.6 237.6
3.2 7.6 2.4 5.6 2.8 10.8
75.3 101.4 73.4 66.0 37.2 176.7
60.3 79.3 44.1 56.8 38.7 139.6
103.2 182.9 81.8 154.9 49.5 286.1
503.9 717.2 365.1 462.6 393.4 1,221.1
86.1 134.1 47.6 86.4 86.1 220.1
6.8 13.6 7.3 8.9 4.3 20.5
78.9 157.1 45.7 117.1 73.3 236.0
315.8 465.0 296.4 303.8 180.6 780.8

7,827 11,958 5,832 8,529 5,424 19,785

Table 1.30
Prevalence estimates of impaired glucose tolerance (IGT), 2025 - South and Central American Region

Argentina 31,093 9.9 10.2

Bolivia 7,490 7.4 8.7
Brazil 154,392 7.4 7.7
Chile 13,639 10.6 10.2
Colombia 38,483 4.4 4.6
Costa Rica 3,866 7.9 7.7
Cuba 8,467 14.5 12.3
Ecuador 10,946 8.2 8.7
Guatemala 10,227 6.0 7.7
Honduras 6,151 6.7 7.7
Nicaragua 4,686 6.6 7.7
Panama 2,810 7.7 7.7
Paraguay 5,389 9.1 10.2
Peru 23,552 8.1 8.7
Puerto Rico 3,031 7.8 7.7
Uruguay 2,627 10.2 10.2
Venezuela 23,232 5.1 5.2

SACA Total 363,651 7.6 7.9


1,112.5 1,979.3 633.1 1,627.8 830.9 3,091.8

234.9 319.8 161.8 207.9 184.9 554.6
4,934.4 6,525.3 2,798.6 4,727.0 3,934.0 11,459.6
517.2 923.3 267.5 718.8 454.1 1,440.4
680.3 1,019.2 536.2 659.3 503.9 1,699.5
130.7 173.0 74.0 120.5 109.2 303.6
568.1 659.4 181.0 487.7 558.8 1,227.5
339.7 474.0 219.3 338.7 255.7 813.7
400.7 500.8 210.8 331.8 358.8 901.4
170.8 224.8 117.3 174.0 104.4 395.6
4.9 9.1 4.7 5.6 3.8 14.0
269.7 341.8 237.7 217.6 156.2 611.5
180.1 234.4 143.0 166.9 104.5 414.5
4.2 7.3 3.0 4.1 4.4 11.4
133.6 174.5 106.8 127.6 73.7 308.1
92.8 122.4 53.4 88.4 73.4 215.2
177.3 313.0 130.0 250.4 110.0 490.3
836.8 1,070.8 460.1 740.1 707.5 1,907.7
102.6 134.6 49.4 90.7 97.1 237.3
8.7 16.7 7.4 11.2 6.8 25.4
96.7 172.4 50.0 140.1 79.0 269.1
471.6 708.1 374.0 446.9 358.8 1,179.7

11,468 16,104 6,819 11,683 9,070 27,572

Table 1.31

Argentinaa,b Argentina (de Sereday et al, 2004)80

Bolivia Bolivia (Barceló et al, 2001)141
Brazil Brazil (Oliveira et al, 1996; Malerbi et al, 1992 and Torquato et al, 2003)81,139,140
Chile Chile (Baechler et al, 2002)82
Colombia Colombia (Aschner et al, 1993)142
Costa Ricac Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79
Cuba Jamaica (Wilks et al, 1999)76
Dominican Republic Jamaica (Wilks et al, 1999)76
Ecuador Bolivia (Barceló et al, 2001)141
El Salvadorc Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79
French Guiana Suriname (Schaad et al, 1985)143
Guatemalac Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79
Hondurasc Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79
Netherlands Antillesb Suriname (Schaad et al, 1985)143
Nicaraguac Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79
Panamac Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79
Paraguay Paraguay (Jimenez et al, 1998)144
Peru Bolivia (Barceló et al, 2001)141
Puerto Rico Jamaica (Wilks et al, 1999)76
Suriname Suriname (Schaad et al, 1985)143
Uruguay Argentina (de Sereday et al, 2004)80
Venezuela Brazil (Oliveira et al, 1996; Malerbi et al, 1992 and Torquato et al, 2003)81,139,140
a. Persons with previously diagnosed diabetes were excluded from the study, and obtained prevalence doubled
b. Because of the absence of data for IGT in the Argentinian and Barbados studies, the following countries had IGT prevalence determined from the study indicated below:
Argentina: Paraguay (Jimenez et al, 1998)144
Netherland Antilles: Jamaica (Wilks et al, 1999)76
c. Diabetes prevalence was derived by combining the data of the two studies indicated; IGT prevalence was calculated from Brazilian data

- South and Central American Region

OGTT WHO - 1999 2,397 20-69

2hBG WHO - 1985 2,948 25+
OGTT WHO - 1985 25,371 30-69
OGTT WHO - 1999 1,315 20+
2hBG WHO - 1985 670 30-79
OGTT/FBG ADA - 1997 84,054 20+
OGTT WHO - 1980 1,303 25-74
OGTT WHO - 1980 1,303 25-74
2hBG WHO - 1985 2,948 25+
OGTT/FBG ADA - 1997 84,054 20+
OGTT WHO - 1980 1,218 30+
OGTT/FBG ADA - 1997 84,054 20+
OGTT/FBG ADA - 1997 84,054 20+
OGTT WHO - 1980 1,218 30+
OGTT/FBG ADA - 1997 84,054 20+
OGTT/FBG ADA - 1997 84,054 20+
OGTT WHO - 1985 1,606 20-74
2hBG WHO - 1985 2,948 25+
OGTT WHO - 1980 1,303 25-74
OGTT WHO - 1980 1,218 30+
OGTT WHO - 1999 2,397 20-69
OGTT WHO - 1985 25,371 30-69

Table 1.32
Prevalence estimates of diabetes mellitus (DM), 2007 – South-East Asian Region

DM prevalence (%)
Bangladesh 80,196 4.8 5.3

Bhutan 1,145 4.7 5.4
India 659,570 6.2 6.7
Maldives 167 6.2 7.1
Mauritius 847 11.3 11.1
Nepal 14,288 3.5 4.2
Sri Lanka 14,136 8.4 8.4

SEA Total 770,350 6.0 6.5
Table 1.33
Prevalence estimates of diabetes mellitus (DM), 2025 – South-East Asian Region

DM prevalence (%)
Bangladesh 120,909 6.1 6.6

Bhutan 1,858 3.6 4.5
India 918,761 7.6 8.2
Maldives 294 9.8 11.2
Mauritius 1,019 14.6 13.4
Nepal 22,915 4.4 5.8
Sri Lanka 16,746 10.7 10.2

SEA Total 1,082,501 7.4 8.0
Table 1.34
Prevalence estimates of impaired glucose tolerance (IGT), 2007 - South-East Asian Region

IGT prevalence (%)
Bangladesh 80,196 8.5 8.9

Bhutan 1,145 3.0 3.2
India 659,570 5.4 5.6
Maldives 167 12.2 12.4
Mauritius 847 16.5 16.3
Nepal 14,288 3.8 4.1
Sri Lanka 14,136 12.1 12.1

SEA Total 770,350 5.9 6.0

1,935.0 1,913.1 1,844.2 2,003.9 1,487.3 1,644.6 716.2 3,848.1

45.2 9.2 29.2 25.2 12.9 22.4 19.0 54.3
20,871.3 19,979.5 22,189.6 18,661.2 8,418.0 19,645.4 12,787.5 40,850.8
3.8 6.6 5.2 5.2 4.5 4.1 1.7 10.4
38.3 57.6 46.9 49.0 15.1 53.4 27.3 95.9
313.6 183.5 186.6 310.5 77.9 233.7 185.5 497.1
645.9 540.7 519.1 667.5 325.0 519.3 342.3 1,186.6

23,853 22,690 24,821 21,722 10,341 22,123 14,079 46,543

2,614.4 4,804.8 3,440.5 3,978.7 2,354.9 3,436.9 1,627.4 7,419.2

38.7 28.5 35.0 32.2 14.3 32.8 20.2 67.2
26,755.7 43,125.9 37,726.1 32,155.5 11,713.0 33,162.1 25,006.5 69,881.6
11.5 17.4 14.5 14.4 11.5 12.0 5.4 28.9
43.5 105.1 70.7 77.9 16.3 68.8 63.6 148.6
474.1 535.3 369.5 640.0 160.6 454.0 394.8 1,009.4
729.0 1,057.2 774.0 1,012.2 361.3 774.7 650.3 1,786.2

30,667 49,674 42,430 37,911 14,632 37,941 27,768 80,341

3,443.1 3,376.2 3,455.2 2,404.9 959.1 6,819.3

17.1 17.2 14.0 9.9 10.4 34.3
18,286.5 17,619.6 15,852.7 12,959.3 7,094.0 35,906.1
11.3 9.0 12.2 5.1 2.9 20.3
55.5 84.2 47.5 66.2 26.0 139.7
191.7 350.6 246.2 153.2 143.0 542.3
920.9 786.6 783.8 541.2 382.6 1,707.5

22,926 22,244 20,412 16,140 8,618 45,169

Table 1.35
Prevalence estimates of impaired glucose tolerance (IGT), 2025 - South-East Asian Region

IGT prevalence (%)
Bangladesh 120,909 8.8 9.2

Bhutan 1,858 3.2 3.6
India 918,761 6.1 6.3
Maldives 294 12.9 13.7
Mauritius 1,019 17.7 17.0
Nepal 22,915 4.8 5.5
Sri Lanka 16,746 13.6 13.4

SEA Total 1,082,501 6.5 6.7
Table 1.36

Bangladesh Bangladesh (Hussain et al, 2005)91

Bangladesh (Sayeed et al, 2003)145
Bhutan India (Sadikot et al, 2004)85
India (Shah et al, 2006)86
India India (Ramachandran et al, 2001)84
India (Sadikot et al, 2004)85
India (Shah et al, 2006)86
Maldives Sri Lanka (Fernando et al, 1994)146
Mauritius Mauritius (Dowse et al, 1990)109
Nepal Nepal (Singh et al, 2003)90
Nepal (Karki et al, 2000)89
Sri Lanka Sri Lanka (Wijewardene et al, 2005)92


5,287.7 5,359.6 4,611.2 4,063.6 1,972.5 10,647.3

29.5 29.4 23.0 19.4 16.4 58.9
28,515.3 27,712.9 21,773.2 21,158.9 13,296.1 56,228.2
20.8 17.2 20.9 10.8 6.3 38.0
72.9 107.2 46.9 77.2 56.0 180.1
394.7 705.6 463.9 320.8 315.7 1,100.4
1,206.3 1,065.8 765.8 764.1 742.2 2,272.1

35,527 34,998 27,705 26,415 16,405 70,525
- South-East Asian Region

OGTT WHO - 1999 6,312 20+

FBG ADA - 1997 4,923 20+
OGTT WHO - 1999 18,363 25+
SR Known Diabetes 39,429 15-64
OGTT WHO - 1999 11,216 20+
OGTT WHO - 1999 18,363 25+
SR Known Diabetes 39,429 15-64
OGTT WHO - 1985 633 30-64
OGTT WHO - 1985 5,080 25-74
FBG WHO - 1999 1,841 20+
OGTT WHO - 1985 1,840 30+
FBG ADA - 1997 6,047 30-65

Table 1.37
Prevalence estimates of diabetes mellitus (DM), 2007 - Western Pacific Region

DM prevalence (%)
Australia 14,504 6.4 5.0

Brunei Darussalam 242 9.3 12.2
Cambodia 7,599 4.3 5.0
China 929,432 4.3 4.1
China, Hong Kong 5,560 9.5 8.2
China, Macau 349 8.5 8.2
Cook Islandsa 13 5.5 5.5
Fiji 510 8.5 9.2
French Polynesia 165 13.1 13.5
Guam 107 6.7 6.5
Indonesia 142,635 2.0 2.3
Japan 97,326 7.2 4.9
Kiribatia 67 6.4 6.4
Korea, Democratic People’s Republic of 15,114 5.3 5.2
Korea, Republic of 35,704 8.6 7.8
Lao People’s Democratic Republic 2,991 2.5 3.1
Malaysia 15,390 9.9 10.7
Marshall Islandsa 38 8.8 8.8
Micronesia, Federated States ofa 55 5.2 5.9
Mongolia 1,598 1.6 1.9
Myanmar 31,394 2.8 3.2
Naurua 8 30.7 30.7
New Caledoniab 154 3.2 4.4
New Zealandc 2,790 7.7 6.4
Niuea 1 4.5 4.5
Palaua 13 8.9 8.9
Papua New Guinea 3,043 1.9 2.9
Philippines 47,038 6.5 7.6
Samoa 90 6.5 7.5
Singapore 3,245 11.9 10.1
Solomon Islands 246 2.0 3.0
Taiwana 14,340 5.7 7.4
Thailand 44,194 7.2 6.9
Timor-Leste 501 1.3 1.7
Tokelaua 1 8.5 8.5
Tongaa 55 11.9 12.9
Tuvalua 7 13.4 13.4
Vanuatu 109 2.2 3.0
Viet Nam 51,972 2.5 2.9
WP Total 1,468,598 4.6 4.4
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2007,
except Taiwan (developed world population)
b. For New Caledonia, the Melanesian population was ascribed as having the national urban/rural population distribution, whereas the French population was deemed
as having the diabetes prevalence of Metropolitan France, and assigned to the urban component, and each assigned 50% of the total population
c. New Zealand data only self-reported

515.8 410.1 40.0 346.4 539.5 925.9

3.3 19.3 10.0 12.6 3.1 14.1 5.4 22.6
178.7 147.4 141.6 184.6 65.9 191.7 68.6 326.2
20,705.1 19,104.5 20,531.5 19,278.2 6,421.0 21,531.4 11,857.3 39,809.6
238.7 287.3 41.6 236.6 247.8 526.0
14.3 15.6 2.6 15.9 11.3 29.9
0.2 0.6 0.3 0.4 0.2 0.4 0.2 0.7
20.2 23.4 20.2 23.3 7.0 26.8 9.7 43.6
5.7 15.9 9.8 11.8 4.2 12.6 4.8 21.6
2.3 4.9 3.7 3.5 1.4 4.0 1.9 7.2
1,102.8 1,785.0 1,353.7 1,534.1 261.4 1,408.3 1,218.1 2,887.8
3,599.1 3,379.3 376.9 2,497.1 4,104.3 6,978.4
1.4 2.8 2.1 2.1 0.9 2.2 1.2 4.2
173.1 633.5 446.0 360.6 145.2 388.6 272.8 806.6
1,647.8 1,426.0 427.3 1,463.0 1,183.4 3,073.8
42.8 30.7 31.3 42.3 13.3 34.1 26.1 73.5
394.1 1,136.6 625.8 904.8 149.7 875.8 505.1 1,530.6
0.4 3.0 1.7 1.7 0.6 1.8 1.0 3.4
1.2 1.6 1.4 1.5 0.7 1.6 0.5 2.8
5.2 20.1 11.3 14.0 5.3 15.1 4.9 25.3
467.9 404.8 369.9 502.8 141.4 412.5 318.8 872.7
0.0 2.6 1.3 1.3 0.5 1.5 0.6 2.6
1.0 3.9 0.8 4.1 1.0 2.2 1.7 4.9
106.3 109.8 20.0 95.7 100.3 216.1
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1
0.1 1.0 0.6 0.6 0.2 0.6 0.3 1.1
27.6 31.6 25.1 34.1 5.7 31.6 21.9 59.2
1,053.6 2,001.5 920.6 2,134.4 553.2 1,627.6 874.2 3,055.1
4.0 1.9 2.7 3.1 0.6 3.1 2.2 5.9
201.6 183.2 21.6 184.4 178.8 384.8
2.1 2.9 2.1 3.0 0.5 2.5 2.0 5.0
324.5 487.8 95.8 355.3 361.3 812.3
2,213.8 948.6 1,436.0 1,726.4 497.7 1,577.1 1,087.6 3,162.4
5.6 0.9 3.3 3.3 0.6 3.5 2.5 6.6
0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1
2.1 4.4 2.9 3.6 1.3 3.4 1.8 6.5
0.3 0.7 0.4 0.5 0.2 0.5 0.3 1.0
1.1 1.4 1.0 1.4 0.2 1.2 1.0 2.4
852.3 442.3 557.6 737.1 217.5 613.7 463.4 1,294.6
27,268 26,778 33,163 33,830 9,526 33,984 23,483 66,993

Table 1.38
Prevalence estimates of diabetes mellitus (DM), 2025 - Western Pacific Region

DM prevalence (%)
Australia 17,547 7.7 6.0

Cambodia 11,743 5.2 6.1
China 1,067,160 5.6 4.8
China, Macau 425 12.8 9.6
Fiji 626 10.2 10.5
Guam 145 8.2 7.9
Indonesia 183,541 2.8 2.9
Japan 90,209 7.9 5.7
Malaysia 22,293 12.3 13.1
Micronesia, Federated States of a 64 8.2 7.3
Mongolia 2,252 2.2 2.2
Myanmar 41,444 3.8 4.1
Naurua 12 33.0 32.3
New Caledoniab 216 3.9 4.3
New Zealandc 3,244 8.8 7.3
Niuea 1 5.3 5.3
Palaua 18 10.3 10.1
Samoa 114 8.1 9.1
Singapore 4,054 17.1 11.9
Taiwana 17,140 6.6 8.4
Thailand 52,258 8.9 8.0
Tokelaua 1 9.4 9.3
Tongaa 63 14.4 15.2
Tuvalua 10 15.8 15.7
Vanuatu 172 3.2 4.3
Viet Nam 72,238 3.5 3.7

WP Total 1,731,564 5.7 5.1
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2025 , except
Taiwan (developed world population)
b. For New Caledonia, the Melanesian population was ascribed as having the national urban/rural population distribution, whereas the French population was deemed as
having the diabetes prevalence of Metropolitan France, and assigned to the urban component, and each assigned 50% of the total population
c. New Zealand data only self-reported; total diabetes calculated as twice the self-reported prevalence

744.2 601.8 44.6 390.5 911.0 1,346.0

4.8 41.8 19.8 26.9 4.2 25.2 17.3 46.6
239.2 368.9 281.0 327.0 132.1 313.9 162.1 608.1
22,105.6 37,164.0 29,474.2 29,795.5 5,854.7 29,076.2 24,338.7 59,269.7
347.7 511.7 39.0 264.9 555.6 859.4
22.9 31.3 3.0 15.7 35.5 54.3
0.2 0.9 0.4 0.7 0.2 0.5 0.4 1.1
21.6 42.5 30.0 34.1 7.6 36.5 20.1 64.2
6.8 28.3 15.4 19.7 5.5 18.7 11.0 35.1
2.6 9.2 6.0 5.8 1.8 5.6 4.5 11.9
1,352.7 3,776.3 2,457.0 2,672.0 309.6 2,499.6 2,319.9 5,129.0
3,674.7 3,496.7 265.2 2,512.2 4,393.9 7,171.4
2.5 4.9 3.7 3.7 1.2 3.7 2.5 7.4
169.3 912.4 598.8 483.0 145.7 567.2 368.8 1,081.8
2,119.8 2,043.5 336.4 1,715.4 2,111.5 4,163.3
62.3 80.7 61.5 81.5 24.3 65.7 53.0 143.0
473.3 2,269.6 1,127.6 1,615.2 204.2 1,345.3 1,193.3 2,742.9
0.5 5.8 3.2 3.1 0.9 3.1 2.2 6.3
1.5 3.8 2.6 2.6 0.9 2.6 1.8 5.3
7.2 41.7 21.5 27.4 7.2 29.4 12.3 48.9
619.2 947.3 636.4 930.1 180.7 713.8 671.9 1,566.4
0.0 4.1 2.1 2.0 0.7 2.2 1.1 4.1
1.2 7.2 1.2 7.2 1.2 3.5 3.7 8.4
138.9 146.7 22.7 96.6 166.4 285.6
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1
0.1 1.7 0.9 0.9 0.3 0.9 0.6 1.8
48.0 90.0 53.6 84.4 12.8 71.0 54.1 137.9
1,565.9 4,006.8 1,620.5 3,952.2 780.7 2,855.0 1,937.0 5,572.7
5.1 4.2 4.4 4.8 0.6 4.7 3.9 9.2
348.8 343.6 22.2 183.2 487.0 692.4
3.6 8.9 4.8 7.7 1.3 6.6 4.6 12.5
433.8 690.0 104.8 449.9 569.1 1,123.9
2,630.4 2,029.8 2,114.4 2,545.8 507.4 2,013.4 2,139.4 4,660.2
9.8 2.9 6.3 6.4 1.4 6.0 5.3 12.7
0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1
2.1 7.0 4.1 5.0 1.4 5.1 2.6 9.1
0.3 1.3 0.7 0.9 0.2 0.9 0.5 1.6
1.7 3.7 2.1 3.3 0.5 2.6 2.3 5.5
1,333.8 1,166.8 1,046.5 1,454.2 290.5 1,132.0 1,078.2 2,500.7

30,672 53,033 47,432 51,969 9,318 46,439 43,643 99,401

Table 1.39
Prevalence estimates of impaired glucose tolerance (IGT), 2007 - Western Pacific Region

Australia 14,504 9.6 8.2

Cambodia 7,599 9.4 10.4
China 929,432 6.9 6.9
China, Macau 349 11.7 10.9
Fiji 510 10.1 10.7
Guam 107 17.7 17.3
Indonesia 142,635 9.9 10.6
Japan 97,326 13.2 10.9
Malaysia 15,390 18.9 14.9
Mongolia 1,598 9.2 10.3
Myanmar 31,394 2.3 2.5
Naurua 8 20.4 20.4
New Caledonia 154 4.9 4.8
New Zealand 2,790 9.6 8.2
Niuea 1 6.9 6.9
Palaua 13 17.3 17.3
Samoa 90 6.0 6.5
Singapore 3,245 17.2 18.7
Taiwana 14,340 3.8 4.6
Thailand 44,194 4.3 4.2
Tokelaua 1 13.0 13.0
Tongaa 55 12.0 13.0
Tuvalua 7 13.0 13.0
Vanuatu 109 8.0 9.4
Viet Nam 51,972 2.3 2.5
WP Total 1,468,598 7.6 7.5
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2007, except


601.5 785.2 215.0 595.3 576.4 1,386.7

25.0 22.4 22.2 21.4 3.7 47.4
306.8 407.3 304.5 268.5 141.1 714.1
40,001.1 24,322.5 24,566.4 25,358.4 14,398.8 64,323.6
307.5 368.9 133.4 350.5 192.5 676.4
19.2 21.7 8.4 23.6 9.0 41.0
0.6 0.7 0.3 0.6 0.5 1.3
21.6 29.9 18.2 23.1 10.1 51.4
10.0 11.3 5.6 12.1 3.6 21.3
8.8 10.2 5.9 9.4 3.7 19.0
7,594.0 6,550.5 4,583.1 5,490.3 4,071.1 14,144.4
5,706.6 7,185.0 2,276.2 4,837.4 5,777.9 12,891.6
5.2 6.3 3.8 5.3 2.4 11.5
651.9 631.7 266.0 577.0 440.6 1,283.6
1,644.5 1,579.2 556.1 1,554.1 1,113.5 3,223.7
24.9 39.8 21.9 30.4 12.5 64.7
1,460.3 1,454.6 1,120.8 1,425.6 368.5 2,914.9
3.0 3.6 2.2 3.0 1.4 6.6
5.2 6.3 3.8 5.3 2.4 11.5
53.6 92.7 66.3 52.9 27.2 146.3
279.9 444.9 223.0 352.6 149.1 724.7
0.8 0.9 0.7 0.7 0.4 1.7
3.0 4.5 1.7 3.7 2.0 7.5
115.2 152.2 40.4 116.4 110.6 267.4
0.0 0.0 0.0 0.0 0.0 0.1
1.0 1.2 0.7 1.0 0.5 2.2
93.7 142.0 90.7 104.9 40.0 235.6
1,264.0 3,146.3 1,135.7 2,134.6 1,140.0 4,410.3
2.3 3.1 1.5 2.6 1.3 5.4
279.3 279.0 121.8 329.3 107.3 558.3
7.4 11.4 7.7 7.6 3.5 18.8
249.0 302.7 135.5 228.0 188.2 551.7
1,025.3 870.3 552.8 977.2 365.6 1,895.6
25.2 20.6 16.1 18.5 11.2 45.8
0.1 0.1 0.0 0.1 0.0 0.1
2.9 3.7 1.8 3.4 1.4 6.6
0.4 0.5 0.2 0.5 0.2 0.9
3.4 5.3 3.3 3.6 1.8 8.8
459.4 715.8 370.1 578.6 226.5 1,175.1
62,263 49,634 36,884 45,507 29,507 111,898

Table 1.40
Prevalence estimates of impaired glucose tolerance (IGT), 2025 - Western Pacific Region

Australia 17,547 10.6 9.1

Cambodia 11,743 10.4 11.6
China 1,067,160 7.4 6.9
China, Macau 425 14.0 11.9
Fiji 626 11.2 11.6
Guam 145 18.1 18.1
Indonesia 183,541 11.2 11.6
Japan 90,209 14.1 11.7
Kiribatia 106 18.1 18.1
Malaysia 22,293 19.9 16.3
Mongolia 2,252 10.2 11.0
Myanmar 41,444 2.6 2.7
Naurua 12 21.2 21.2
New Zealand 3,244 10.6 9.1
Niuea 1 7.4 7.4
Palaua 18 18.1 18.1
Philippines 70,161 10.8 12.1
Samoa 114 6.4 7.1
Singapore 4,054 17.6 19.7
Taiwana 17,140 4.2 5.1
Thailand 52,258 4.6 4.4
Tokelaua 1 13.8 13.8
Tongaa 63 13.3 13.8
Tuvalua 10 13.8 13.8
Vanuatu 172 9.0 10.5
Viet Nam 72,238 2.6 2.7
WP Total 1,731,564 8.2 7.8
a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2025, except


825.5 1,042.8 234.9 663.2 970.1 1,868.2

38.0 37.1 28.4 35.0 11.7 75.1
533.3 688.3 493.3 430.3 297.9 1,221.5
45,482.7 33,576.0 19,175.3 31,709.5 28,173.8 79,058.6
406.9 526.3 119.0 377.6 436.6 933.1
26.5 32.9 8.9 22.3 28.2 59.4
0.9 1.1 0.4 0.8 0.8 1.9
28.8 41.2 19.9 30.3 19.8 70.0
14.5 16.6 6.7 16.6 7.8 31.1
12.3 14.0 7.3 11.2 7.7 26.3
11,572.2 9,024.9 4,787.6 8,643.7 7,165.8 20,597.1
5,691.4 7,013.1 1,628.4 4,885.1 6,191.0 12,704.5
8.9 10.4 5.5 8.6 5.1 19.3
821.1 803.2 256.8 797.5 570.1 1,624.3
2,177.5 2,062.3 436.3 1,798.7 2,004.8 4,239.8
43.8 67.8 35.6 52.8 23.2 111.6
2,237.5 2,204.0 1,486.7 2,097.0 857.8 4,441.5
5.1 6.0 3.2 5.0 2.9 11.1
8.9 10.4 5.5 8.6 5.1 19.3
94.2 136.2 75.2 95.8 59.3 230.4
409.4 677.0 253.6 548.8 284.1 1,086.4
1.3 1.4 0.9 1.0 0.7 2.6
5.3 6.2 2.1 5.5 4.0 11.5
150.7 193.7 44.5 116.2 183.7 344.3
0.1 0.1 0.0 0.0 0.0 0.1
1.5 1.7 0.9 1.4 0.9 3.2
161.3 260.6 146.0 186.0 89.8 421.8
2,168.7 5,413.7 1,560.4 3,611.8 2,410.1 7,582.3
3.3 4.0 1.7 3.3 2.4 7.3
370.9 344.2 130.1 300.3 284.7 715.1
13.9 22.3 12.6 16.3 7.3 36.2
332.0 395.8 145.9 284.5 297.4 727.8
1,291.8 1,107.0 545.4 1,164.9 688.5 2,398.8
45.9 38.0 30.1 30.8 23.0 83.9
0.1 0.1 0.0 0.1 0.0 0.1
4.0 4.4 1.9 4.7 1.9 8.4
0.7 0.8 0.3 0.8 0.4 1.4
5.8 9.7 5.2 6.5 3.8 15.4
736.9 1,165.5 444.2 953.4 504.8 1,902.4
75,733 66,960 32,141 58,926 51,627 142,693

Table 1.41

Australia Australia (Dunstan et al, 2002)107

Brunei Darussalam Singapore (Ministry of Health Survey, 1998)103
Cambodiaa Cambodia (King et al, 2005)93
China China (Gu et al, 2003)99
China, Hong Kongb Hong Kong (Janus et al, 2000 and Cockram et al, 1993)147,148
China, Macau Hong Kong (Janus et al, 2000 and Cockram et al, 1993)147,148
Cook Islands Rarotonga (King et al, 1986)149
Fiji Fiji (Zimmet et al, 1983)150
French Polynesia Tonga (Colaguiri et al, 2002)151
Guam Kiribati (King et al, 1984)152
Indonesia Indonesia (Waspadji et al, 1983)153
Japanb Japan (Ohmura et al, 1993 and Sekikawa et al, 2000)154,155
Kiribati Kiribati (King et al, 1984)152
Korea, Democratic People’s Republic of Republic of Korea (Park et al, 1995)102
Korea, Republic of c Republic of Korea (Kim et al, 2006)96
Lao People’s Democratic Republic Viet Nam (Duc Son et al, 2004)97
Malaysia Singapore (Ministry of Health Survey, 1998)103
Marshall Islands Kiribati (King et al, 1984)152
Micronesia, Federated States of Kiribati (King et al, 1984)152
Mongolia Mongolia (Suvd et al, 2002)156
Myanmar Viet Nam (Duc Son et al, 2004)97
Nauru Nauru (Zimmet et al, 1984)157
New Caledonia New Caledonia (Zimmet et al, 1982)158
New Zealandd New Zealand (Ministry of Health, 2002)159
Niue Niue (King et al, 1986)149
Palau Kiribati (King et al, 1984)152
Papua New Guinea Fiji Melanesians (Zimmet et al, 1983)150
Philippines Philippines (Baltazar et al, 2004)94
Samoa Samoa (Collins et al, 1994)160
Singapore Singapore (Ministry of Health Survey, 2004)98
Solomon Islands Fiji Melanesians (Zimmet et al, 1983)150
Taiwanb Taiwan (Chou et al, 1992, 1994)161,162
Thailanda Thailand (Aekplakorn et al, 2003)95
Timor-Lested Indonesia (Waspadji et al, 1983)153
Tokelau Tonga (Colaguiri et al, 2002)151
Tonga Tonga (Colaguiri et al, 2002)151
Tuvalu Tonga (Colaguiri et al, 2002)151
Vanuatu Fiji Melanesians (Zimmet et al, 1983)150
Viet Nam Viet Nam (Duc Son et al, 2004)97
a. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from unpublished Indonesian data163 (862 participants)
b. The prevalences for the studies based on the Hong Kong, Japanese and Taiwanese studies were obtained by combining the data from the two studies respectively
c. IGT figures were calculated using data from Park et al, 1995102
d. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Australian data

- Western Pacific Region

OGTT WHO - 1999 11,247 25+

OGTT WHO - 1985 3,568 18-69
OGTT WHO - 1999 2,246 25+
FBG ADA - 1997 15,838 35-74
OGTT WHO - 1985 4,413 20-79
OGTT WHO - 1985 4,413 20-79
OGTT WHO - 1985 1,127 20+
OGTT WHO - 1980 2,638 20+
OGTT WHO - 1999 1,024 15+
OGTT WHO - 1980 2,938 20+
OGTT WHO - 1980 2,704 15+
OGTT WHO - 1985 5,211 40+
OGTT WHO - 1980 2,938 20+
OGTT WHO - 1985 2,520 30+
FBG ADA - 1997 5,844 20+
FBG WHO - 1999 2,932 15+
OGTT WHO - 1985 3,568 18-69
OGTT WHO - 1980 2,938 20+
OGTT WHO - 1980 2,938 20+
OGTT WHO - 1999 2,996 35+
FBG WHO - 1999 2,932 15+
OGTT WHO - 1980 1,583 20+
OGTT WHO - 1980 707 20+
SR Known Diabetes 7,862 25+
OGTT WHO - 1985 1,149 20+
OGTT WHO - 1980 2,938 20+
OGTT WHO - 1980 1,340 20+
OGTT WHO - 1999 7,044 20-65
OGTT WHO - 1985 1,776 25-74
OGTT WHO – 1999 4,168 18-69
OGTT WHO - 1980 1,340 20+
OGTT WHO - 1985 4,287 30-79
FBG ADA - 1997 5,350 35+
OGTT WHO - 1980 2,704 15+
OGTT WHO - 1999 1,024 15+
OGTT WHO - 1999 1,024 15+
OGTT WHO - 1999 1,024 15+
OGTT WHO - 1980 1,340 20+
FBG WHO - 1999 2,932 15+

1.2
Known and Newly Diagnosed Diabetes
Studies have shown that a substantial proportion of all

people found to have diabetes had not been previously
diagnosed.
Introduction percentage indicates successful screening, while a low number

reflects an inability of medical services to screen for diabetes,
I t has been a consistent finding of population-based diabetes

studies that a substantial proportion of all people found to
have diabetes had not been previously diagnosed. Thus, diabetes
and is often seen in developing countries where resources are
limited.
surveys identify people with previously diagnosed, or known, Studies

diabetes (KDM), as well as those with newly diagnosed diabetes,
whose diabetes is only found through blood tests undertaken Tables 1.42-1.48 show the numbers with KDM as a percentage
in the survey. of all those with diabetes in over 80 studies. In general, the lowest
percentages were seen in studies from developing countries,
The uncovering of new cases of diabetes when mass blood and the highest from developed countries. In Tanzania, rural
testing is undertaken is primarily because of the lack of symptoms India, Nepal, Tonga and China only 20-25% of all people with
associated with the early years of type 2 diabetes, meaning that diabetes had been previously diagnosed. Overall, across all the
those with diabetes may be unaware of their condition and surveys, approximately 50% of all people with diabetes were
therefore not seek medical attention for it. However, it should undiagnosed.
also be noted that since the clinical diagnosis of diabetes requires
diagnostic blood glucose levels on two separate days, a It should be noted that in some studies that report a high
proportion of those labelled as having undiagnosed diabetes in percentage of previously diagnosed cases, there may have been
research studies may not in fact have diabetes if re-tested. some bias in study design, which resulted in this finding. For
example, the study from Ireland127 only undertook blood glucose
In any survey, the percentage of all people with diabetes, whose testing on those individuals with symptoms or risk factors for
diabetes has been previously diagnosed, is often taken as a diabetes. This is likely to have underestimated the numbers of
measure of how well the standard clinical services are managing individuals with newly diagnosed diabetes, as some of these
to screen for and identify people with diabetes. A high individuals may not have had risk factors or symptoms.
KNOWN
AND NEWLY DIAGNOSED DIABETES CHAPTER 1 105
Table 1.42
Proportion of known diabetes (KDM) in studies - African Region
Country/territory Author Journal Total KDM KDM proportion of

diabetes total diabetes
(n) (n) (%)
Cameroon Mbanya, 200629 Unpublished 489 101 21

Ghana Amoah et al, 200228 Diabetes Research and Clinical Practice 300 91 30
South Africa Levitt et al, 199325 Diabetes Care 46 24 52
Omar et al, 199326 South African Medical Journal 20 12 60
Motala, 200627 Unpublished 488 101 21
Tanzania, United Republic of McLarty et al, 198921 Lancet 53 7 13
Mean 33
Median 26
Table 1.43
Proportion of known diabetes (KDM) in studies - Eastern Mediterranean and Middle East Region

(n) (n) (%)
Algeria Malek et al, 200150 Diabetes and Metabolism 120 54 45

Bahrain al-Mahroos et al,199832 Diabetes Care 604 393 65
Egypt Herman et al, 199533 Diabetic Medicine N/A N/A 57
Iran, Islamic Republic of Azizi et al, 2003164 Eastern Mediterranean Health Journal 21,637 12,024 56
Jordan Ajlouni et al, 1998110 Journal of Internal Medicine 379 N/A 67a
Kuwait Abdella et al, 199835 Diabetes Research and Clinical Practice 443 N/A 50a
Lebanon Salti et al, 1997111 Eastern Mediterranean Health Journal 331 259 78
Occupied Palestinian Territory Abdul-Rahim et al, 200153 Eastern Mediterranean Health Journal 59 46 78
Husseini et al, 2003165 Medical Science Monitor 49 35 71
Oman Al-Lawati et al, 200236 Diabetic Medicine 677 N/A 33a
Pakistan Shera et al, 199548 Diabetic Medicine 131 72 55
Shera et al, 199947 Diabetes Research and Clinical Practice 127 69 54
Shera et al, 199949 Journal of the Pakistan Medical Association 115 42 37
Saudi Arabia Al-Nuiam, 199739 Diabetic Medicine 41 21 51
Al-Nozha, 200438 Saudi Medical Journal 4,004 2,888 72
Sudan Elbagir,199630 Diabetes Care 44 16 36
Tunisia Papoz et al, 1988114 International Journal of Epidemiology 168 97 58
United Arab Emirates Malik et al, 200541 Diabetes Research and Clinical Practice 505 299 59
Mean 57
Median 57
a. These figures were quoted in the original papers as simple fractions (e.g. 1/2, 2/3), or provided
only separate prevalences of new and known diabetes, so that the ratio could be deduced
N/A not available

Table 1.44
Proportion of known diabetes (KDM) in studies – European Region

(n) (n) (%)
Albania Shapo et al, 2004117 Diabetic Medicine 70 38 54

Cyprus Loizou et al, 2006121 Diabetes Care 123 84 68
Denmark Glumer et al, 2003122 Diabetes Care 404 139 34
Finland Ylihärsilä et al, 2005124 Diabetic Medicine 188 83 44
France Gourdy et al, 200170 Diabetes and Metabolism 230 121 53
Lecomte et al, 2002166 Diabetes and Metabolism 1,675 993 59
Germany Rathmann et al, 200371 Diabetologia 253 128 51
Greece Panagiotakos et al, 2005125 Diabetic Medicine 210 154 73
Iceland Vilbergsson et al, 1997126 Diabetic Medicine 467 282 60
Ireland Smith et al, 2003127 Diabetic Medicine 353 270 76
Israel Stern et al, 1988167 Diabetes 192 113 59
Stern et al, 1999129 Acta Diabetologica 345 310 90
Bar-On et al, 1992128 Nutrition, Metabolism and Cardiovascular Diseases 100 N/A 67a
Italy Garancini et al, 1995134 Diabetologia 476 213 45
Netherlands Mooy et al, 199572 Diabetes Care 184 78 42
Poland Lopatynski et al, 200161 Polskie Archiwum Medycyny Wewnetrznej 586 204 35
Szurkowska et al, 200160 Polskie Archiwum Medycyny Wewnetrznej 321 161 50
Spain Botas et al, 2003168 Diabetic Medicine 120 47 39
Castell et al, 1999118 Diabetes Research and Clinical Practice 258 167 65
Sweden Eliasson et al, 2002133 Diabetic Medicine 214 N/A 50a
169
Turkey Kelestimur et al, 1999 Acta Diabetologica 99 58 59
Satman et al, 200258 Diabetes Care 1,792 578 32
United Kingdom Forrest et al, 1986170 Diabetic Medicine N/A N/A 45a
Uzbekistan King et al, 1998130 Diabetic Medicine 162 49 30
King et al, 2002131 Diabetes Research and Clinical Practice 61 26 43
Mean 53
Median 51
Table 1.45
Proportion of known diabetes (KDM) in studies – North American Region

(n) (n) (%)
Guadeloupe Costagliola et al, 199138 Diabetes Research and Clinical Practice 81 66 81

Jamaica Ragoobirsingh et al, 1995171 Diabetes Care 378 196 52
Mexico Aguilar-Salinas et al, 200378 Diabetes Care 3,597 2,878 80
United States of America CDC, 200374 Morbidity and Mortality Weekly Report N/A 288 71a
Mean 71
Median 76
N/A not available
KNOWN AND NEWLY DIAGNOSED DIABETES CHAPTER 1 107

Table 1.46
Proportion of known diabetes (KDM) in studies – South and Central American Region

(n) (n) (%)
Bolivia Barceló et al, 2001141 Revista Panamericana de Salud Pública 185 132 71
Brazil Malerbi et al, 1992140 Diabetes Care 1,660 896 54
Chile Baechler et al, 200282 Revista Medica de Chile 115 63 55
Colombia Aschner, 1993142 Diabetes Care 34 22 65
Paraguay Jimenez et al, 1998144 Diabetic Medicine 99 44 45
Mean 58
Median 55
Table 1.47
Proportion of known diabetes (KDM) in studies – South-East Asian Region
Country/ Author Journal Total KDM KDM proportion of

territory diabetes total diabetes
(n) (n) (%)
Bangladesh Abu Sayeed et al, 1997172 Diabetes Care 123 35 28

India Ramachandran et al (large cities), 200184 Diabetologia 1,684 1,175 70
Sadikot et al (urban), 200485 Diabetes Research and Clinical Practice 624 199 32
Sadikot et al (rural), 200485 Diabetes Research and Clinical Practice 193 37 19
Mauritius Dowse et al, 1990109 Diabetes 633 269 42
Soderberg et al, 2005173 Diabetic Medicine 1,317 671 51
Nepal Karki et al, 200089 Southeast Asian Journal of Tropical 116 30 25
Medicine and Public Health
Mean 38
Median 32

Table 1.48
Proportion of known diabetes (KDM) in studies – Western Pacific Region
Country/ Author Journal Total KDM KDM proportion of

territory diabetes total diabetes
(n) (n) (%)
Australia Dunstan et al, 2002107 Diabetes Care 943 475 50

Cambodia King et al, 200593 Lancet 185 66 36
China Gu et al, 200399 Diabetologia N/A N/A 24
China, Hong Kong Cockram et al, 1993148 Diabetes Research and Clinical Practice 41 16 38
Janus, 2000147 Diabetic Medicine 269 77 29
Japan Sekikawa et al, 1993174 Diabetes Care 109 52 48
Korea, Republic of Kim et al, 200696 Diabetes Care N/A N/A 57a
Mongolia Suvd et al, 2002156 Diabetic Medicine 72 46 64
Nauru Zimmet et al, 1984157 Diabetes Research 374 221 59
Philippines Baltazar, 200494 Diabetes Research and Clinical Practice 362 N/A 67a
Samoa Collins et al, 1994160 Diabetes Care 203 101 50
Singapore Ministry of Health, Singapore, 1999103 Government Report N/A N/A 38
Taiwan Chou et al, 1992161 Diabetes Care 143 77 54
Chou et al, 1994162 Diabetes Care 209 63 30
Thailand Aekplakorn et al, 200395 Diabetes Care 607 N/A 50a
Tonga Colagiuri et al, 2002151 Diabetes Care 106 N/A 20a
Viet Nam Duc Son et al, 2004 97 Diabetic Medicine 194 118 61
Mean 46
Median 50
N/A not available
KNOWN AND NEWLY DIAGNOSED DIABETES CHAPTER 1 109

1.3
Complications of Diabetes
Diabetic complications account for much of the social and

financial burden of diabetes. Diabetes is ranked among
the leading causes of blindness, renal failure and lower limb
amputation in many countries, while some 50% of people
with diabetes die of cardiovascular disease.
Introduction often serious, disease. Whilst evidence of tissue damage can

be found in many organ systems, it is the kidneys, eyes,
O ver the last 30 years, type 2 diabetes has changed from

being seen as a relatively mild ailment associated with
ageing and the elderly (‘just a touch of sugar’) to one of the
peripheral nerves and vascular tree, which manifest the most
significant, and sometimes fatal, diabetic complications.
Indeed, diabetic complications are those aspects of the
major contemporary causes of premature mortality and disease that are most feared (such as blindness and
morbidity in most countries. In virtually every developed amputation), and account for much of the social and financial
society, diabetes is ranked among the leading causes of burden of diabetes.
blindness, renal failure and lower limb amputation. Through
its effects on cardiovascular disease (50% of people with The mechanism by which diabetes leads to these complications
diabetes die of cardiovascular disease), it is also now one of is complex, and not yet fully understood, but involves the direct
the leading causes of death. toxic effects of high glucose levels, along with the impact of
elevated blood pressure, abnormal lipid levels and both
The changing perceptions of diabetes relate partly to a better functional and structural abnormalities of small blood vessels.
appreciation of its devastating complications, but mainly to
the rapid rise in its prevalence that has occurred in the last In an attempt to better describe and understand the burden
few decades. The main relevance of diabetic complications of diabetic complications, this section presents data on the
in a public health perspective is the relationship to human rates of coronary heart disease (CHD), stroke, diabetic
suffering and disability, and the huge socio-economic costs retinopathy, diabetic nephropathy, diabetic peripheral
through premature morbidity and mortality175. neuropathy and lower extremity amputations. The results of
each study are presented against the country in which it was
Chronic elevation of blood glucose, even when no symptoms conducted, although given the design and small size of
are present to alert the individual to the presence of diabetes, some of the studies, the results should not necessarily be
will eventually lead to tissue damage, with consequent, and seen as being representative of that country.
COMPLICATIONS
OF DIABETES CHAPTER 1 111
THE MAJOR DIABETIC COMPLICATIONS Figure 1.14
Heart attacks in people with and without diabetes over a period of
seven years
Brain and cerebral circulation Incidence (%)

Eyes (retinopathy) (cerebrovascular disease) 50
45
Heart and coronary 40

circulation (coronary
heart disease) 35
30
Kidney
(nephropathy)
25
20
15
10
5
Peripheral nervous system
Lower limbs (peripheral (neuropathy) 0
vascular disease) People without diabetes People with diabetes
Diabetic foot No prior heart attack

(ulceration and amputation) Prior heart attack Adapted from Haffner et al, 1998176
Major diabetic complications often fatal. People with diabetes without previous heart
attacks have been shown to have as high a risk of heart
Over the last two or three decades, there has been an increasing attacks as have non-diabetic persons with previous heart
awareness of the magnitude of the problem presented by attacks (see Figure 1.14)176.
diabetic complications. The major complications are:
• cardiovascular disease (CVD); Strokes occur when areas of the brain die from arterial
• nephropathy; blockage or arterial breakage and bleeding. Strokes are also
• neuropathy; sometimes fatal but they also often cause paralysis and loss
• amputation; and of speech, and other problems. Peripheral artery disease
• retinopathy. results from blockages in arteries that feed the legs; it causes
pain while walking and can lead to major surgery and the
Cardiovascular disease need for amputation. Heart failure results when the heart
cannot pump strongly and fluid backs up in the legs, lungs
Cardiovascular disease is the major cause of death in diabetes, and other tissues.
accounting for some 50% of all diabetes fatalities, and much
disability. The kinds of CVD that accompany diabetes include Smoking, high cholesterol, high blood pressure, stress from
angina, myocardial infarction (heart attack), stroke, peripheral social inequality and oppressive work environments, poor
artery disease, and congestive heart failure (CHF). diet, high blood sugar and abdominal fat all increase the
likelihood of cardiovascular disease events in persons living
Angina is the pain that arises when the blood supply to the with diabetes and impaired glucose tolerance. Several
heart muscle itself is temporarily insufficient. This is usually interventions, some of which are relatively inexpensive, can
due to narrowing of the arteries feeding the heart muscle. dramatically reduce the risk of CVD, including stopping
When one of these arteries becomes fully blocked, a smoking, general blood pressure control, low-dose daily
myocardial infarction occurs, which kills heart muscle and is aspirin, ACE-inhibitor pills, and statin drugs, which improve

Figure 1.15
Numbers of people with diabetes entering the Australian dialysis register 1980-2004178
People with diabetes (n)

600
500
400
300
200
100
0
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04
Year of entry
cholesterol in the blood. More information on diabetes and cause tingling, burning, and stabbing pain, extreme
CVD can be found online at www.cvd.idf.org. sensitivity to touch, aching and numbness. Both pain and
loss of feeling can occur at the same time. Loss of feeling
Nephropathy (loss of protective sensation) is a particular risk because it can
allow foot injuries to escape notice and treatment, leading
Diabetes is an increasingly important cause of renal failure to major infections and amputation.
(see Figure 1.15), and indeed has now become the single
most common cause of end stage renal disease, i.e. that Good blood sugar and blood pressure control can help
which requires either dialysis or kidney transplantation, in prevent peripheral neuropathy; smoking and heavy drinking
the USA177, and in other countries. A more detailed discussion make it much more likely. Regular inspection of the feet,
of diabetic nephropathy can be found in the publication careful nail trimming, avoidance of ill-fitting footwear, and
Diabetes and Kidney Disease: Time to Act, International wearing shoes or sandals rather than going barefoot can all
Diabetes Federation, 2003. prevent foot injury, ulceration and amputation.
Neuropathy Amputation
When blood sugar and blood pressure are not controlled, Through effects on peripheral nerves and arteries, diabetes
diabetes can harm nerves throughout the body. Problems with can lead to foot ulceration, infection and the need for
digestion and urination, impotence, and many other functions amputation. People with diabetes carry a risk of amputation
can result, but the most commonly affected area is the feet and that may be more than 25 times greater than that seen in
legs. Nerve damage in these areas is called peripheral those without diabetes179. A recent publication, Diabetes and
neuropathy, and leads to loss of feeling in the feet and toes. Foot Care: Time to Act, International Diabetes Federation,
2005, takes a closer look at the diabetic foot and ways in
Peripheral neuropathy is frequently asymptomatic, but can which complications can be prevented.
COMPLICATIONS
Retinopathy 2. Studies with ≥100 participants were included; where more
than one study was available for a country, preference was
Diabetes can harm sight and cause blindness in several ways. given to larger and population-based studies, those
The most common cause of blindness in diabetes is macular published after 1989, and those with the fewest
oedema, caused by fluid build-up behind the retina of the restrictions.
eye. A more common complication is background and
proliferative retinopathy, which can cause blindness as a 3. Prevalences are reported for coronary heart disease, stroke,
result of repeated haemorrhages at the back of the eye. nephropathy, neuropathy, retinopathy, and incidence and
Diabetes also increases the risk of cataracts and glaucoma. prevalence for lower extremity amputations.
However, the risk of blindness in diabetes can be greatly 4. Where possible, the age ranges of the populations are
reduced by strict control of blood sugar and blood pressure; reported. Where the age range of the population was not
and regular eye exams can detect macular oedema and available, the mean or median age is reported.
proliferative retinopathy so that laser treatments can be used
to control these conditions before they cause visual loss. 5. Diagnostic criteria for each complication are recorded, as
variation in definitions can affect the prevalences
Methods reported.
Details of the methods used in this report on diabetic 6. For some countries, results from more than one study are
complications are found in Appendix 1.2. The main principles presented. This is usually because they cover different
in collating available prevalence data were: aspects of the diabetic population.
1. Studies were identified through a detailed literature search, There are some important differences between this section
as well as contact with IDF member organizations. and Chapter 1.1 on diabetes prevalence and IGT. The total

numbers of individuals within a country who may have prevalences were between 17.9% and 23.8% for type 1
complications are not estimated, nor is a national prevalence. diabetes, and between 19.4% and 42.0% for type 2 diabetes.
Furthermore, data have not been projected from one country For overt nephropathy, the middle fifty percent of the
onto other countries. This is for two reasons: firstly, such prevalences in type 1 diabetes were between 6.1% and
calculations require knowledge of the age and sex structure 13.8%, and between 10.1% and 18.2% for type 2 diabetes.
of both the original study population, and of the target
(national diabetic) population. In most cases, neither of these Neuropathy
is known. Secondly, many studies are clinic-based, and so
their generalizability is limited. The prevalence of neuropathy in those with type 1 diabetes
ranged from 3.0% to 65.8% in clinic-based populations and from
Results 12.8% to 54.0% in population-based studies (see Table 1.53).
Among those with type 2 diabetes, the prevalence of neuropathy
The results are provided in Tables 1.49 - 1.58. A brief summary ranged from 7.6% to 68.0% in clinic-based populations, and
of results for each complication is presented below. The from 13.1% to 45.0% in population-based studies.
interquartile range was used to describe the middle fifty
percent of prevalences for each complication. The middle fifty percent of the neuropathy prevalences for
type 1 diabetes were between 21.2% and 29.3%, and
Cardiovascular disease between 19.7% and 37.5% for type 2 diabetes.
The prevalence of coronary heart disease in those with Amputations

diabetes (both type 1 and type 2) ranged from 1.0% to 25.2%
in clinic-based populations and from 1.8% to 43.4% in The prevalence of lower extremity amputations ranged from
population-based studies (see Table 1.49). The prevalence of 0.2% to 4.8%, and the annual incidence ranged from 46.1 to
stroke in those with type 1 and type 2 diabetes ranged from 936 per 100,000 diabetic population (see Table 1.55).
1.0% to 11.3% in clinic-based populations and from 2.8% to
12.5% in population-based studies. The middle fifty percent of the amputation prevalences were
between 0.9% and 2.4%, and between 181 per 100,000
For CHD, the middle fifty percent of the prevalences were diabetic population and 463 per 100,000 diabetic population
between 4.0% and 13.5%. For stroke, the middle fifty percent for the incidence of amputations.
of the prevalences were between 4.0% and 6.2%.
Retinopathy
Nephropathy
The prevalence of retinopathy in those with type 1 diabetes
The prevalence of microalbuminuria in those with type 1 ranged from 10.8% to 60.0 % in clinic-based populations and
diabetes ranged from 4.3% to 37.6% in clinic-based from 14.5% to 79.0% in population-based studies (see Table
populations and from 12.3% to 27.2% in population-based 1.57). Among those with type 2 diabetes, the prevalence of
studies (see Table 1.51). Among those with type 2 diabetes, retinopathy ranged from 10.6% to 65.4% in clinic-based
the prevalence of microalbuminuria ranged from 2.5% to populations and from 10.1% to 55.0% in population-based
57.0% in clinic-based populations and from 19.4% to 42.1% studies.
in population-based studies.
The middle fifty percent of the retinopathy prevalences for
The prevalence of overt nephropathy in those with type 1 type 1 diabetes were between 34.1% and 53.0%, and
diabetes ranged from 0.7% to 27.0% in clinic-based populations, between 23.7% and 36.2% for type 2 diabetes.
and from 0.3% to 24.0% in population-based studies. Among
those with type 2 diabetes, the prevalence of overt nephropathy Discussion
ranged from 5.4% to 20.0% in clinic-based populations, and
from 9.2% to 32.9% in population-based studies. The aims of this section were to describe the burden of
diabetic complications, and to be able to examine the
For microalbuminuria, the middle fifty percent of the differences existing between countries and between ethnic
COMPLICATIONS
IN TOUCH WITH: RAMÓN AGUIRRE
People with diabetes are at an increased risk of developing a Ramón Aguirre, 52, was born
number of complications associated with the disease. Diabetes in Argentina, and took his
is among the leading causes of blindness, renal failure first job in a bakery when he
and lower limb amputation. Many complications have the was eight years old, after his
potential to reduce the quality of life of people with diabetes mother’s death. Eight years
and their families. However, diabetic complications may be ago, while working as a pastry
prevented or delayed by good diabetes management by the cook, he started feeling ill
person with diabetes and the healthcare team. and went to the doctor. He
was diagnosed with a discus
hernia, tuberculosis and type 2
diabetes. He started treatment but was soon without a job
or income, and could not afford to continue with the insulin
and medication his doctor had prescribed. It was not long
before Ramón developed complications.
His feet problems brought him to a podologist who

recommended an urgent consultation with a doctor
specialized in diabetes. Ramón rejected the idea because he
did not want to lose a day’s work which he now had, but after
some months he started having symptoms of blindness: he
could not see his hands, so needed for his work.
groups. In order to do this with confidence, it is necessary Neither the diagnostic tools nor diagnostic thresholds used
that there is a degree of uniformity in the methodology of to define a complication were equivalent across studies. For
the different studies. This, however, was not the case. example, neuropathy was defined as the absence of ankle
reflexes in one study181, and as the presence of symptoms
For each of the complications, a wide range of results was and clinical signs (using validated scales) in another182. The
found, but understanding the underlying causes of this inconsistent use of diagnostic tools to classify a complication
diversity is difficult. For example, the low prevalence of has been shown to dramatically affect the prevalence
neuropathy seen in Mauritius180 could be due to a low inherent reported. The Diabetes Control and Complications Trial
risk for neuropathy in that population, the availability of high (DCCT) compared the prevalence of neuropathy using 11
quality diabetes care, the relative youth of a population in a different criteria and found that within the one population,
developing country, the methods used in the study for the prevalence of neuropathy varied from 0.3%, using
defining neuropathy or the population-based study design. In sensory examination, reflexes and symptoms, through to
the absence of similar studies, it is almost impossible to 21.8% using nerve conduction tests183.
determine which of these explanations may be correct.
Another example of the variability brought about by
The problem of accurately describing the burden and changing methodology is highlighted by a study on
making comparisons is made particularly difficult by the amputation. The study compared the incidence of lower
relative lack of population-based studies. Studies based on extremity amputations in one population, when primary or
secondary care tend to over-represent those with advanced all amputations were included184. The incidence of lower
disease, as those requiring more intensive treatment are extremity amputations varied from 276 per 100,000 person
generally referred on for specialist care. Furthermore, years (primary amputation) to 388 per 100,000 person years
prevalences in clinic populations will depend on local referral (all amputations). Further differences in amputation
patterns, which are likely to vary widely around the world. incidences are likely to be due to the (rather imprecise)
method of estimating the total diabetic population from
116 PART 1 DIABETES ATLAS THIRD EDITION

With the help of Estela, his wife, Ramón went to see the new house that the Government of Buenos Aires plans
recommended diabetologist, Dra María Teresa Enrico. to give the community where he has lived for 10 years.
Ramón’s retinopathy had developed to an advanced Ramón reminds people with diabetes “not to lose time,
stage and the retina in one eye had loosened. He was because diabetes is controllable and everything depends
given an appointment for surgery in a year’s time at the on oneself”.
Ophthalmology Hospital. However, with his condition,
Ramón could not wait. But without money he could not pay
for the intervention elsewhere. Dr Enrico put him in contact
with the ‘Fundación de Cirugía Ocular Dr. Zambrano’ and
with the diabetes association, Liga Argentina de Protección
al Diabético (LAPDI). These associations helped Ramón
obtain the surgery he so needed and paid half of the
hospital costs. Once his sight was regained, he would pay
the rest.
Today, with the help of his family, Ramon has bought the
necessary machines to start again as a pastry cook. He
works from home making bread and pastries that his wife
and his mother-in-law sell every day. He keeps his diabetes
under control with the free medication from the hospital.
His dream is to open a bakery and move with Estela to a
which those with amputations were drawn. • Of the seven population-based studies giving figures for
One large study, EURODIAB, examined the prevalence of neuropathy in type 2 diabetes, two of the three highest
retinopathy, neuropathy and nephropathy in type 1 prevalences were from the USA.
diabetes across several European countries185,186. This study
used standard methodology, making it possible to gain • Populations from Europe had high rates of heart disease
some insight into whether observed differences in and stroke, while migrant Indian populations (Mauritius
prevalence estimates are due to methodological problems and Fiji) also had high rates of heart disease.
or represent actual differences. The study found the
prevalence of complications did vary between countries. • No discernable patterns relating to geographic distribution
The prevalence of retinopathy ranged from 21% in Germany or study design were apparent for nephropathy or
to 60% in Portugal. However, much less variation was seen amputations.
for neuropathy and microalbuminuria, for which the
prevalences clustered fairly tightly around 25% and 23%, In summary, the interpretation of these studies of diabetic
respectively. complications is severely hampered by the lack of population-
based studies, and the wide variability in study design.
Any conclusions about the burden of disease attributable to Nevertheless, the data from EURODIAB would indicate that
diabetic complications must be very guarded, and at least for some complications in type 1 diabetes, genuine
comparisons between different parts of the world should be differences exist between countries. What is absolutely clear
extremely cautious. Nevertheless, some tentative comments from this review is that there are large parts of the world for
can be made: which there are no useful data, and that there is a great need
for population-based studies, using standardized protocols
• The prevalence of retinopathy is probably around 30% in so that meaningful estimates of the prevalence of diabetic
type 2 diabetes. complications can be made.
COMPLICATIONS
OF DIABETES PART 1 117
Table 1.49
Prevalence of cardiovascular disease

Region Country/territory Data used U
AFR South Africa Rotchford et al, 2002187

EMME Egypt Arab et al, 2002188
Pakistan Hashim et al, 1999189
Sudan Elmahdi et al, 1991190
EUR Austria Muhlhauser et al, 1992191
Belgium Van Acker et al, 2001192
Denmark Gall et al, 1991193
Estonia Vides et al, 2001194
Finland Isomaa et al, 2001195
Hu, 2003a,196
France Delcourt et al, 1998197
Le Floch et al, 2000198
Germany Liebl et al, 2002199
Italy DAI Study Group, 2004200
Netherlands Verhoeven et al, 1991201
Reenders et al, 1993202
de Visser et al, 2002203
Spijkerman et al, 2004204
Serbia and Montenegro Vlajinac et al, 1992205
Miljus, 2002206
Slovakia Slovakian Diabetes Society, 2002a,207
Spain Esmatjes et al, 1996208
Diamante, 1997209
Arteagoitia et al, 2003210
Sweden Lundman et al, 1998211
Wandell, 2004212
United Kingdom Morgan et al, 2000213
NA United States of America Maser et al, 1991214
Qureshi et al, 1998215

Alexander et al, 2000216
Barzilay et al, 2001217
Alexander et al, 2003218
Malik et al, 2005219
SEA Bangladesh Sayeed et al, 1998220
Chuang et al, 2002b,221
India Ramachandran et al, 1999b,222
Ramachandran et al, 2000223
Mauritius Collins et al, 1993224

Sri Lanka Fernando et al, 1993225
WP China Chi et al, 2001226
Fiji (Asian Indian) Tuomilehto et al, 1988227
Indonesia Chuang et al, 2002b,221
Japan Kuzuya et al, 1994228
Korea, Republic of Lee et al, 1995229
Malaysia Chuang et al, 2002b,221
Nauru Collins et al, 1993224
New Zealand (European) Simmons et al, 1996230
New Zealand (Maori) Simmons et al, 1996230
New Zealand (Pacific Islanders) Simmons et al, 1996230
Philippines Chuang et al, 2002b,221

Coronary heart disease (%) Stroke (%)
d UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM Total DM
• • • • • • • 7.5
• • • 15.0 • • • •
• • • 19.8 • • • 6.2
• • 5.1 • • • 4.4 •
• • • 11.3 • • • 6.2
• 6.2 30.8 21.0 • • • •
• • 26.4 • • • • •
• • • 7.7 • • • 2.8
• • 13.4 • • • 5.2 •
• • • 8.1 • • • 7.6
• • 8.4 • • • • •
• 16.3 13.3 13.5 • 4.3 4.1 4.1
• • 10.6 • • • 6.7 •
• • • 9.9 • • • •
• • 40.0 • • • • •
• • 9.0 • • • 5.0 •
• • • 20.9 • • • 9.1
13.3 • 13.4 • • • • •
• • 35.5 • • • • •
• • • 3.3 • • • •
• • • 6.0 • • • 5.6
• • 11.0 • • • 5.0 •
• 0.5 • • • 0.5 • •
• • 12.4 • • • 9.8 •
• 4.7 12.3 11.5 • 3.1 12.3 11.3
• • 12.1 • • 5.4 •
• • • 25.2 • • • 9.6
• 3.4 • • • • • •
• • • 10.7 • • • 5.0
(incl UnDM) (incl UnDM)
• • • 9.8 • • • •
• • • 43.4 • • • 12.5
• • • 17.6 • • • •
• • • 26.7 • • • •
18.6 • • • • • • •
• • • 2.0 • • • 1.0
• • 11.4 • • • • •
• 0.5 • • • • • •
• • • Male 22.0 • • • •
Female 33.7
• • 12.0 • • • 3.6 •
• • • 6.0 • • • 2.0
• • • 8.7 • • • 3.4
• • • 1.0 • • • 5.0
• • • 31.3 • • • •
• • • 5.0 • • • 4.0
• • • 2.1 • • • 5.7
• • 7.8 • • • 8.4 •
• • • 3.0 • • • 6.0
• • • 12.0 • • • 6.0
• • • 15.8 • • • •
• • • 11.0 • • • •
• • • 11.0 • • • •
• • • 6.0 • • • •
• • • 3.0 • • • 6.0
COMPLICATIONS OF DIABETES CHAPTER 1 119

Table 1.49
Prevalence of cardiovascular disease

Region Country/territory Data used U
WP Singapore Thai et al, 1990231

Taiwan Chuang et al, 2002b,221
Fuh, 2002a,232
Tseng et al, 2005233
Thailand Thai Multicenter Group, 1994234
Tatsanavivat et al, 1998235
Tandhanand et al, 2001236
Viet Nam Chuang et al, 2002b,221

DM diabetes mellitus
Total DM previously diagnosed diabetes (both type 1 and type 2)
UnDM undiagnosed diabetes
a. Unpublished data
b. Extra details supplied by authors

Coronary heart disease (%) Stroke (%)
d UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM Total DM
• • • 12.8 • • • •
(incl UnDM)
• • • 5.0 • • • 3.0
• • • 4.0 • • • 6.0
• • 18.1 • • • 4.7
• • • • • • 7.5 •
• • 10.5 • • • 3.7 •
• • • 1.8 • • • •
• • • 3.0 • • • 3.0
• • • 1.0 • • • 3.0


Table 1.50
Data sources: prevalence of cardiovascular disease

Region Country/territory Data used Study type Sample size A
AFR South Africa Rotchford et al, 2002187 Clinic (secondary care) 253
EMME Egypt Arab et al, 2002188 Clinic (primary care) 2,000
Pakistan Hashim et al, 1999189 Clinic (primary care) 805
Sudan Elmahdi et al, 1991190 Clinic (secondary care) 413
EUR Austria Muhlhauser et al, 1992191 Clinic (primary care) 375
Belgium Van Acker et al, 2001192 Clinic (secondary care) 1,653
Denmark Gall et al, 1991193 Clinic (secondary care) 549
Estonia Vides et al, 2001194 Register 181
Finland Isomaa et al, 2001195 Clinic (primary care) 1,697
Hu, 2003a,196 Population based 172
France Delcourt et al, 1998197 Clinic (secondary care) 427
Le Floch et al, 2000198 Clinic (primary care) 7,391
Germany Liebl et al, 2002199 Clinic (primary and secondary care) 2,701

Italy DAI Study Group, 2004200 Clinic (secondary care) 19,468
Netherlands Verhoeven et al, 1991201 Clinic (primary care) 137
Reenders et al, 1993202 Clinic (primary care) 387
de Visser et al, 2002203 Population based 281
Spijkerman et al, 2004204 Population based 255
Serbia and Montenegro Vlajinac et al, 1992205 Population based 152
Miljus, 2002206 N/A N/A
Slovakia Slovakian Diabetes Society, 2002a,207 Clinic (secondary care) N/A
Spain Esmatjes et al, 1996208 Clinic (primary and secondary care) 1,157
Diamante, 1997209 Clinic (secondary care) 1,822
Arteagoitia et al, 2003210 Clinic (primary care) 2,920
Sweden Lundman et al, 1998211 Clinic (primary and secondary care) 4,027
Wandell, 2004212 Clinic (primary care) 389
United Kingdom Morgan et al, 2000213 Clinic (primary and secondary care) 10,287
NA United States of America Maser et al, 1991214 Clinic (secondary care) 657
Qureshi et al, 1998215 Population based 1,532
Alexander et al, 2000216 Population based N/A
Barzilay et al, 2001217 Population based 479

Alexander et al, 2003218 Population based 600
Malik et al, 2005219 Population based 465
SEA Bangladesh Sayeed et al, 1998220 Clinic (secondary care) 693
Chuang et al, 2002b,221 Clinic (secondary care) 1,607
India Ramachandran et al, 1999b,222 Clinic (secondary care) 3,010
Ramachandran et al, 2000223 Clinic (secondary care) 617
Mauritius Collins et al, 1993224 Population based 259
Sri Lanka Fernando et al, 1993225 Clinic (secondary care) 500
WP China Chi et al, 2001226 Clinic (secondary care) 447
Fiji (Asian Indian) Tuomilehto et al, 1988227 Population based 151
Indonesia Chuang et al, 2002b,221 Clinic (secondary care) 2,093
Japan Kuzuya et al, 1994228 Clinic (secondary care) 2,120
Korea, Republic of Lee et al, 1995229 Clinic (secondary care) 631
Chuang et al, 2002b,221 Clinic (secondary care) 952
Malaysia Chuang et al, 2002b,221 Clinic (secondary care) 1,045
Nauru Collins et al, 1993224 Population based 215
New Zealand (European) Simmons et al, 1996230 Population based 176
New Zealand (Maori) Simmons et al, 1996230 Population based 286
New Zealand (Pacific Islanders) Simmons et al, 1996230 Population based 495
Philippines Chuang et al, 2002b,221 Clinic (secondary care) 2,657
Singapore Thai et al, 1990231 Population based 117

Age (yrs) Duration DM (yrs) Diagnostic tool - CHD# Diagnostic tool - stroke+
21-81 4 ± N/A N/A Self-report / medical record review

N/A N/A Self-report (angina) •
31->70 N/A Medical record review / self-report (MI, angina) Medical record review (includes TIA)
20+ <5->15 Self-report confirmed by ECG (CHD) Self-report (stroke, TIA)
median=67 median=6 Self-report (MI) Self-report (stroke)
21-69 range 5-27 Medical record review (CHD) Medical record review (CBVD)
<76 range 0-20 ECG (Minnesota codes) N/A
15-82 11 ± 10 ECG / self-report / medical record review (CHD) Self-report / medical record review (CBVD)
35-70 N/A Self-report / medical record review (MI) Self-report / medical record review (stroke)
25-64 N/A Self-report Self-report
35-74 11 ± 7 Self-report / ECG (MI) N/A
mean=63 11 ± 0.1 Self-report / medical record review (CHD) Self-report / medical record review (CBVD)
mean=67 N/A Medical record review (MI, angina, Medical record review (stroke)
congestive heart failure, coronary bypass surgery)
66 (9) 9.5 (7.5) Hospital admission or ECG/ CABG or PTCA (MI, angina) •
mean=68 8 ± 7 ECG (Minnesota codes) N/A
mean=68 8 ± 6 Medical record review (MI, angina) Medical record review (stroke)
22-96 8 ± 7 Medical record review (MI, PTCA, coronary artery bypass) Medical record review (stroke, TIA)
62.9 (7.0) 0 Prior MI •
35-54 N/A ECG (Minnesota codes), questionnaire (MI, angina) N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
45-70 9 ± 7 Self-report (CHD) Self-report (stroke)
>18 14 ± 9 Self-report (CHD) Self-report (stroke)
68 (11) 8.1 (5.4) Self report (MI or angina) Medical record review (stroke)
≥18 10 ± 7 Medical record review (MI, angina) Medical record review (stroke)
54.6 (6.9) 6.5 (5.3) Medical history (MI, angina) Medical record review (stroke, TIA)
mean=61 N/A Hospital codes and primary care audit (CHD) Hospital codes and primary care audit (CBVD)
mean=28 19 ± 8 ECG / medical record review (MI, angina) N/A
40-74 N/A Self-report (MI) Self-report (stroke)
≥20 N/A Self-report, Rose questionnaire (MI, angina) N/A
≥65 N/A Medical record review (MI, angina, Medical record review (stroke, TIA)
congestive heart failure, coronary bypass surgery)
55 N/A Self report (MI, angina) •
52.8 (>18) N/A Self report (MI, stroke or CCF ) •
30-60 0-2 ECG and self-report (MI, angina) N/A
10-91 8 ± 6 Medical record review (CHD) Medical record review (CBVD)
mean=52 8 ± 6 ECG (Minnesota codes) / medical record review (MI) N/A
10-50 median=4 ECG (Minnesota codes) / medical record review (MI) N/A
35-74 N/A ECG (Minnesota codes) N/A
mean=52 8 ± N/A ECG (Minnesota codes) Questionnaire
35-54 range <7-14 ECG (Minnesota codes) / self-report (MI, angina) Self-report (stroke)
N/A N/A ECG (Minnesota codes) N/A
<24->75 11 ± N/A Doctor questionnaire (CHD) Doctor questionnaire (CBVD)
30-75 8 ± 7 ECG (Minnesota codes) / self-report (MI, angina) Self-report (stroke)
35-80 N/A ECG (Minnesota codes) N/A
median=61 N/A Self-report (MI) N/A
18+ N/A ECG (Minnesota codes) / self-report (MI, angina) N/A

Table 1.50
Data sources: prevalence of cardiovascular disease

Singapore Chuang et al, 2002b,221 Clinic (secondary care) 1,674

Taiwan Chuang et al, 2002b,221 Clinic (secondary care) 2,420
Fuh, 2002a,232 Clinic (secondary care) 4,535
Tseng et al, 2005233 Clinic (primary and secondary care) 12,531
Thailand Thai Multicenter Group, 1994234 Clinic (secondary care) 1,747
Tatsanavivat et al, 1998235 Population based 278
Tandhanand et al, 2001236 Clinic (secondary care) 2,379
Viet Nam Chuang et al, 2002b,221 Clinic (secondary care) 1,169
CABG coronary artery bypass graft

CBVD cerebrovascular disease
CCF congestive cardiac failure
CHD coronary heart disease
ECG electrocardiogram
MI myocardial infarction
N/A not available
PTCA percutaneous transluminal coronary angioplasty
TIA transient ischaemic attack
Diagnostic tool:
# The type of CHD (e.g MI or MI and angina) reported is stated. If this was not reported in the study, the term CHD is used.
+ The type of CBVD (e.g stroke or stroke and TIA) reported is stated. If this was not reported in the study, the term CBVD is used.
a. Unpublished data

Age (yrs) Duration DM (yrs) Diagnostic tool - CHD# Diagnostic tool - stroke+

15-92 10 ± 7 Medical record review (CHD) Medical record review (stroke)
N/A N/A N/A N/A
64.1 (10.8) 10.4 (6.9) • Self report (interview)
24-88 8 ± 7 ECG Self-report (CBVD) / examination
≥30 N/A ECG (Minnesota codes) N/A
mean=59 10 ± 7 Medical record review (CHD) Medical record review (CBVD)

Table 1.51
Prevalence of diabetic nephropathy

PREVALENCE OF DIABETIC NEPHROPATHY (%) - OVERT PREVALENCE
Region Country/territory Data used UnDM Type 1 DM Type 2 DM Total DM U
AFR Cameroon Sobngwi et al, 1999238 • • • •

Ethiopia Rahlenbeck et al, 1997239 • • • 17.1
Nigeria Erasmus et al, 1992240 • • • •
Senegal Cisse et al, 2003241 • • • •
South Africa Kalk et al, 1997242 • • • 14.5
Levitt et al, 1997243 • • • 5.3
Rotchford et al, 2002187 • • • 13.4
Zambia Rolfe, 1988245 • • • 23.8
EMME Egypt Herman et al, 1998246 6.8 • • 6.7
Iran, Islamic Republic of Manaviat et al, 2004247 • • 14.5 •
Saudi Arabia Alzaid et al, 1994248 • • 12.8 •
Sudan Elmahdi et al, 1991190 • • 9.2 •
EUR Austria Muhlhauser et al, 1992191 • • • 15.0
EuroDiab, 1994b,185 • 3.6 • •
Belgium Bouten et al, 1996249 • • • •
EuroDiab, 1994b,185 • 13.0 • •
Van Acker et al, 2001192 • • • •
Croatia EuroDiab, 1994b,185 • 15.9 • •
Czech Republic Perusicova et al, 1993c,250 • 13.8 • •
Czech Health Statistics, 2002d,251 • • • •
Denmark Mortensen et al, 1990252 • 0.7 • •
Gall et al, 1991193 • • 14.0 •
Finland EuroDiab, 1994b,185 • 15.1 • •
France EuroDiab, 1994b,185 • 11.2 • •
Delcourt et al, 1998197 • • 6.1 •
Germany EuroDiab, 1994b,e,185 • 7.5 • •
Bennett et al, 2001253 • • • 7.9
Greece EuroDiab, 1994b,185 • 6.5 • •
Hungary EuroDiab, 1994b,e,185 • 6.1 • •
Ireland EuroDiab, 1994b,185 • 12.5 • •
Israel Norymberg et al, 1991254 • • 7.0 •
Italy EuroDiab, 1994b,e,185 • 6.9 • •
Bruno et al, 2003255 • • • •
Bo et al, 2005256 • • 18.2 •
Luxembourg EuroDiab, 1994b,185 • 3.9 • •
Netherlands Verhoeven et al, 1991201 • • 16.0 •
Reenders et al, 1993202 • • 13.0 •
EuroDiab, 1994b,185 • 7.0 • •
Spijkerman et al, 2003257 • • • •
Norway Joner et al, 1992258 • 0.3 • •
Poland EuroDiab, 1994b,185 • 8.6 • •
Bennett et al, 2001253 • • • 9.7
Portugal EuroDiab, 1994b,185 • 15.8 • •
Romania EuroDiab, 1994b,185 • 17.3 • •
Slovakia Slovakian Diabetes Society, 2002d,207 • • • 7.6
Spain Esmatjes et al, 1996208 • • 5.4 •
Diamante, 1997209 • 5.0 • •
Arteagoitia et al, 2003210 • • 23.0 •
Sweden Lundman et al, 1998211 • 11.8 12.1 12.1
Wandell, 2004212 • • 10.9 •
Ukraine Kravchenko et al, 1996259 • • • •
United Kingdom Higgs et al, 1992260 • 24.0 • •
EuroDiab, 1994b,185 • 5.7 • •
Harvey et al, 2001b,261 • (cumulative prevalence) 9.6 • •
NA Mexico Cueto-Manzano et al, 2005262 • • 10.1 •
United States of America Orchard et al, 1990263 • 26.4 • •

OVERT PREVALENCE OF DIABETIC NEPHROPATHY (%) - MICROALBUMINURIA
M UnDM Type 1 DM Type 2 DM Total DM
• • • 53.1
• • • 34.1
• • 57.0 •
• 19.6 16.7 •
• • • 31.0
• • • 36.7a
• • • 32.8
• • • •
14,1 • • 14.3
• • 25.9 •
• • 36.0 •
• • • •
• • • 32.0
• 23.4 • •
• 14.0 • •
• 25.2 • •
• 37.6a 35.6a 35.4a
• 29.0 • •
• • • •
• • • 7.3a
• 4.3 • •
• • 27.0 •
• 23.7 • •
• 21.6 • •
• • 21.8 •
• 21.6 • •
• • • 14.5
• 23.8 • •
• 19.8 • •
• 17.9 • •
• • • •
• 19.3 • •
• • 38.9 •
• • 12.6 •
• 23.5 • •
• • 42.0 •
• • 44.0 •
• 23.4 • •
17,2 • 19.4 •
• 12.3 • •
• 19.8 • •
• • • 18.8
• 24.8 • •
• 26.4 • •
• • • •
• • 23.1 •
• 14.1 • •
• • • •
• • • •
• • • •
• • • 9.6
• 17.0 • •
• 21.7 • •
• (cumulative prevalence) 27.2 • •
• • 18.7 •
• 21.6 • •

Table 1.51
Prevalence of diabetic nephropathy

PREVALENCE OF DIABETIC NEPHROPATHY (%) - OVERT PREVALENCE
Region Country/territory Data used UnDM Type 1 DM Type 2 DM Total DM U
United States of America Garg et al, 2002264 • • • 6.1
SACA Brazil Foss et al, 1989265 • • • 11.3
SEA India Ramachandran et al, 1999b,222 • • (persistant 5.5%) 19.7 •
Ramachandran et al, 2000223 • 7.1 • •
Mohan et al, 2000266 • • 10.7 •
Mauritius Dowse et al, 1998267 • • • 3.8
Sri Lanka Weerasuriya et al, 1998268 • • • •
WP Australia Tapp et al, 2004269 2.4 • 6.1 4.3
China Chi et al, 2001226 • • • 57.1
China, Hong Kong Chan et al, 1993270 • • 20.0 •
Ko et al, 1999271 • • • •
Tam et al, 2004272 • • • •
Indonesia Diabcare Asia, 2003d,273 • • • 3.3
Japan Kuzuya et al, 1994228 • 27.0 19.5 20.1
Kawano et al, 2001181 • • • 27.3
Korea, Republic of Lee et al, 1995229 • • 14.0 •
Malaysia Shriwas et al, 1996274 • • • 28.2
Nauru Collins et al, 1989275 24.4 • 32.9 •
New Zealand (European) Simmons et al, 1994276 • • • 5.4
New Zealand (Pacific Islanders) Simmons et al, 1994276 • • • 13.0
Philippines Lantion-Ang, 2000277 • • • 1.0
Samoa Collins et al, 1995278 • • • (incl UnDM) 5.0
Singapore Thai et al, 1990231 • • • (incl UnDM) 18.3
Taiwan Fuh, 2002d,232 • • • 19.0
Thailand Thai Multicenter Group, 1994234 • • 18.7 •
Viet Nam Diabcare Asia, 2003d,273 • • • 6.1

a. Includes both micro and macroalbuminuria

c. Abstract only
d. Unpublished data
e. More than one centre used to derive prevalence figure

OVERT PREVALENCE OF DIABETIC NEPHROPATHY (%) - MICROALBUMINURIA
M UnDM Type 1 DM Type 2 DM Total DM
• • • 28.1
• • • •
• • • •
• • • •
• • 2.5 •
• • • 10.7
29.0a • • •
15.4 • 26.5 21.0
• • • •
• • 27.0 •
• • 24.8a 22.7a
• • 13.4 •
• • • 4.6
• • • •
• • • •
• • 20.0 •
• • • •
38.9 • 42.1 •
• • • 22.1
• • • 33.3
• • • 48.7
• • • (incl UnDM) 19.9
• • • •
• • • •
• • • •
• • • 14.2

Table 1.52
Data sources : Prevalence of diabetic nephropathy

AFR Cameroon Sobngwi et al, 1999238 Clinic (secondary care) 64

Ethiopia Rahlenbeck et al, 1997239 Clinic (secondary care) 170
Nigeria Erasmus et al, 1992240 Clinic (secondary care) 113
Senegal Cisse et al, 2003241 Clinic (secondary care) 587
South Africa Kalk et al, 1997242 Clinic (secondary care) 448
Levitt et al, 1997243 Clinic (primary care) 243
Rotchford et al, 2002187 Clinic (secondary care) 253

Zambia Rolfe, 1988245 Population based 600
EMME Egypt Herman et al, 1998246 Population based 283
Iran, Islamic Republic of Manaviat et al, 2004247 Clinic (secondary care) 330
Saudi Arabia Alzaid et al, 1994248 Clinic (secondary care) 211
EUR Austria Muhlhauser et al, 1992191 Clinic (primary care) 375
EuroDiab, 1994b,185 Clinic (secondary care) 111
Belgium EuroDiab, 1994b,185 Clinic (secondary care) 123
Bouten et al, 1996249 Clinic (secondary care) 271
Van Acker et al, 2001192 Clinic (secondary care) 1,653
Croatia EuroDiab, 1994b,185 Clinic (secondary care) 138
Czech Republic Perusicova et al, 1993c,250 Register 1,443
Czech Health Statistics, 2002d,251 Population based N/A
Denmark Mortensen et al, 1990252 Clinic (secondary care) 957
Gall et al, 1991193 Clinic (secondary care) 549
Finland EuroDiab, 1994b,185 Clinic (secondary care) 139
France EuroDiab, 1994b,185 Clinic (secondary care) 116
Delcourt et al, 1998197 Clinic (secondary care) 427
Germany EuroDiab, 1994b,e,185 Clinic (secondary care) 241
Bennett et al, 2001253 Clinic (secondary care) 214
Greece EuroDiab, 1994b,185 Clinic (secondary care) 231
Hungary EuroDiab, 1994b,e,185 Clinic (secondary care) 131
Ireland EuroDiab, 1994b,185 Clinic (secondary care) 112
Israel Norymberg et al, 1991254 Clinic (secondary care) 1,019
Italy EuroDiab, 1994b,e,185 Clinic (secondary care) 944
Bruno et al, 2003255 Clinic (primary and secondary care) 1,253
Bo et al, 2005256 Clinic (secondary care) 3,892
Luxembourg EuroDiab, 1994b,185 Clinic (secondary care) 102
Netherlands Verhoeven et al, 1991201 Clinic (primary care) 137
Spijkerman et al, 2003257 Clinic (primary care) and population based 255
Norway Joner et al, 1992258 Population based 351
Poland EuroDiab, 1994b,185 Clinic (secondary care) 116
Bennett et al, 2001253 Clinic (secondary care) 186
Portugal EuroDiab, 1994b,185 Clinic (secondary care) 137
Romania EuroDiab, 1994b,185 Clinic (secondary care) 110
Slovakia Slovakian Diabetes Society, 2002d,207 Clinic (secondary care) N/A
Diamante, 1997209 Clinic (secondary care) 1,822
Sweden Lundman et al, 1998211 Clinic (secondary care) 4,027
Wandell, 2004212 Clinic (primary care) 389
Ukraine Kravchenko et al, 1996259 Clinic (secondary care) 4,123
United Kingdom Higgs et al, 1992260 Population based 358
Harvey et al, 2001b,261 Population based 903


Age (yrs) Duration DM (yrs) Overt diagnostic criteria Microalbuminuria diagnostic criteria
51.9 (1.9) 5 ± 0.7 • Albuminuria > 30 mg/24hr

mean=42 6 ± 5 Albuminuria >300mg/la Albuminuria 30-299 mg/la
mean=51 5 ± 1 N/A Albuminuria 20-199 µg/mina
41.3 (17.2) 5.9 (5.6) • Albuminuria > 30mg/l
mean=54 6 ± 6 A/CR >19.9 mg/mmol A/CR 3.0-19.9 mg/mmol
20-85 8 ± 8 N/A A/CR >3.4 mg/mmola
21-81 4 ± N/A A/CR ≥20 mg/mmol Men A/CR 2.6-19.9 mg/mmol,
women A/CR 3.6-19.9 mg/mmol
mean=49 9 ± 6 Grade 2 proteinuria N/A
20+ N/A A/CR ≥300 mg/g A/CR 100-299 mg/g
54.9 (10.2) 10.2 (6.6) A/CR >300 mg/g A/CR 30-300 mg/g
56 10 ± 5 Dipstick proteinuria AER 30-300 mg/24hr
20+ <5->15 Proteinuria >0.5g/24h or blood urea of >40mg%a N/A
median=67 median=6 Albuminuria >200 mg/l Albuminuria 21-200 mg/l
15-60 16 ± 10 AER ≥200 µg/min AER 20-199 µg/min
mean=37 15 ± 10 N/A AER 20-200 µg/mina
21-69 range 5-27 N/A Albuminuria ≥ 30mg/dl
>18 N/A N/A N/A
N/A N/A N/A N/A
<20 5 ± 3 AER>150µg/mina AER >20-150µg/mina
<76 range 0-20 AER ≥300 mg/24hr AER 31-299 mg/24hr
35-74 11 ± 7 AER >300 mg/24hr or proteinuria >0.5g/24h AER 31-300mg/24hr
N/A N/A A/CR ≥300 mg/g A/CR 30-299 mg/g
31+ 12 ± 9 Proteinuria >30mg/dla N/A
67.5 (10.2) • AER > 200 µg/min AER 20-200 µg/min
69.7 (10.2) 11.7 ± 8.6 AER ≥ 200 µg/min AER 20-199 µg/min
15-60 14 ± 9 AER >200 µg/min AER 20-199 µg/min
mean=68 8 ± 7 Proteinuria >0.5 g/24h Albuminuria 20-200 µg/min
mean=68 8 ± 6 AER >200 mg/la AER 20-200 mg/la
62.9 (7.0) Not relevant • A/CR ≥ 2.0 mg/mmol
8-30 10 ± 3 AER >200 µg/mina AER 16 -200 µg/mina
N/A N/A A/CR ≥300 mg/g A/CR 30-299 mg/g
N/A N/A N/A N/A
45-70 9 ± 7 AER >200 µg/mina AER 20-200 µg/mina
>18 14 ± 9 AER >200 µg/mina AER 20-200 µg/mina
68 (11) 8.1 (5.4) N/A AER ≥20 mg/l or albuminuria >30 mg/24 h
18+ 10 ± 7 Proteinuria ≥300mg/ga N/A
54.6 (6.9) 6.5 (5.3) AER >200 µg/min AER 20-200 µg/mina
14-75 N/A N/A Albuminuria ≥20 mg/la
6-92 11 ± N/A Albustix reading ≥0.3 g/l A/CR ≥2.5 mg/mmol
3-80 N/A AER >200 µg/mina AER 20-200 µg/mina


Table 1.52
Data sources: Prevalence of diabetic nephropathy

NA Mexico Cueto-Manzano et al, 2005262 Clinic (primary care) 756

United States of America Orchard et al, 1990263 Clinic (secondary care) 592
Garg et al, 2002264 Population based 1,192
SACA Brazil Foss et al, 1989265 Clinic (secondary care) 546
SEA India Ramachandran et al, 1999b,222 Clinic (secondary care) 3,010
Mohan et al, 2000266 Clinic (secondary care) 1,848
Mauritius Dowse et al, 1998267 Population based 746
Sri Lanka Weerasuriya et al, 1998268 Clinic (primary care) 597
WP Australia Tapp et al, 2004269 Population based 879

China Chi et al, 2001226 Clinic (secondary care) 447
China, Hong Kong Chan et al, 1993270 Clinic (secondary care) 397
Ko et al, 1999271 Clinic (secondary care) 150
Tam et al, 2004272 Clinic (primary care) 1,161
Indonesia Diabcare Asia, 2003d,273 Clinic (primary care) 717

Japan Kuzuya et al, 1994228 Clinic (secondary care) 2,120
Kawano et al, 2001181 Clinic 6,472
Korea, Republic of Lee et al, 1995229 Clinic (secondary care) 631
Malaysia Shriwas et al, 1996274 Clinic (secondary care) 131
Nauru Collins et al, 1989275 Population based 318
New Zealand (European) Simmons et al, 1994276 Clinic (primary and secondary care) 297
New Zealand (Pacific Islanders) Simmons et al, 1994276 Clinic (primary and secondary care) 123
Philippines Lantion-Ang, 2000277 Clinic (primary care) 359
Samoa Collins et al, 1995278 Population based 141
Taiwan Fuh, 2002d,232 Clinic (secondary care) 4,535

Thailand Thai Multicenter Group, 1994234 Clinic (secondary care) 2,060
Viet Nam Diabcare Asia, 2003d,273 Clinic (primary care) 521

A/CR albumin/creatinine ratio

AER albumin excretion rate
N/A not available
a. Diagnosis of nephropathy required two or more urine samples

c. Abstract only
d. Unpublished data
e. More than one centre used to derive prevalence figure

Age (yrs) Duration DM (yrs) Overt diagnostic criteria Microalbuminuria diagnostic criteria
59 (11) N/A AER >300 mg/daya AER 30-30 mg/daya

18-30+ 16 ± N/A AER >200 µg/mina AER 20-200µg/mina
20-80+ N/A A/CR >37.8mg/mmol A/CR 3.0-37.8mg/mmol
25-84 8 ± 7 Proteinuria >200 mg/24hra N/A
mean=52 8 ± 6 Proteinuria ≥500 mg/24hra N/A
mean=52 7 ± 6 Proteinuria ≥500 mg/24hra Proteinuria 150-499 mg/24hra
10-50 median=4 Proteinuria ≥500 mg/24hra N/A
25+ 6 ± N/A Albuminuria ≥300 mg/ml Albuminuria 30-299 mg/ml
25-65 0 ± 0 Albuminuria >50 mg/l N/A
25+ median=5 A/CR ≥25 mg/mmol Men A/CR 2.5-25 mg/mmol,
women 3.5-25 mg/mmol
35-54 N/A Semi-quantitative test N/A
mean=57 range 0-30 A/CR >40.3 mg/mmola A/CR 5.4-40.3 mg/mmola
<40 5 ± 0 N/A A/CR ≥3.5 mg/mmol and AER ≥20 µg/mina
18-81, mean=58 (21) 5.7 N/A A/CR ≥ 30 mg/g
25-85 7 ± 6 Albuminuria >300 mg/l Albuminuria 20-300mg/l
A/CR >25 mg/mol Men A/CR 2.5-25mg/mol,
women A/CR 3.5-25 mg/mol
<24->75 11 ± N/A Doctor report Doctor report
mean=61 10 ± 10 Doctor report Doctor report
30-75 8 ± 7 AER >200 µg/mina AER 20-200 µg/mina
0-80+ range <5->20 Dipstick proteinuria or creatinine > 97µmol/l N/A
25+ range 0->15 Albuminuria ≥300 µg/ml Albuminuria 30 -299 µg/ml
18-79 range 0-47 AER ≥300mg/24hr AER 30-299 mg/24hr
18-79 range 0-32 AER ≥300mg/24hr AER 30-299 mg/24hr
7-93 9 ± 7 Albuminuria >300 mg/l Albuminuria 20-300 mg/l
25-74 4 ± N/A Albuminuria ≥300 µg/ml Albuminuria 30-299 µg/ml
18+ N/A Albuminuria ≥30 mg/dl or creatinine ≥1.5 mg/dl N/A
N/A N/A A/CR >300 mg/g or blood urea N/A
>26 mg/dl or serum creatinine >1.3 mg/dl
24-88 8 ± 7 Dipstick proteinuria 2+ N/A
1-85 7 ± 5 Albuminuria >300 mg/l Albuminuria 20-300mg/l
A/CR >25 mg/mol Men A/CR 2.5-25mg/mol,
women A/CR 3.5-25 mg/mol

Table 1.53
Prevalence of diabetic neuropathy

Prevalence of diabetic neuropathy (%)
Region Country/territory Data used UnDM Type 1 DM Type 2 DM Total DM
AFR South Africa Levitt et al, 1997243 • • • 27.6

Tanzania, United Republic of Wikblad et al, 1997280 • • • 28.1
Zambia Rolfe, 1988245 • • • 31.2
EMME Egypt Herman et al, 1998246 13.6 • • 21.9
Arab et al, 2002188 • • • 55.0
Saudi Arabia Nielsen, 1998281 • • 19.7 •
Akbar et al, 2000282 • • • 56.0
Sudan Elmahdi et al, 1991190 • • 31.5 •
EUR Austria Muhlhauser et al, 1992191 • • • 26.0
EuroDiab, 1996a,283 • 23.3 • •
Kastenbauer et al, 2004284 • 16.0 37.5 •
Belgium EuroDiab, 1996a,283 • 29.3 • •
Van Acker et al, 2001192 • 25.7 38.3 33.7
Croatia EuroDiab, 1996a,283 • 57.6 • •
Czech Republic Perusicova et al, 1993b,250 • 32.8 • •
Finland Partanen et al, 1995285 8.3 • • •
EuroDiab, 1996a,283 • 26.1 • •
France EuroDiab, 1996a,283 • 21.2 • •
Delcourt et al, 1998197 • • 28.8 •
Detournay et al, 2000286 • • 8.8 •
Germany EuroDiab, 1996a,c,283 • 20.1 • •
Greece EuroDiab, 1996a,c,283 • 25.5 • •
Manes et al, 2002287 • • • 33.5
Hungary EuroDiab, 1996a,283 • 29.0 • •
Ireland EuroDiab, 1996a,283 • 24.1 • •
Israel Norymberg et al, 1991254 • • 23.4 •
Italy Veglio et al, 1993288 • 28.5 • •
EuroDiab, 1996a,c,283 • 26.0 • •
Fedele et al, 1997289 • • • 32.3
Luxembourg EuroDiab, 1996a,283 • 21.5 • •
Netherlands Verhoeven et al, 1991201 • • 18.0 •
Reenders et al, 1993202 • • 68.0 •
EuroDiab, 1996a,283 • 23.9 • •
Spijkerman et al, 2003257 48.1 • • •
Poland EuroDiab, 1996a,283 • 25.6 • •
Portugal EuroDiab, 1996a,283 • 36.9 • •
Romania EuroDiab, 1996a,283 • 65.8 • •
Spain Esmatjes et al, 1996208 • • 20.0 •
Cabezas-Cerrato, 1998290 • 12.9 24.1 22.7
Arteagoitia et al, 2003210 • • 19.0 •
Sweden Lundman et al, 1998211 • 22.8 27.9 27.3
Turkey Bolukbasi, 1998b,291 • • • 26.9
Bürö et al, 2004292 • • 60.0 •
Ukraine Kravchenko et al, 1996259 • • • 27.9
United Kingdom Walters et al, 1992293 • 12.8 17.2 16.8
Young et al, 1993294 • 22.7 32.1 28.5
Kumar et al, 1994295 • • 41.6 •
EuroDiab, 1996a,283 • 22.7 • •
Abbott et al, 2005296 • • • 21.2
NA United States of America Orchard et al, 1990263 • 32.4 • •
Franklin et al, 1990297 • • 27.8 •
Dyck et al, 1993182 • 54.0 45.0 47.6
Lavery et al, 2003298 • • • 41.4
Gregg et al, 2004299 • • • 28.5
SACA Brazil Foss et al, 1989a,b,265 • • 50.9 •

Prevalence of diabetic neuropathy (%)
Region Country/territory Data used UnDM Type 1 DM Type 2 DM Total DM
SEA Bangladesh Chuang et al, 2002a,221 • • • 15.0

India Ramachandran et al, 1999222 • • 27.5 •
Ramachandran et al, 2000223 • 3.0 • •
Mauritius Shaw et al, 1998180 3.6 • • 12.7
Sri Lanka Fernando, 1996300 • • 30.6 •
Weerasuriya et al, 1998268 10.0 • • •
WP Australia Tapp et al, 2004269 7.1 • 13.1 •
China Chuang et al, 2002a,221 • • • 31.0
China, Hong Kong Ko et al, 1999271 • • 7.6 7.3
Indonesia Chuang et al, 2002a,221 • • • 55.0
Japan Kawano et al, 2001181 • • • 41.4
Korea, Republic of Chuang et al, 2002a,221 • • • 33.0
Malaysia Chuang et al, 2002a,221 • • • 61.0
Philippines Chuang et al, 2002a,221 • • • 42.0
Singapore Thai et al, 1990231 • • • (incl UnDM)15.9
Chuang et al, 2002a,221 • • • 12.0
Taiwan Wang et al, 2000301 • • • 32.4
Fuh, 2002d,232 • • 24.4 •
Hsu et al, 2005302 • • 32.4 •
Thailand Tandhanand et al, 2001236 • • • 27.0
Viet Nam Chuang et al, 2002a,221 • • • 44.0


a. Extra details supplied by authors
b. Abstract only
c. More than one centre used to derive prevalence figure
d. Unpublished data

Table 1.54
Data sources: Prevalence of diabetic neuropathy

AFR South Africa Levitt et al, 1997243 Clinic (primary care) 243
Tanzania, United Republic of Wikblad et al, 1997280 Clinic (secondary care) 153
Zambia Rolfe, 1988245 Clinic (secondary care) 600
EMME Egypt Herman et al, 1998246 Population based 509
Arab et al, 2002188 Clinic (primary care) 2,000
Saudi Arabia Nielsen, 1998281 Clinic (secondary care) 375
Akbar et al, 2000282 Clinic (secondary care) 237
EUR Austria Mühlhauser et al, 1992191 Clinic (primary care) 395
EuroDiab, 1996a,283 Clinic (secondary care) 116
Kastenbauer et al, 2004284 Clinic (secondary care) 350
Belgium EuroDiab, 1996a,283 Clinic (secondary care) 116
Van Acker et al, 2001192 Clinic (secondary care) 1,653
Croatia EuroDiab, 1996a,283 Clinic (secondary care) 132
Czech Republic Perusicova et al, 1993b,250 Register 1,443
Finland Partanen et al, 1995285 Clinic 132
France EuroDiab, 1996a,283 Clinic (secondary care) 104
Delcourt et al, 1998197 Clinic (secondary care) 427
Detournay et al, 2000286 Clinic (primary and secondary care) 4,119
Germany EuroDiab, 1996a,c,283 Clinic (secondary care) 229
Greece EuroDiab, 1996a,c,283 Clinic (secondary care) 216
Manes et al, 2002287 Population based 821
Hungary EuroDiab, 1996a,283 Clinic (secondary care) 138
Ireland EuroDiab, 1996a,283 Clinic (secondary care) 116
Israel Norymberg et al, 1991254 Clinic (secondary care) 1,019
Italy Veglio et al, 1993288 Clinic (secondary care) 379
EuroDiab, 1996a,c,283 Clinic (secondary care) 894
Fedele et al, 1997289 Clinic (secondary care) 8,757
Luxembourg EuroDiab, 1996a,283 Clinic (secondary care) 107
Netherlands Verhoeven et al, 1991201 Population based 137
Spijkerman et al, 2003257 Clinic (primary care) and population based 255
Poland EuroDiab, 1996a,283 Clinic (secondary care) 117
Portugal EuroDiab, 1996a,283 Clinic (secondary care) 130
Romania EuroDiab, 1996a,283 Clinic (secondary care) 114
Cabezas-Cerrato, 1998290 Population based 2,644
Sweden Lundman et al, 1998211 Clinic (primary and secondary care) 4,027
Turkey Bolukbasi, 1998b,291 Clinic (secondary care) 297
Börü et al, 2004292 Clinic (secondary care) 866
Ukraine Kravchenko et al, 1996259 Clinic (secondary care) 4,123
United Kingdom Walters et al, 1992293 Population based 1,077
Young et al, 1993294 Clinic (secondary care) 6,487
Kumar et al, 1994295 Clinic (primary care) 811
Abbott et al, 2005296 Population based 15,692
NA United States of America Orchard et al, 1990263 Clinic (secondary care) 588
Franklin et al, 1990297 Population based 279
Dyck et al, 1993182 Population based 359
Lavery et al, 2003298 Clinic (primary and secondary care) 1,666
Gregg et al, 2004299 Population based (NHANES) 419
SACA Brazil Foss et al, 1989a,b,265 Clinic (secondary care) 546


Age (yrs) Duration DM (yrs) Diagnostic tool
20-85 8 ± 8 Clinical score

mean=44 5 ± 6 Clinical score (NDS, NSS), quantitative sensory testing
≥35 7 ± 6 Clinical score
≥20 N/A Quantitative sensory testing
20-70 N/A Clinical score
median=50 median=8 Clinical score
mean=54 11 ± 7 Clinical score (DNI)
20+ N/A Clinical score
mean=67 N/A Quantitative sensory testing
15-60 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests
57.1 (11.9) 11.8 (9.7) NSS (Michigan Neuropathy Screening Instrument)
21-69 range 5-27 Quantitative sensory testing
>18 N/A N/A
45-65 0 ± 0 Clinical score, electrophysiology
35-74 11 ± 7 Clinical score, quantitative sensory testing
mean=66 9 ± N/A Medical record review
18-70 8 ± 7 Clinical score (NDS, NSS), quantitative sensory testing
≥31 12 ± 9 Clinical score
15-59 N/A Clinical score, autonomic function tests
18-70 12 ± 9 Clinical score (DNI)
mean=68 8 ± 7 Clinical score
mean=68 8 ± 6 Clinical score, autonomic function tests
62.9 (7.0) 0 Quantitative sensory testing (monofilament)
45-70 9 ± 7 Clinical score
15-74 10 ± 0 Clinical score (NDS, NSS)
68 (11) 8.1 (5.4) Clinical score, quantitative sensory testing
≥18 10 ± 7 Clinical score, quantitative sensory testing
N/A N/A Clinical score, electrophysiology
57.2 (10.3) 8.5 (7.1) NDS, NSS
30-80+ N/A Clinical score, quantitative sensory testing
18-90 range 0-62 Clinical score (NDS, NSS)
34-96 7 ± N/A Clinical score (NDS), quantitative sensory testing
61.4 (13.8) mean=5.0 Clinical score (NDS)
mean=24 16 ± N/A Clinical score
57 N/A Clinical score (NSS, NDS, NSP), quantitative sensory testing, electrophysiology, autonomic function test
69.1 (11.1) 11.2 (9.5) Quantitative sensory testing (monofilament, VPT)
40+ N/A Quantitative sensory testing (monofilament)
25-84 8 ± 7 Clinical score, quantitative sensory testing


Table 1.54
Data sources: Prevalence of diabetic neuropathy

SEA Bangladesh Chuang et al, 2002a,221 Clinic (secondary care) 1,606

India Ramachandran et al, 1999222 Clinic (secondary care) 3,010
Mauritius Shaw et al, 1998180 Population based 847
Sri Lanka Fernando, 1996300 Clinic (secondary care) 500
Weerasuriya et al, 1998268 Clinic (primary care) 597
WP Australia Tapp et al, 2004269 Population based 821
China Chuang et al, 2002a,221 Clinic (secondary care) 2,344
China, Hong Kong Ko et al, 1999271 Clinic (secondary care) 150
Indonesia Chuang et al, 2002a,221 Clinic (secondary care) 2,084
Japan Kawano et al, 2001181 Clinic 6,472
Korea, Republic of Chuang et al, 2002a,221 Clinic (secondary care) 948
Malaysia Chuang et al, 2002a,221 Clinic (secondary care) 1,045
Philippines Chuang et al, 2002a,221 Clinic (secondary care) 2,635
Chuang et al, 2002a,221 Clinic (secondary care) 1,625
Taiwan Wang et al, 2000301 Population based 219
Fuh, 2002d,232 Clinic (secondary care) 4,535
Hsu et al, 2005302 Population based 587
Thailand Tandhanand et al, 2001236 Clinic (secondary care) 2,314
Viet Nam Chuang et al, 2002a,221 Clinic (secondary care) 1,179

DNI diabetic neuropathy index
N/A not available
NDS neuropathy disability score
NSP neuropathy symptom profile
NSS neuropathy symptom score
VPT vibration perception threshold

a. Extra details supplied by authors
b. Abstract only
c. More than one centre used to derive prevalence figure
d. Unpublished data

Age (yrs) Duration DM (yrs) Diagnostic tool
10-91 8 ± 6 Medical record review

mean=52 8 ± 6 Clinical score, quantitative sensory testing
10-50 median=4 Clinical score
≥25 N/A Quantitative sensory testing
30-60 5 ± 6 Clinical score (NDS, NSS), quantitative sensory testing
25-65 0 ± 0 Clinical score (NDS, NSS), quantitative sensory testin
≥25 median=5 Clinical score (NSS, NDS), quantitative sensory testing
<40 5 ± 0 Clinical score, quantitative sensory testing
mean=61 10 ± 10 Clinical score
18+ N/A Clinical score
N/A N/A Quantitative sensory testing
N/A N/A Clinical score (NSS), electrophysiology
mean=59 10 ± 7 Medical record review

Table 1.55
Prevalence and incidence of lower limb amputations

Incidence per 100,000
Region Country/territory Data used Prevalence (%) diabetic population
AFR South Africa Levitt et al, 1997243 1.4 •

EMME Egypt Arab, 2002188 3.0 •
Saudi Arabia Nielsen, 1998281 1.3 •
(below ankle only)
EUR Austria Muhlhauser et al, 1992191 3.5 •
Belgium Van Acker et al, 2001192 4.2 •
Czech Republic Czech Health Statistics, 2002a,251 0.9 •
Denmark Ebskov et al, 1996303 • 156b
304
Holstein et al, 2000 • 430c
Finland Siitonen et al, 1993305 • 480b
Germany Trautner et al, 2001306 • 463b
Heller et al, 2004 307 • •
Netherlands van Houtum et al, 1996308 • 251
(age adjusted)c
van Houtum et al, 2004309 • 363b
310
Norway Witso et al, 2001 • 440b
d,311
Poland Nazim, 2001 • 165c
Slovakia Slovakian Diabetes Society, 2002a,207 1.3 •
Spain Calle-Pascual et al, 1997312 • 46b
Almaraz et al, 2000d,313 • 136c
Arteagoitia et al, 2003 210 1.4 •
Sweden Larsson et al, 1995314 • 410b
Lundman et al, 1998211 1.8 •
United Kingdom Deerochanawong et al, 1992315 • 570c
Morris et al, 1998316 • 367b
Abbott et al, 2002317 1.3 •
Rayman et al, 2004318 • 285c
Rayman et al, 2004318 • 162c
319
NA Barbados Hennis et al, 2004 • 936c
Hennis et al, 2004319 • 379c
Canada Lawee et al, 1992320 • 400c
Trinidad and Tobago Gulliford et al, 2002321 4.0 •
United States of America Humphrey et al, 1994184 • 271b
Lavery et al, 2003298 3.5 590c
MMWR, 2003322 • 340b
Gregg et al, 2004299 2.4 •
SACA Brazil Spichler et al, 2001323 • 181c
SEA India Ramachandran et al, 1999222 0.7 (type 2 DM) •
Mauritius Shaw et al, 1998180 0.2 (incl UnDM) •
Sri Lanka Fernando, 1996300 4.8 (type 2 DM) •
WP China Chi et al, 2001226 0.7 •
Japan Kuzuya et al, 1994228 0.6 •
Nauru Humphrey et al, 1996324 • 810b
301
Taiwan Wang et al, 2000 1.4 (incl UnDM) •
Thailand Tandhanand et al, 2001236 1.0 •
Thai Multicenter Group, 1994234 1.3 •
a. Unpublished data
b. First amputation
c. All amputations or not stated
d. Abstract only

Table 1.56
Data sources: prevalence and incidence of lower limb amputations

Region Country/territory Data used Study type S

AFR South Africa Levitt et al, 1997243 Clinic (primary care)
EMME Egypt Arab, 2002188 Clinic (primary care)
Saudi Arabia Nielsen, 1998281 Clinic (secondary care)
EUR Austria Muhlhauser et al, 1992191 Clinic (primary care)
Belgium Van Acker et al, 2001192 Clinic (secondary care)
Czech Republic Czech Health Statistics, 2002a,251 Population based
Denmark Ebskov et al, 1996303 Register
Holstein et al, 2000304 Clinical records
Finland Siitonen et al, 1993305 Operating theatre records
Germany Trautner et al, 2001306 Operating theatre records
Heller et al, 2004307 Hospital discharge codes
Netherlands van Houtum et al, 1996308 Hospital discharge records
van Houtum et al, 2004309 Hospital discharge records
Norway Witso et al, 2001310 Hospital records
Poland Nazim, 2001b,311 Hospital records and limb fitting centre
Slovakia Slovakian Diabetes Society, 2002a,207 Clinic (secondary care)
Spain Calle-Pascual et al, 1997312 Operating theatre records, hospital discharge records, medical records
Almaraz et al, 2000b,313 Hospital records
Arteagoitia et al, 2003210 Clinic (primary care)
Sweden Larsson et al, 1995314 Amputation register
Lundman et al, 1998211 Clinic (primary and secondary care)
United Kingdom Deerochanawong et al, 1992315 Operation records and hospital discharge records
Morris et al, 1998316 Hospital discharge records and database of rehabilitation service
Abbott et al, 2002317 Clinic (primary and secondary care)
Rayman et al, 2004318 Clinic (secondary care)
Rayman et al, 2004318 Clinic (secondary care)
NA Barbados Hennis et al, 2004319 Operating theatre records
Hennis et al, 2004319 Operating theatre records
Canada Lawee et al, 1992320 Hospital discharge records
Trinidad and Tobago Gulliford et al, 2002321 Clinic (secondary care)
United States of America Humphrey et al, 1994184 Hospital discharge codes
Lavery et al, 2003298 Clinic (primary and secondary care)
MMWR, 2003322 Hospital discharge records
Gregg et al, 2004299 Clinic (secondary care)
SACA Brazil Spichler et al, 2001323 Register
SEA India Ramachandran et al, 1999222 Clinic (secondary care)
Mauritius Shaw et al, 1998180 Population based
Sri Lanka Fernando, 1996300 Clinic (secondary care)
WP China Chi et al, 2001226 Clinic (secondary care)
Japan Kuzuya et al, 1994228 Clinic (secondary care)
Nauru Humphrey et al, 1996324 Operating theatre records, welfare office and health survey data
Taiwan Wang et al, 2000301 Population based
Thailand Thai Multicenter Group, 1994234 Clinic (secondary care)
Tandhanand et al, 2001236 Clinic (secondary care)

a. Unpublished data
b. Abstract only

Sample size Age (yrs) No. of amputees Lowest level of amputation

243 20-85 3 N/A
2,000 20-70 N/A N/A
375 N/A 5 N/A
375 N/A 13 below ankle
1,653 21-69 69 toe
• N/A N/A N/A
• 25-97 2,848 ray
• N/A 463 ankle
• all 254 toe
• all 39 toe
• all 29,000 toe
• all 1,575 toe
N/A 71.5 (11.9) 1,673 toe
• all 74 toe
• N/A 139 toe
• N/A N/A N/A
• all 48 toe
• N/A 316 N/A
2,920 68 (11) 41 N/A
• all 21 toe
4,027 >18 73 toe
• N/A 93 toe
7,079 all 52 toe
9,710 mean=62 122 toe
N/A N/A 79 toe
N/A N/A 79 above ankle
• 70.9 (12.6) 167 toe
• 70.9 (12.6) 167 tibia
• all 926 toe
2,106 all 84 toe
2,015 N/A 57 toe
1,666 69.1 (11.1) N/A toe
N/A N/A 307 toe
3,515 ≥40 N/A toe
• N/A N/A N/A
3,010 mean=52 21 N/A
847 mean=54 2 •
500 30-60 24 N/A
447 35-54 3 toe
2,115 <24-75+ 13 N/A
375 25+ 46 toe
219 35-85 3 N/A
2,060 24-88 27 toe
2,378 N/A N/A N/A


Table 1.57
Prevalence of diabetic retinopathy
Proliferative
Total retinopathy (%) retinopathy (%)
Region Country/territory Data used UnDM Type 1 DM Type 2 DM Total DM Total DM
AFR Cameroon Moukouri Dit Nyolo et al, 1995325 • • • 37.3 •

Sobngwi et al, 1999238 • • • 37.5 •
Ethiopia Seyoum et al, 2001326 • 34.1 41.0 37.8 1.7
Nigeria Erasmus et al, 1989327 • • • 15.1 0,0
South Africa Kalk et al, 1997242 • • • 39.3 •
Levitt et al, 1997243 • • • 55.4 4.3
Rotchford et al, 2002187 • • • 40.3 5.6
Zambia Rolfe, 1988245 • • • 34.0 4.0
Zimbabwe Bartels et al, 1999329 • • • 35.9 •
EMME Egypt Herman et al, 1998246 15.7 • • 41.5 •
Arab et al, 2002188 • • • 32.1 9.5
Iran, Islamic Republic of Manaviat et al, 2004247 • • 39.3 • 5.4
Jordan Al-Till et al, 2005330 • 43.9 65.4 64.1 9.3
Oman el Haddad et al, 1998331 • • • 42.4 12.8
Khandekar et al, 2003332 • 19.8 15.0 14.4 2.7
Sudan Elmahdi et al, 1991190 • • 17.4 • •
EUR Austria Muhlhauser et al, 1992191 • • • 23.3 •
EuroDiab, 1994185 • 23.0 • • •
Belgium EuroDiab, 1994185 • 47.0 • • •
Van Acker et al, 2001192 • 43.6 35.0 38.5 •
Croatia EuroDiab, 1994185 • 59.0 • • •
Czech Republic Perusicova et al, 1993a,250 • 42.2 • • •
Czech Health Statistics, 2002b,251 • • • 11.3 2.4
Denmark Hove et al, 2004333 • • 31.2 • 2.9
Finland Falck et al, 1993334 • 10.8 • • •
EuroDiab, 1994185 • 54.0 • • •
France EuroDiab, 1994185 • 35.0 • • •
Delcourt et al, 1998197 • • 33.5 • 1.4
Detournay et al, 2000286 • • 10.6 • •
Germany EuroDiab, 1994c,185 • 21.0 • • •
Hesse et al, 2001a,335 • • • 16.1 •
Greece EuroDiab, 1994c,185 • 46.7 • • •
Hungary EuroDiab, 1994185 • 51.0 • • •
Ireland EuroDiab, 1994185 • 53.0 • • •
Israel Norymberg et al, 1991254 • • 28.0 • •
Italy Segato et al, 1991336 • 46.2 24.6 26.2 1.8
EuroDiab, 1994c,185 • 40.8 • • •
Giuffre et al, 2004337 • • • 34.1 4.5
Bo et al, 2005256 • • 29.3 • •
Luxembourg EuroDiab, 1994185 • 30.0 • • •
Netherlands Verhoeven et al, 1991201 • • 35.0 • 4.0
Reenders et al, 1993202 • • 13.5 • •
EuroDiab, 1994185 • 47.0 • • •
Spijkerman et al, 2003257 7.6 • 6.3 • •
Norway Joner et al, 1992258 • 32.8 • • 0.0
Hapnes et al, 1996338 • 34.4 10.1 13.8 2.4
Poland Luzniak et al, 1997 a,339 • • 31.4 • •
Portugal Pinto-Figueiredo et al, 1992340 • 41.6 • • 7.3
EuroDiab, 1994185 • 60.0 • • •
Russian Federation Betts et al, 1999341 • 12.0 • • 1.1
Slovakia Slovakian Diabetes Society, 2002b,207 • • • 17.4 •
Spain Fernandez•Vigo et al, 1993342 • • • 44.7 5.8
Esmatjes et al, 1996208 • • 29.0 • •
Arteagoitia et al, 2003210 • • 20.0 • 9.2
Sweden Falkenberg et al, 1994343 • • 26.5 • 3.4

DM diabetes mellitus Total DM previously diagnosed diabetes (both type 1 and type 2) UnDM undiagnosed diabetes a. Abstract only b. Unpublished data

Proliferative
Total retinopathy (%) retinopathy (%)
Region Country/territory Data used UnDM Type 1 DM Type 2 DM Total DM Total DM
EUR Sweden Henricsson et al, 1996344 • 64.0 36.0 43.6 6.7

Kernell et al, 1997345 • 14.5 • • 2.3
Larsson et al, 1999346 • 75.1 • • 21.8
Wandell, 2004212 • • 25.2 • •
Turkey Bürö et al, 2004292 • • 27.8 • •
Ukraine Kravchenko et al, 1996259 • • • 22.4 •
United Kingdom Higgs et al, 1992260 • • • 42.6 2.7
Sparrow et al, 1993347 • • 52.0 • 4.0
EuroDiab, 1994185 • 51.0 • • •
Broadbent et al, 1999348 • 36.7 36.2 33.6 1.1
NA Barbados Leske et al, 1999349 • • • 28.5 0.9
Mexico Gonzalez Villalpando et al, 1994350 • • 49.5 • 5.7
Cueto-Manzano et al, 2005262 • • 23.1 • •
United States of America Klein et al, 1992351 10.2 68.4 • 36.8 (incl UnDM) 1,8
Dyck et al, 1993182 • 79.0 55.0 62.1 8.9
Kramer et al, 2003352 • • 16.7 • •
USA (Mexican Americans) Harris et al, 1998353 • • 33.4 • 5.6
USA (Non-Hispanic Blacks) Harris et al, 1998353 • • 26.5 • 1.8
USA (Non-Hispanic Whites) Harris et al, 1998353 • • 18.2 • 0.9
SACA Brazil Foss et al, 1989a,265 • • 29.1 • •
Brazil (Caucasians) Santos et al, 2005354 • • 47.1 • •
SEA Bangladesh Chuang et al, 2002d,221 • • • 11.0 •
India Rema et al, 1996355 • • 34.1 • 3.4
Ramachandran et al, 1999222 • • 23.7 • 3.7
Dandona et al, 1999356 • • • 23.5 0.8
Ramachandran et al, 2000223 • 13.4 • • 1.9
Mauritius Dowse et al, 1998267 14.8 • 44.3 30.2 (incl UnDM) 1.3
Sri Lanka Fernando et al, 1993357 • • 31.3 • 5.9
Weerasuriya et al, 1998268 15.2 • • • •
WP Australia Fairchild et al, 1994358 • 42.0 • • 0.0
McKay et al, 2000359 • • • 29.1 4.2
Tapp et al, 2003360 6.2 • 21.9 24.5 2.1
China Hu et al, 1991361 31.0 • • • 2.8
Chi et al, 2001226 • • • 47.4 •
Chuang et al, 2002d,221 • • • 28.0 •
China, Hong Kong Wang et al, 1998362 21.9 • • • •
Ko et al, 1999271 • • 11.4 14.0 •
Fiji Brooks et al, 1999363 • • 52.6 • •
Indonesia Chuang et al, 2002d,221 • • • 17.0 •
Japan Kuzuya et al, 1994228 • 56.0 35.9 38.3 10.3
Kawano et al, 2001181 • • • 34.5 •
Korea, Republic of Lee et al, 1995229 • • 35.2 • 8.2
Chuang et al, 2002d,221 • • • 33.0 •
Malaysia Shriwas et al, 1996274 • • 47.3 48.6 3.6
Chuang et al, 2002d,221 • • • 37.0 •
New Zealand Florkowski et al, 2001364 • 37.4 • • •
Philippines Chuang et al, 2002d,221 • • • 18.0 •
Samoa Collins et al, 1995278 15.4 • 43.2 • 4.5
Singapore Lau et al, 1995365 • • • 21.8 0.6
Chuang et al, 2002d,221 • • • 12.0 •
Taiwan Chen et al, 1992366 • • 35.0 • 2.2
Fuh, 2002232 • • 25.1 • •
Thailand Tandhanand et al, 2001236 • • • 21.0 •
Thai Multicenter Group, 1994234 • • 32.1 • 6.6
Viet Nam Chuang et al, 2002c,221 • • • 13.0 •

c. More than one centre used to derive prevalence figure d. Extra details supplied by authors

Table 1.58
Data sources: prevalence of diabetic retinopathy


AFR Cameroon Moukouri Dit Nyolo et al, 1995325 Clinic (secondary care)
Sobngwi et al, 1999238 Clinic (secondary care)
Ethiopia Seyoum et al, 2001326 Clinic (secondary care)
Nigeria Erasmus et al, 1989327 Clinic (secondary care)
South Africa Kalk et al, 1997242 Clinic (secondary care)
Levitt et al, 1997243 Clinic (primary care)
Rotchford et al, 2002187 Clinic (secondary care)
Zambia Rolfe, 1988245 Clinic (secondary care)
Zimbabwe Bartels et al, 1999329 Clinic (secondary care)
EMME Egypt Herman et al, 1998246 Population based
Arab et al, 2002188 Clinic (primary care)
Iran, Islamic Republic of Manaviat et al, 2004247 Clinic (secondary care)
Jordan Al-Till et al, 2005330 Clinic (primary and secondary care)
Oman el Haddad et al, 1998331 Clinic (secondary care)
Khandekar et al, 2003332 Clinic (secondary care)
Sudan Elmahdi et al, 1991190 Clinic (secondary care)
EUR Austria Muhlhauser et al, 1992191 Clinic (primary care)
EuroDiab, 1994185 Clinic (secondary care)
Belgium EuroDiab, 1994185 Clinic (secondary care)
Van Acker et al, 2001192 Clinic (secondary care)
Croatia EuroDiab, 1994185 Clinic (secondary care)
Czech Republic Perusicova et al, 1993a,250 Register
Czech Health Statistics, 2002b,251 Population based
Denmark Hove et al, 2004333 Population based
Finland Falck et al, 1993334 Clinic (secondary care)
France EuroDiab, 1994185 Clinic (secondary care)
Delcourt et al, 1998197 Clinic (secondary care)
Detournay et al, 2000286 Clinic (primary and secondary care)
Germany EuroDiab, 1994c,185 Clinic (secondary care)
Hesse et al, 2001a,335 Population based
Greece EuroDiab, 1994c,185 Clinic (secondary care)
Hungary EuroDiab, 1994185 Clinic (secondary care)
Ireland EuroDiab, 1994185 Clinic (secondary care)
Israel Norymberg et al, 1991254 Clinic (secondary care)
Italy Segato et al, 1991336 Population based
EuroDiab, 1994c,185 Clinic (secondary care)
Giuffre et al, 2004337 Population based
Bo et al, 2005256 Clinic (secondary care)
Luxembourg EuroDiab, 1994185 Clinic (secondary care)
Netherlands Verhoeven et al, 1991201 Population based
Reenders et al, 1993202 Clinic (primary care)
Spijkerman et al, 2003257 Clinic (primary care) and population based
Norway Joner et al, 1992258 Population based
Hapnes et al, 1996338 Population based
Poland Luzniak et al, 1997 a,339 Clinic (secondary care)
Portugal Pinto-Figueiredo et al, 1992340 Clinic (secondary care)
Russian Federation Betts et al, 1999341 Clinic (secondary care)
Slovakia Slovakian Diabetes Society, 2002b,207 Clinic (secondary care)
Spain Fernandez-Vigo et al, 1993342 Clinic (primary and secondary care)
Esmatjes et al, 1996208 Clinic (primary and secondary care)
Arteagoitia et al, 2003210 Clinic (primary care)
Sweden Falkenberg et al, 1994343 Population based
Henricsson et al, 1996344 Population based

Sample size Age (yrs) Duration DM (yrs) Diagnostic tool

284 10-79 range 0-20 Clinical fundoscopy
64 51.9 5 ± 0.7 Clinical fundoscopy
302 14-85 9 ± 5 Clinical fundoscopy
377 11-60+ range 0-22 Clinical fundoscopy
507 mean=54 7 ± 7 Fundus photography
251 21-81 4 ± N/A Clinical fundoscopy
600 mean=49 9 ± 6 Clinical fundoscopy
117 N/A N/A Clinical fundoscopy
376 20+ N/A Fundus photography
2,000 20-70 N/A Clinical fundoscopy
585 54.9 (10.2) 10.2 (6.6) Clinical fundoscopy
2,249 40+ median 6-10 Clinical fundoscopy
413 20+ <5->15 Clinical fundoscopy
375 median=67 median=6 Clinical fundoscopy or fundus photography
122 15-60 16 ± 10 Fundus photography
1,653 21-69 range 5-27 Medical record review
1,443 >18 N/A N/A
N/A N/A N/A N/A
378 65 (12) 9 (8) Fundus photography
4,119 mean=66 9 ± N/A Questionnaire
2,801 mean=66 10 ± 8 Medical record review
1,019 31-71+ 12 ± 9 Clinical fundoscopy
1,291 mean=60 range <5->20 Clinical fundoscopy
132 40+ N/A Clinical fundoscopy and fundus photography
3,892 69.7 (10.2) 11.7 ± 8.6 Clinical fundoscopy and fundus photography
137 mean=68 8 ± 7 Clinical fundoscopy and fundus photography
255 62.9 (7.0) 0 Fundus photography
210 mean=66 9 ± 8 Clinical fundoscopy and fundus photography
1,334 N/A N/A N/A
1,302 <9-79 10 ± 10 Clinical fundoscopy and fundus photography
266 <16 3 ± N/A Clinical fundoscopy
N/A N/A N/A N/A
1,179 8-93 range <5->15 Clinical fundoscopy and fundus photography
1,157 45-70 9 ± 7 Clinical fundoscopy
2,920 68 (11) 8.1 (5.4) Clinical fundoscopy
117 <70 8 ± 5 Fundus photography
2,232 <75 8 ± 8 Fundus photography

Table 1.58
Data sources: prevalence of diabetic retinopathy


Sweden Kernell et al, 1997345 Population based
Larsson et al, 1999346 Population based
Wandell, 2004212 Clinic (primary care)
Turkey Bürö et al, 2004292 Clinic (secondary care)
Ukraine Kravchenko et al, 1996259 Clinic (secondary care)
United Kingdom Higgs et al, 1992260 Population based
Sparrow et al, 1993347 Population based
Broadbent et al, 1999348 Clinic (primary care)
NA Barbados Leske et al, 1999349 Population based
Mexico Gonzalez Villalpando et al, 1994350 Population based
Cueto-Manzano et al, 2005262 Clinic (primary care)
United States of America Klein et al, 1992351 Population based
Dyck et al, 1993182 Population based
Kramer et al, 2003352 Population based
USA (Mexican Americans) Harris et al, 1998353 Population based
USA (Non-Hispanic Blacks) Harris et al, 1998353 Population based
USA (Non-Hispanic Whites) Harris et al, 1998353 Population based
SACA Brazil Foss et al, 1989a,265 Clinic (secondary care)
Brazil (Caucasians) Santos et al, 2005354 Clinic (secondary care)
SEA Bangladesh Chuang et al, 2002d,221 Clinic (secondary care)
India Rema et al, 1996355 Clinic (secondary care)
Ramachandran et al, 1999222 Clinic (secondary care)
Dandona et al, 1999356 Population based
Ramachandran et al, 2000223 Clinic (secondary care)
Mauritius Dowse et al, 1998267 Population based
Sri Lanka Fernando et al, 1993357 Clinic (secondary care)
Weerasuriya et al, 1998268 Clinic (primary care)
WP Australia Fairchild et al, 1994358 Clinic (secondary care)
McKay et al, 2000359 Population based
Tapp et al, 2003360 Population based
China Hu et al, 1991361 Clinic (primary care)
Chi et al, 2001226 Clinic (secondary care)
Chuang et al, 2002d,221 Clinic (secondary care)
China, Hong Kong Wang et al, 1998362 Clinic (secondary care)
Ko et al, 1999271 Clinic (secondary care)
Fiji Brooks et al, 1999363 Population based
Indonesia Chuang et al, 2002d,221 Clinic (secondary care)
Japan Kuzuya et al, 1994228 Clinic (secondary care)
Kawano et al, 2001181 Clinic
Korea, Republic of Lee et al, 1995229 Clinic (secondary care)
Malaysia Shriwas et al, 1996274 Clinic (secondary care)
New Zealand Florkowski et al, 2001364 Population based
Philippines Chuang et al, 2002d,221 Clinic (secondary care)
Samoa Collins et al, 1995278 Population based
Singapore Lau et al, 1995365 Clinic (primary care)
Taiwan Chen et al, 1992366 Population based
Fuh, 2002232 Clinic (secondary care)
Thailand Thai Multicenter Group, 1994234 Clinic (secondary care)
Tandhanand et al, 2001236 Clinic (secondary care)
Viet Nam Chuang et al, 2002c,221 Clinic (secondary care)
DM diabetes mellitus N/A not available a. Abstract only b. Unpublished data c. More than one centre used to derive prevalence figure

Sample size Age (yrs) Duration DM (yrs) Diagnostic tool

557 mean=15 5 ± N/A Fundus photography
285 15-50 17 ± 11 Clinical fundoscopy and fundus photography
389 54.6 (6.9) 6.5 (5.3) Fundus photography
4,123 14-75 N/A Clinical fundoscopy
291 6-92 11 ± N/A Fundus photography
101 28-91 7 ± 6 Clinical fundoscopy and fundus photography
357 13-92 N/A Clinical fundoscopy and fundus photography
636 40-84 median=5 Clinical fundoscopy and fundus photography
756 59 (11) N/A Clinical fundoscopy
435 43-84 range 0-20+ Fundus photography
380 mean=57 range 0-64 Fundus photography
1,127 61 (21) N/A Fundus photography
308 40+ range 0-15+ Fundus photography
210 58.7 (12) 10.5 (9.7) Clinical fundoscopy
1,608 10-91 8 ± 6 Medical record review
6,792 mean=55 9 ± 6 Clinical fundoscopy
119 31-86 range 0-20+ Clinical fundoscopy
617 10-50 median=4 Clinical fundoscopy
746 ≥25 6 ± N/A Fundus photography
255 median=15 2 ± 18 Fundus photography
234 40+ 9.1 ± N/A Fundus photography
703 ≥25 median=5 Fundus photography
447 35-54 range <7-14 Clinical fundoscopy
465 mean=54 N/A Clinical fundoscopy
150 <40 5 ± 0 Clinical fundoscopy
403 mean=56 8 ± N/A Clinical fundoscopy
2,120 <24->75 11 ± N/A Doctor report
6,472 mean=61 10 ± 10 Doctor report
934 15-92 11 ± 7 Medical record review
140 0-80+ range <5->20 Clinical fundoscopy
166 25-74 4 ± N/A Fundus photography
13,296 <30->70 N/A Fundus photography
527 40+ <4->10 Clinical fundoscopy
4,535 N/A N/A N/A
2,060 24-88 8 ± 7 Clinical fundoscopy
2,034 mean=59 10 ± 7 Medical record review
d. Extra details supplied by authors

CHAPTER 2
DIABETES IN THE YOUNG

Some 70,000 children aged
14 years and under develop
type 1 diabetes annually.
2.0
DIABETES IN THE YOUNG
Type 1 diabetes is the predominant form of the disease

in children and adolescents in most developed countries,
where there is still a significant number of diabetes-related
deaths among children. Further, mortality in undiagnosed
diabetes is probably a large but hidden problem in the
global perspective. At the same time, type 2 diabetes in the
young is an emerging problem with potentially
serious outcomes.
D iabetes is rapidly increasing in children and adolescents

in many countries and a shift to younger age at onset
is indicated. The increase in incidence in type 1 diabetes has
that type 2 diabetes in the young is an emerging problem
with potentially serious outcomes, at least in some ethnic
groups. Yet our understanding of the worldwide burden of
been shown in countries having both high and low this disease among the young is somewhat fractured, with
prevalence. There is, however, an indication of a steeper few studies mainly not population based but rather reporting
increase in some of the low prevalence countries and an on specific communities or ethnic groups.
association between the risk increase and gross national
product (GNP) estimates. Thus part of the increasing trend This chapter looks at the global trends in childhood type 1
may be due to potentially preventable lifestyle factors. diabetes and reviews the available epidemiological data on
type 2 diabetes in the young from around the world. By
Although type 1 diabetes usually accounts for only a focusing on such data it is hoped that deficiencies in our
minority of the total burden of diabetes in a population, knowledge of the disease will be highlighted, and that
it is the predominant form of the disease in younger age strategies to deal with it will be developed.
groups in most developed countries. Apart from the rise
in the incidence, factors contributing to a continued
upward trend in the global prevalence include better
diagnosis of type 1 diabetes, improving availability of
insulin and access to treatment, and increases in overall
population growth. Further, there are also indications of a
decrease in deaths from both unrecognized diabetic
ketoacidosis in children and from late complications in
young adults in some developed countries which could
lead to an additional increase in the prevalence of type 1
diabetes. At the same time, there is a growing awareness
DIABETES IN THE YOUNG CHAPTER 2 153

2.1
GLOBAL TRENDS IN CHILDHOOD TYPE 1 DIABETES
The incidence of type 1 diabetes in the young is increasing

in many countries in the world, and there is indication that
the incidence is rising more steeply in some of the low
prevalence countries. The rapidity of the changes and the
almost universally increasing trends in younger age groups
are unlikely to be due to changes in the genetic background
of the disease.
Introduction microvascular complications still face the prospect of

accelerated atherosclerosis.
T he incidence of childhood onset diabetes is increasing

in many countries in the world. There are clear
indications of geographic differences in trends but the
In addition, unsatisfactory metabolic control in children can
result in stunted growth and exposure to severe
overall annual increase is estimated at around 3%1-3. Some hypoglycaemia may affect neurodevelopment so that in
70,000 children worldwide are expected to develop type children who develop type 1 diabetes very early in age,
1 diabetes annually. There is some indication that structural brain abnormalities and impaired cognitive
incidence is increasing more steeply in some of the low function7,8 may occur making the everyday treatment
prevalence countries such as those in Central and Eastern specifically important. Therefore type 1 diabetes places a
Europe. Moreover, several European studies have particularly heavy burden on the individual, the family and
suggested that, in relative terms, increases are greatest in the health services.
young children4-6 .
Children are more sensitive to a lack of insulin than adults
The predominant cause of hyperglycaemia in type 1 diabetes and are at higher risk of a rapid and dramatic development
is an autoimmune destruction of the beta cells leading to of diabetic ketoacidosis. It has also been shown that in
absolute dependence on insulin treatment and a high rate developed countries there is still significant excess mortality
of complications typically occurring at relatively young ages from ketoacidosis9-12 among children with type 1 diabetes,
(see section on ‘What is Diabetes?’). and mortality in undiagnosed diabetes is probably a large
but hidden problem in the global perspective.
Although the cumulative incidence of diabetic nephropathy
(kidney disease) has fallen over the last decades in dedicated Increasing incidence among the young
centres, this trend is by no means universal. Recent
observations have shown, however, that those who survive Analyses of cumulative incidence rates into the fourth decade

Figure 2.1
Incidence rates of type 1 diabetes with onset in the age range 0-29 years in 1996-1997 for three European countries
Incidence rate per 100,000

60
50
40
30
20
10
0
Age groups 0 - 4 5-9 10 -14 15 -19 20 -24 24 -29
Italy - Sardinia Female Male

Sweden
Spain - Catalonia
Source: Green et al, 20013 and Kyvik et al, 200420
of life13,14 suggest that incidence is not increasing among autoimmune diabetes mellitus in adults (LADA)21, and in the
young adults indicating rather a shift to a younger age at new WHO classification, LADA falls within type 1 autoimmune
onset. The causes of these changes with time are unknown diabetes but in a slowly progressive form.
but the rapidity of the changes and the almost universally
increasing trends in younger age groups are unlikely to be The continued mapping of global trends in incidence of type
due to changes in the genetic background of the disease. 1 diabetes in all age groups is thus important, and in
conjunction with other scientific research may provide a
Historically studies have tended to record incidence data of logical basis for intervention studies and future primary
type 1 diabetes only up to the age of 15 years although prevention strategies which must be the ultimate goal. Two
recently studies reporting results up to the age of 30 or 35 international collaborative projects, the Diabetes Mondiale
years have become more common15-20. From these more study (DiaMond), and the Europe and Diabetes study
recent studies it would seem that the incidence in older age (EURODIAB), began in the 1980s and have been instrumental
groups is lower than that seen in the 0-14 year age range in monitoring trends in incidence through the establishment
confirming the incidence peak occurring around puberty. An of population-based registries using standardized definitions,
increased male to female sex ratio is also seen in these data collection forms and methods for validation.
studies (see Figure 2.1 and Table 2.1).
Methods
It is important to remember that the distinction between
type 1 and type 2 diabetes becomes more difficult in these Systematic searches of bibliographic databases were
older age groups since people with type 2 diabetes may performed as explained in Appendix 2 to identify studies
receive insulin therapy. Moreover, type 1 diabetes in an adult that provided incidence or prevalence rates of type 1
may masquerade as type 2 diabetes at presentation with a diabetes in children. Criteria were then applied to select the
slow deterioration in metabolic control, and subsequent most suitable study in a given country or, if necessary, results
progression to insulin dependency. This form is called latent from a number of studies were pooled.
GLOBAL TRENDS IN CHILDHOOD TYPE 1 DIABETES CHAPTER 2 155

Type 1 diabetes among children AT A GLANCE
Type 1 diabetes (0 – 14 years) 2007
Total child population (billion) 1.8

Number of children with type 1 diabetes 440,000
Type 1 diabetes prevalence (%) 0.02
Annual increase of incidence (%) 3.0
Estimated number of newly-diagnosed
cases per year 70,000
For countries that had no incidence or prevalence rates X Extrapolation using rates from a different country, the
available the choice of country to use for extrapolation was identity of the chosen country being indicated.
based on proximity, the state of economic development
measured by the gross domestic product (GDP) per capita Results
and the ethnic composition as assessed from the Central
Intelligence Agency (CIA) World Factbook 200222. The choice Tables 2.2 – 2.15 contain information on population size in
was also influenced by the quality rating of the studies in the the 0-14 age group together with incidence and estimated
various countries. numbers of prevalent cases in 2007, organized by IDF region.
In those countries for which rates were found in the literature
The majority of studies found by the literature search search the following information is given:
provided incidence rates rather than prevalence rates,
and the method used to translate incidence rates to • geographical coverage;
prevalence rates is described in Appendix 2. The quality • calendar period;
of estimates was assessed using the following simple • number of cases;
rating system: • estimated completeness of ascertainment; and
• a classification of the source as either A or B using the
A Studies from the country in question that were criteria described under ‘Methods’. Countries for which no
based on registers that were population based with rates were found in the literature search were assigned the
validated ascertainment levels of 90% or more. classification X, as described under ‘Methods’.
B Other studies from the country in question, Incidence and prevalence

provided population denominators were given to
enable rates to be calculated (so excluding case-series It is estimated that on an annual basis some 70,000 children
studies which provided no population denominator). aged 14 years and under develop type 1 diabetes worldwide.

Estimated number of prevalent cases of type 1 diabetes in children Top 10 countries: incidence rate for type 1 diabetes in children
by region (0-14 years)
Thousands Finland
120
Sweden
100 Norway
United Kingdom
80 Canada
Australia
60
Denmark
Germany
40
New Zealand
20 Puerto Rico
Incidence rate 0 5 10 15 20 25 30 35 40 45
0
per 100,000
AFR EMME EUR NA SACA SEA WP per year
Only countries where studies have been carried out in that country have been
included
Of the estimated total of approximately 440,000 prevalent mainly derived directly from prevalence rates rather than
cases of type 1 diabetes in childhood, more than a quarter indirectly from incidence rates the effects of mortality are
come from the South-East Asian (SEA) Region, and more incorporated in the estimates in Table 2.2. Tropical and
than a fifth from the European (EUR) Region, where reliable, malnutrition diabetes may account for a proportion of cases
up-to-date estimates of incidence were available for the in this region, but reliable data are lacking. For these reasons
majority of countries (see Figure 2.2). Only some 5% of the validity of the estimates of numbers of children with type
children with type 1 diabetes come from the Western Pacific 1 diabetes in many parts of this region are questionable and
(WP) Region, despite it having the largest childhood must therefore be treated with considerable caution.
population. Figure 2.3 shows the top 10 countries in
incidence rates for type 1 diabetes in children. Eastern Mediterranean and Middle East
In contrast to the situation in sub-Saharan Africa, reliable
Regions data are available for childhood type 1 diabetes rates in a
number of the African countries bordering the Mediterranean
Africa Sea. About half of the countries in the Eastern Mediterranean
The need for extrapolation of rates of childhood type 1 and Middle East (EMME) Region as a whole have published
diabetes was particularly evident in the sub-Saharan African incidence rates.
(AFR) Region. Published rates were found for only three of
the countries in this region, and some of the studies were of By far the largest contribution to the total number of
poor quality and based on small numbers. Consequently estimated childhood type 1 cases for this region comes from
imperfect estimates of rates from Nigeria, Zambia and Egypt whose estimate accounts for almost a quarter of the
Tanzania have had to be used for widespread extrapolations region’s total (see Table 2.4). In Egypt the incidence of type 1
because of the dearth of published studies. Mortality among diabetes is reported as 8 per 100,000 population per year for
children with diabetes is likely to be high in parts of this those aged 14 years and under, while in Pakistan it is less
region, but as numbers of cases in these countries were than 1 per 100,000 population.

Europe 2.13). The rate from China, although outside the region, was
Compared with other regions, the European (EUR) Region used for some extrapolations, but the rate for India was more
has by far the most complete and reliable data on the rates frequently used and it therefore plays a pivotal role in the
of childhood type 1 diabetes with a large proportion of estimates for this region.
countries having registries that are either nationwide or
cover several different parts of the country (see Table 2.7). Two sources of rates for India were available, both from urban
Where extrapolation for the incidence rate was necessary it Madras and therefore probably not representative of the
was usually for countries with small populations, and country as a whole. The first was a small prevalence study25
therefore any error associated with the extrapolation will giving an equivalent incidence rate which was less than half
have little impact on the estimate of the region’s total. that of the second, larger study26, the rate from the latter
study having needed correction for under-ascertainment.
The countries making the largest contribution to the total Given that even the lower of these two rates far exceeds the
rates for childhood type 1 diabetes were United Kingdom, rates reported from other countries in the area and that the
Germany and Russia reflecting to some degree the large incidence in urban Madras is likely to be higher than that for
childhood populations in these countries (see Table 2.6). It is India as a whole, the decision was made to use the lower of
worth noting that the estimates for Russia were based on a these two rates even though it was based on the smaller
study from Karelia in the north-west of the country which study.
may not be representative of such a large country although
very similar rates have also been reported in the northern The large childhood population in India and the widespread
region of Novosibirsk23. use of the Indian data for extrapolation in this region means
that this decision has important consequences not only for
North America the total in the region but also for the worldwide estimate,
Although no published rates were available for childhood both of which would be considerably larger had the higher
type 1 diabetes in many of the smaller Caribbean islands in estimate of incidence been used. Notwithstanding the use
the North American (NA) Region, it was usually possible to of the lower rate, the South-East Asian Region contributes
extrapolate rates from an island in close proximity, although more than any other to the worldwide childhood type 1
such rates were often based on very small numbers of cases. diabetes total (see Table 2.12).
The USA estimate, which accounts for more than three-
quarters of the region’s total, and to a lesser extent the Diabetes-associated mortality and tropical or malnutrition
estimate for Canada predominate (see Table 2.8). diabetes are also likely to play important roles in this region,
but unfortunately there is inadequate information to address
South and Central America these issues. These points reinforce the need for much more
Although the incidence of childhood type 1 diabetes in the detailed data on childhood diabetes in this region.
South and Central American (SACA) Region is generally low,
there are some sharp contrasts between the rates in Western Pacific
neighbouring countries (see Table 2.10). In this region a With the exception of Australia and New Zealand, the rates
strong inverse ecological correlation has been reported24 of childhood type 1 diabetes in the Western Pacific (WP)
between a country’s incidence rate and the proportion of its Region appear uniformly low (see Table 2.14). Few of the
population that is Amerindian (indigenous). This has Pacific islands had published data and the rate for Papua
influenced the selection of countries to use for extrapolation, New Guinea had to be extrapolated far into the Pacific
but the choice can still make a considerable difference to the Ocean, although any error induced in the region’s total by
resulting estimate. Such estimates must therefore be this extrapolation is likely to be small because of the generally
interpreted with caution. The Brazilian estimate accounts for low rates and small populations involved. The rate for
more than half of the region’s total. Thailand was used extensively for extrapolation in the
Indochina peninsula. Despite its very low incidence, China
South-East Asia accounts for almost half of the region’s total. However, the
Only two countries in the South-East Asian (SEA) Region Western Pacific Region makes the smallest contribution of all
have published rates for type 1 diabetes in childhood and to the world total of type 1 diabetes even though it has the
therefore extrapolation of rates was necessary (see Table largest childhood population.

Map 2.1
Incidence rates of type 1 diabetes in children - 0-14 years (cases per 100,000 population per year)
>20
16 - 20
12 - 16
8 - 12
4 - 8
<4
No data
Mortality in childhood indicates large area to area variations. This variability may
partly be due to different distributions of risk genes for the
Small numbers of deaths either before or at the time of disease as well as different distributions of environmental
diagnosis continue to occur in many countries, but exposures, but part of the apparent variability both between
ascertainment of such deaths may be incomplete so countries and regions may also be due to methodological
comparison between countries is difficult. A recent study of problems:
mortality among children diagnosed with type 1 diabetes from
10 European centres27 showed that there were 78 deaths during • The available incidence data sometimes covers only one
follow up, approximately twice as many as would have been small part of a large country. For example, in India incidence
expected from the national age/sex specific mortality rates in data were extrapolated from studies performed in Madras
the countries (see Table 2.16). However the standardized and data from Russia were extrapolated from a small dataset
mortality ratio (SMR), defined as the ratio of observed deaths to from Karelia. Obviously there may be considerable variability
expected deaths, varied from under 1 to 4.7 in the various within such large countries in both the distribution of risk
countries. Over a third of the deaths could be directly attributed genes and environmental exposures such as climate and
to diabetes, and these were mainly from metabolic disturbances, lifestyle-related factors28.
with very few deaths in this age range from cardiovascular or
renal complications. These results are in good accordance with • The need for extrapolation was evident in the African
several larger studies from single European centres. continent, particularly in sub-Saharan Africa. Here rates from
undesirably small datasets have had to be used in
Discussion extrapolations because of the lack of published studies.
Methodology • Another problem was the need to make extrapolations

involving isolated island populations such as in Polynesia
The global distribution of childhood type 1 diabetes clearly where both genetic predisposition and lifestyle habits may

IN TOUCH WITH: NZAMBA MULOPO AND IKULE BOLIA
These are the stories of two young lives touched by type 1

diabetes in Kinshasa, Democratic Republic of Congo.
The difference between them was not a problem of access to
insulin and treatment: the real difference was that Nzamba
has a loving mother, very poor but caring, and Ikule was
rejected, and in fact died from lack of love.
Nzamba Mulopo, 11, was diagnosed with type 1 diabetes

when he was six years old. That year he was admitted to
hospital after having fallen into a coma from ketoacidosis.
When he was admitted he weighed only 14 kg and was 105
cm tall.
A very lively and happy boy, Nzamba does the best he can
to manage his diabetes. The health centre not far from his
home has done everything to help mother and child.
be very different. The danger inherent in such extrapolations for mortality was not necessary. In such countries the relationship
is clear from recent publications of island populations that between incidence rate and prevalence rate is difficult to
have very different rates compared with their mainland predict, and consequently incidence rates are not available from
neighbours: Crete has a lower rate than mainland Greece29, sub-Saharan Africa other than Tanzania (see Table 2.2).
Newfoundland has a higher rate than other parts of Canada30
and Sardinia has a higher rate than peninsular Italy31. Time trends
• For some extrapolations a choice had to be made between In addition to the geographical variation in the incidence of
countries whose reported incidence rates were very different, childhood type 1 diabetes there are also well-documented
possibly on occasions because they were based on small secular trends over time, which may also differ from country
datasets. to country and from region to region within a country. Such
time trends have not explicitly been incorporated in these
• Another methodological problem is the lack of data on estimates since reliable data are available for only a very
mortality rates among children with diabetes in most small number of countries, but these trends are of
populations. In less developed countries, in which mortality considerable importance for healthcare planning. Only a few
could have a significant impact, the disease rates were often studies looked at time trends for the age group over 15 years
based on small numbers of cases or on extrapolation so that and the trend so far is not clearly an increase and cumulative
the application of an adjustment to incidence data to allow rates from 0 to 3413-15,19 have not shown an increase so far,
for mortality was not justified. indicating rather a shift to younger ages.
In sub-Saharan Africa, where mortality among children with Potential risk factors
diabetes are reported to be high32,33, numbers of cases were
mainly derived from Nigerian and Zambian prevalence rates The causes of the changes over time are unknown and although
rather than indirectly from incidence rates so that adjustment migration might slowly change the genetic background within

A special programme provides Nzumba with insulin and Ikule’s father had died a few years before, he lived in his
other supplies totally free of charge. He is now able to inject uncle’s house, while his mother lived in her village.
insulin three times a day without help from his mother.
However, it is difficult for Nzamba to have regular meals Ikule was a very quiet and sad boy. He was rejected by the
according to the schedules of insulin injections. His family and accused to be a sorcerer, an easy way to get
mother is sometimes too busy fending for the whole rid of a person. He was allowed to live in a small corner of
family’s survival to be able to provide regular meals. the house, and was not cared for. Food was very irregular
although his uncle was well fed and could afford the care.
Another major concern is his blood glucose control, which Ikule was a regular customer of a health centre, which, in a
is not very good, but it is not from lack of trying. Nzamba certain way, was his home. Insulin was given free as well as
does urine testing, but for blood glucose he has to go the treatment and tests for blood glucose. However, it was
either to the health centre or to a clinic for children. The not possible to inject enough insulin due to the irregular food
health centre programme does not have the resources to supply. Many other patients helped him with food or money.
provide patients with personal blood glucose meters or
strips for frequent testing. His blood glucose level remained between 250 and 400 mg/dl
most of the time. Ketoacidosis occurred from time to time.
Ikule Bolia was diagnosed with type 1 diabetes when he Between 1997 and 2003 when he died his weight stayed at 30
presented with the classical signs of diabetes — frequent kg. In 2002 he was diagnosed with pulmonary tuberculosis.
urination accompanied by excessive thirst — at the age of Together with diabetes this was to cause his death. He did not
14 years. He was 149 cm tall and weighed only 30 kg. As die of lack of insulin but lack of care and love.
a population, the rapid changes in incidence rate reported to an increased height, weight, weight for height and body
occur within comparatively short time spans are more likely to mass index (BMI) have repeatedly been shown to be risk
be due to changes in environmental risk factors. These factors for childhood onset diabetes 39-43 . Although
environmental risk factors may initiate autoimmunity or autoimmune mechanisms are responsible for the beta cell
accelerate and precipitate an already ongoing beta cell destruction leading to type 1 diabetes, overload factors may
destruction28, and are discussed in more detail in the section on accelerate this process44-46.
‘What is Diabetes?’. Briefly, these risk factors include:
Early events
Potential risk factors, such as early fetal events34, viral infections
during pregnancy35,36 , and early exposure to cow’s milk
components and other nutritional factors37 may initiate the
autoimmune process.
Lifestyle
Since type 1 diabetes in childhood is associated with
estimates of general wealth such as GDP 38 it has been
suggested that lifestyle habits related to welfare might be
responsible for the changes in trend. Wealth is a well-
known determinant of birth weight and childhood
growth.
Weight and growth

Different estimates of child growth such as high birth weight,

Table 2.1
Incidence rates of type 1 diabetes with onset in the age range 0-29 years in 1996-1997 for eight European countries
BELGIUM ITALY LITHUANIA ROMANIA

Antwerp Sardinia Whole nation Bucharest
Age 0-4 M Cases 6 30 13 3

Population 56,217 76,738 221,212 90,118
Rate 10.7 39.1 5.9 3.3
F Cases 5 15 14 2
Population 53,700 71,147 210,441 85,070
Rate 9.3 21.1 6.7 2.4

Age 5-9 M Cases 4 40 13 8
Population 56,331 89,523 289,484 162,968
Rate 7.1 44.7 4.5 4.9
F Cases 4 36 29 9
Population 54,343 84,418 276,717 154,996
Rate 7.4 42.6 10.5 5.8

Age 10-14 M Cases 8 54 37 10
Population 55,132 100,176 289,460 164,148
Rate 14.5 53.9 12.8 6.1
F Cases 9 40 36 11
Population 52,491 94,320 278,996 157,520
Rate 17.1 42.4 12.9 7.0

Age 15-19 M Cases 2 27 22 10
Population 54,912 132,228 266,393 198,462
Rate 3.6 20.4 8.3 5.0
F Cases 6 15 22 10
Population 52,860 126,304 257,848 189,204
Rate 11.4 11.9 8.5 5.3

Age 20-24 M Cases 6 23 20 10
Population 55,357 147,940 270,050 174,890
Rate 10.8 15.6 7.3 5.7
F Cases 5 13 12 8
Population 54,646 142,850 568,420 183,266
Rate 9.2 9.1 4.5 4.4

Age 25-29 M Cases 9 21 39 25
Population 67,298 142,134 289,658 198,906
Rate 13.4 14.7 13.5 12.6
F Cases 5 5 17 14
Population 65,205 140,826 274,912 217,588
Rate 7.7 3.6 6.2 6.4

Source: Green et al, 20013 and Kyvik et al, 200420

SPAIN UNITED KINGDOM UNITED KINGDOM SWEDEN SLOVAKIA
Catalonia Leicestershire West Yorkshire Whole nation Whole nation
31 5 32 130 34
274,557 64,190 242,127 547,816 336,840
11.3 7.8 13.2 23.7 10.1
25 8 31 135 16
263,120 60,930 230,864 522,206 321,105
9.5 13.1 13.4 25.9 5.0

35 12 40 199 52
286,845 65,360 259,279 623,091 400,974
12.2 18.4 15.4 31.9 13.0
44 15 55 204 44
274,515 61,300 248,317 589,826 383,414
16.0 24.5 22.1 34.6 11.5

58 15 64 232 59
339,875 62,090 246,602 530,995 445,100
17.1 24.2 26.0 43.7 13.3
45 11 53 179 33
326,575 58,060 233,500 501,943 426,343
13.8 18.9 22.7 35.7 7.7

60 7 17 82 31
469,466 58,200 138,793 517,570 477,822
12.8 12.0 12.3 15.8 6.5
37 3 13 46 28
451,474 56,766 129,020 429,652 464,422
8.2 5.3 10.1 9.3 6.0

76 6 16 79 27
518,716 65,512 145,760 583,936 459,071
14.7 9.2 11.0 13.5 5.9
42 9 9 41 14
502,088 66,112 139,750 561,884 430,154
8.8 13.6 6.4 7.3 3.3

64 16 34 77 19
489,730 66,170 166,989 628,080 381,718
13.0 24.2 20.4 12.3 5.0
37 10 13 40 7
477,504 68,650 159,238 601,842 362,530
7.8 14.6 8.2 6.7 1.9

Table 2.2
Estimates of type 1 diabetes in children - African Region
COUNTRY/TERRITORY POPULATION SIZEa INCIDENCE RATESb PREVALENT CASES

(000’s) (cases per 100,000 population per year) (000’s)
0-14 yrs 0-4 yrs 5-9 yrs 10-14 yrs Total
Angola 7,787 0.4

Benin 3,921 0.7
Botswana 648 0.0
Burkina Faso 6,578 1.2
Burundi 3,608 0.2
Cameroon 6,818 1.2
Cape Verde 204 0.0
Central African Republic 1,768 0.3
Chad 4,878 0.9
Comoros 349 0.0
Congo 2,009 0.1
Congo, Democratic Republic of 29,025 1.4
Côte d’Ivoire 7,727 1.4
Djibouti 334 0.2
Equatorial Guinea 235 0.0
Eritrea 2,095 0.1
Ethiopia 35,674 2.0
Gabon 558 0.1
Gambia 632 0.1
Ghana 8,773 1.6
Guinea 4,259 0.8
Guinea-Bissau 803 0.1
Kenya 15,410 0.9
Lesotho 676 0.0
Liberia 1,634 0.3
Madagascar 8,540 0.7
Malawi 6,354 0.3
Mali 6,891 1.2
Mauritania 1,395 0.3
Mozambique 8,959 0.5
Namibia 828 0.0
Niger 7,309 1.3
Nigeria 60,024 10.8
Réunion 216 0.0
Rwanda 4,040 0.2
Sao Tome and Principe 64 0.0
Senegal 5,109 0.9
Seychellesc 21 0.0
Sierra Leone 2,490 0.4
Somalia 3,883 0.2
South Africad 15,359 5.0
Swaziland 408 0.0
Tanzania, United Republic of 16,654 0.1 0.5 2.2 0.9 0.5
Togo 2,779 0.5
Uganda 15,639 0.9
Western Sahara 123 0.1
Zambia 5,477 0.3
Zimbabwe 5,130 0.3

AFR Total 324,099 • • • • 38.8
a. UN population projections for 2007 - medium variant 2004

b. Likely high mortality rate and shortage of good-quality incidence studies makes it problematic to derive incidence from prevalence in these countries
c. Population estimates extracted from CIA World Factbook 2005
d. Adjusted to take account of the higher rates in those of European origin

Table 2.3
Data sources: estimates of type 1 diabetes in children - African Region

COUNTRY/TERRITORY DATA USED PERIOD

Angola Zambia (Rolfe et al, 1989)47
Benin Nigeria (Afoke et al, 1992)48
Botswana Zambia (Rolfe et al, 1989)47
Burkina Faso Nigeria (Afoke et al, 1992)48
Burundi Tanzania (Swai et al, 1993)49
Cameroon Nigeria (Afoke et al, 1992)48
Cape Verde Nigeria (Afoke et al, 1992)48
Central African Republic Nigeria (Afoke et al, 1992)48
Chad Nigeria (Afoke et al, 1992)48
Comoros Tanzania (Swai et al, 1993)49
Congo Zambia (Rolfe et al, 1989)47
Congo, Democratic Republic of Zambia (Rolfe et al, 1989)47
Côte d’Ivoire Nigeria (Afoke et al, 1992)48
Djibouti Sudan (Elamin et al, 1997)50
Equatorial Guinea Nigeria (Afoke et al, 1992)48
Eritrea Tanzania (Swai et al, 1993)49
Ethiopia Tanzania (Swai et al, 1993)49
Gabon Nigeria (Afoke et al, 1992)48
Gambia Nigeria (Afoke et al, 1992)48
Ghana Nigeria (Afoke et al, 1992)48
Guinea Nigeria (Afoke et al, 1992)48
Guinea-Bissau Nigeria (Afoke et al, 1992)48
Kenya Tanzania (Swai et al, 1993)49
Lesotho Zambia (Rolfe et al, 1989)47
Liberia Nigeria (Afoke et al, 1992)48
Madagascar Mauritius (Karvonen et al, 2000)51
Malawi Zambia (Rolfe et al, 1989)47
Mali Nigeria (Afoke et al, 1992)48
Mauritania Nigeria (Afoke et al, 1992)48
Mozambique Tanzania (Swai et al, 1993)49
Namibia Zambia (Rolfe et al, 1989)47
Niger Nigeria (Afoke et al, 1992)48
Nigeria Nigeria (Afoke et al, 1992)48 1990
Réunion Mauritius (Karvonen et al, 2000)51
Rwanda Tanzania (Swai et al, 1993)49
Sao Tome and Principe Nigeria (Afoke et al, 1992)48
Senegal Nigeria (Afoke et al, 1992)48
Seychelles Mauritius (Karvonen et al, 2000)51
Sierra Leone Nigeria (Afoke et al, 1992)48
Somalia Tanzania (Swai et al, 1993)49
South Africa Zambia (Rolfe et al, 1989)47 & UK (EURODIAB, 2006)52
Swaziland Zambia (Rolfe et al, 1989)47
Tanzania, United Republic of Tanzania (Swai et al, 1993)49 1982-1991
Togo Nigeria (Afoke et al, 1992)48
Uganda Tanzania (Swai et al, 1993)49
Western Sahara Algeria (DIAMOND, 2006)53
Zambia Zambia (Rolfe et al, 1989)47 pre-1989
Zimbabwe Zambia (Rolfe et al, 1989)47
A Studies from the country in question that were based on population-based registers with validated ascertainment levels of 90% or more.
B Other studies from the country in question, provided population denominators were given to enable rates to be calculated (excludes case-series studies which
provided no population denominator).
X Extrapolation using rates from a different country.
N/A Not available

GEOGRAPHY NO. OF CASES COMPLETENESS CLASSIFICATION

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Anambra 14 N/A B
X
X
X
X
X
X
X
X
X
Dar es Salaam 36 100% A
X
X
X
Copperbelt 37 90% B
X

Table 2.4
Estimates of type 1 diabetes in children - Eastern Mediterranean and Middle East Region
COUNTRY/TERRITORY POPULATION SIZEa INCIDENCE RATES PREVALENT CASES


Algeria 9,584 3.9 9.0 13.1 8.6 4.8
Armenia 576 8.1 0.3
Bahrain 196 2.5 0.0
Egypt 25,402 8.0 12.6
Iran, Islamic Republic of 19,085 2.3 3.6 5.2 3.7 4.5
Iraq 12,187 3.7 2.8
Jordan 2,168 1.3 3.2 5.5 3.2 0.4
Kuwait 685 12.3 26.3 28.4 22.3 0.9
Lebanon 1,014 3.2 0.2
Libyan Arab Jamahiriya 1,807 2.6 7.3 17.1 9.0 0.7
Morocco 9,852 8.6 5.3
Oman 895 1.3 2.6 4.0 2.5 0.1
Pakistan 61,196 0.3 0.4 0.8 0.5 1.6
Qatar 186 11.4 0.1
Saudi Arabia 9,352 5.7 8.5 24.2 12.3 5.9
Sudan 14,608 10.1 9.1
Tunisia 2,539 4.2 5.9 11.8 7.3 1.1
Yemen 10,194 2.5 1.6

EMME Total 206,454 • • • • 55.1

Table 2.5
Data sources: estimates of type 1 diabetes in children - Eastern Mediterranean and Middle East Region

Afghanistan Uzbekistan (Rakhimova et al, 2002)54
Algeria Algeria (DIAMOND, 2006)53 1990-1999
Armenia Ukraine (Timchenko et al, 1996)55
Bahrain Oman (Soliman et al, 1996)56
Egypt Egypt (Arab, 1992)57 pre-1992
Iran, Islamic Republic of Iran (Pishdad, 2005)58 1991-1996
Iraq Iran (Pishdad, 2005)58
Jordan Jordan (Ajlouni et al, 1999)59 1992-1996
Kuwait Kuwait (DIAMOND, 2006)53 1992-1999
Lebanon Jordan (Ajlouni et al, 1999)59
Libyan Arab Jamahiriya Libya (Kadiki et al, 2002)60 1991-2000
Morocco Algeria (DIAMOND, 2006)53
Occupied Palestinian Territory Jordan (Ajlouni et al, 1999)59
Oman Oman (Soliman et al, 1996)56 1993-1994
Pakistan Pakistan (DIAMOND, 2006)53 1990-1999
Qatar Qatar (Al-Zyoud et al, 1997)61 1992-1996
Saudi Arabia Saudi Arabia (Kulaylat et al, 2000)62 1986-1997
Sudan Sudan (Elamin et al, 1997)50 1991-1995
Syrian Arab Republic Jordan (Ajlouni et al, 1999)59
Tunisia Tunisia (DIAMOND, 2006)53 1990-1999
United Arab Emirates Oman (Soliman et al, 1996)56
Yemen Oman (Soliman et al, 1996)56

N/A not available

X
Oran 223 N/A B
X
X
Alexandria, Damahour N/A N/A B
Fars 298 100% A
X
Whole country 275 96% A
Whole country 531 79-96% B
X
Benghazi 276 100% A
X
X
Karachi 104 51% B
Whole country 80 N/A B
Eastern Province 46 100% A
Khartoum 534 97% A
X
Beja, Gafsa, Kairoan, Monastir 297 N/A B
X
X

Table 2.6
Estimates of type 1 diabetes in children - European Region

Albania 816 • • • 3.9 0.2

Andorrab 10 • • • 12.9 0.0
Austria 1,225 11.1 14.6 14.4 13.3 1.2
Azerbaijan 2,043 • • • 1.2 0.2
Belarus 1,390 • • • 5.6 0.5
Belgium 1,722 10.9 18.3 16.8 15.3 1.9
Bosnia and Herzegovina 622 0.6 4.7 5.2 3.5 0.1
Bulgaria 1,013 5.9 9.6 12.7 9.4 0.6
Channel Islands 24 • • • 22.5 0.0
Croatia 685 2.6 8.2 8.5 6.4 0.3
Cyprus 161 • • • 14.8 0.1
Czech Republic 1,431 13.2 18.2 18.7 16.7 1.7
Denmark 1,014 • • • 19.4 1.2
Estonia 194 14.5 19.4 11.9 14.9 0.2
Finland 887 • • • 41.4 2.3
France 11,022 4.6 8.8 11.6 8.3 5.5
Georgia 784 • • • 4.6 0.2
Germany 11,487 13.3 19.3 21.4 18.0 14.6
Greece 1,574 12.9 7.3 9.6 10.4 1.3
Hungary 1,526 7.9 12.1 13.9 11.3 1.2
Iceland 64 • • • 14.7 0.1
Ireland 858 10.9 21.3 16.9 16.3 0.9
Israel 1,922 4.3 10.5 13.2 9.3 1.0
Italy 8,089 6.7 9.8 9.0 8.4 4.9
Kazakhstan 3,273 • • • 1.2 0.2
Kyrgyzstan 1,630 • • • 1.2 0.1
Latvia 317 5.0 8.2 9.2 7.5 0.2
Liechtensteinb 6 • • • 9.2 0.0
Lithuania 528 4.3 8.1 10.9 7.8 0.3
Luxembourg 89 10.0 16.0 16.7 14.2 0.1
Macedonia, the Former Yugoslav Republic of 380 1.4 5.7 4.8 3.9 0.1
Malta 68 11.1 16.4 18.9 15.6 0.1
Moldova 713 • • • 4.7 0.2
Monacob 5 • • • 8.3 0.0
Netherlands 2,938 12.9 19.3 24.2 18.6 3.6
Norway 894 17.1 30.6 36.0 27.9 1.6
Poland 5,974 8.1 14.4 16.6 13.0 5.3
Portugal 1,673 13.1 11.2 15.4 13.2 1.6
Romania 3,223 • • • 4.7 0.9
Russian Federation 21,293 • • • 7.4 9.8
San Marinob 5 • • • 8.4 0.0
Serbia and Montenegroc 1,869 • • • 10.7 1.2
Slovakia 853 10.8 13.4 16.5 13.5 0.8
Slovenia 267 6.7 11.7 13.8 10.7 0.2
Spain 6,342 6.7 14.1 18.0 12.9 4.7
Sweden 1,536 22.8 34.6 37.8 31.7 3.4
Switzerland 1,157 6.5 8.4 12.0 9.2 0.7
Tajikistan 2,507 • • • 1.2 0.2
Turkey 21,480 • • • 3.2 4.3
Turkmenistan 1,494 • • • 1.2 0.1
Ukraine 6,388 • • • 8.1 3.2
United Kingdom 10,491 15.4 23.0 29.3 22.5 15.7
Uzbekistan 8,642 • • • 1.2 0.6

EUR Total 156,599 • • • • 99.7
a. UN population projections for 2007 - medium variant 2004 b. Population estimates extracted from CIA World Factbook 2005 c. Estimates made prior to
establishment of Serbia and Montenegro as independent countries

Table 2.7
Data sources: estimates of type 1 diabetes in children - European Region

Albania Macedonia (Green et al, 2001)3
Andorra Spain (EURODIAB, 2006)52
Austria Austria (EURODIAB, 2006)52 1999-2003
Azerbaijan Uzbekistan (Rakhimova et al, 2002)54
Belarus Belarus (Zalutskaya et al, 2004)63 1997-2002
Belgium Belgium (EURODIAB, 2006)52 1999-2003
Bosnia and Herzegovina Bosnia and Herzegovina (Bratina et al, 2001)64 1990-1998
Bulgaria Bulgaria (DIAMOND, 2006)52 1990-1999
Channel Islands United Kingdom (EURODIAB, 2006)52
Croatia Croatia (Green et al, 2001)3 1994-1998
Cyprus Cyprus (Bacopoulou et al, 2005)65 2000-2004
Czech Republic Czech Republic (EURODIAB, 2006)52 1999-2003
Denmark Denmark (Svensson et al, 2002)66 1996-2000
Estonia Estonia (Tillman et al, 2004)67 1999-2003
Finland Finland (Kondrashova et al, 2005)68 1990-1999
France France (EURODIAB ACE, 2000)2 1989-1994
Georgia Georgia (Amirkhanashvili et al, 2000)69 1998-1999
Germany Germany (EURODIAB, 2006)52 1999-2003
Greece Greece (EURODIAB, 2006)52 1995-1999
Hungary Hungary (EURODIAB, 2006)52 1999-2003
Iceland Iceland (EURODIAB, 2006)52 1994-1998
Ireland Ireland (Roche et al, 2002)70 1997
Israel Israel (Israel IDDM Registry Study Group, 2002)71 1998
Italy Italy (Carle et al, 2004)31 1990-1999
Kazakhstan Uzbekistan (Rakhimova et al, 2002)54
Kyrgyzstan Uzbekistan (Rakhimova et al, 2002)54
Latvia Latvia (Green et al, 2001)3 1994-1998
Lithuania Lithuania (EURODIAB, 2006)52 1999-2003
Liechtenstein Switzerland (Schoenle et al, 2001)78
Luxembourg Luxembourg (EURODIAB, 2006)52 1997-2001
Macedonia, the Former Yugoslav Republic of Macedonia (Green et al, 2001)3 1994-1998
Malta Malta (Schranz, 1998)72 1990-1996
Moldova Romania (Serban et al, 2005)73
Monaco France (EURODIAB ACE, 2000)2
Netherlands Netherlands (van Wouwe et al, 2002)74 1996-1999
Norway Norway (Joner et al, 2005)75 1999-2003
Poland Poland (EURODIAB, 2006)52 1999-2003
Portugal Portugal (Green et al, 2001)3 1994-1998
Romania Romania (Serban et al, 2005)73 1995-2004
Russian Federation Russia (Kondrashova et al, 2005)68 1990-1999
San Marino Italy (Carle et al, 2004)31
Serbia and Montenegro Serbia and Montenegro (Mira et al, 2004)76 1993-2002
Slovakia Slovakia (EURODIAB, 2006)52 1999-2002
Slovenia Slovenia (EURODIAB, 2006)52 1999-2003
Spain Spain (EURODIAB, 2006)52 1999-2003
Sweden Sweden (Pundziute-Lycka et al, 2004)77 1992-2000
Switzerland Switzerland (Schoenle et al, 2001)78 1991-1999
Tajikistan Uzbekistan (Rakhimova et al, 2002)54
Turkey Jordan (Ajlouni et al, 1999)59
Turkmenistan Uzbekistan (Rakhimova et al, 2002)54
Ukraine Ukraine (Timchenko et al, 1996)55 1985-1992
United Kingdom United Kingdom (EURODIAB, 2006)52 1999-2003
Uzbekistan Uzbekistan (Rakhimova et al, 2002)54 2000
A Studies from the country in question that were based on population-based registers with validated ascertainment levels of 90% or more. B Other studies from the country

in question, provided population denominators were given to enable rates to be calculated (excludes case-series studies which provided no population denominator).
X Extrapolation using rates from a different country. N/A not available

x
X
X
Gomel, Minsk approx 375 100% A
Antwerp 124 54% B
Tuzla 43 100% A
Varma, West Bulgaria 924 99-100% A
X
Zagreb 69 100% A
Greek population approx 110 N/A B
Whole country 1,419 99% A
Whole country approx 3,800 100% A
Four regions 837 99% A
Dusseldorf, Baden-Württemberg, Westphalia 4,570 95-100% A
Attica 279 100% A
18 counties 737 79% B
Whole country approx 150 100% A
Eight peninsular centres 2,515 96-99% A
X
X
X
X
X
Whole country 1,264 N/A B
Whole country 1,260 100% A
Gliwice 548 N/A B
Algarve, Madeira 74 85-100% A/B
Whole country N/A N/A B
Karelia 133 100% A
X
Montenegro 166 N/A B
Catalonia 571 99% A
Whole country approx 4,000 96% A
X
X
X
Leeds, Oxford, N Ireland 1,847 99% A

Table 2.8
Estimates of type 1 diabetes in children - North American Region

0-14 yrs 0-4 yrs 5-9 yrs Total 10-14 yrs
Anguillab 3 3.5 0.0

Antigua and Barbudab 19 3.5 0.0
Arubab 14 0.1 0.0
Bahamas 91 10.1 0.1
Barbados 50 2.0 0.0
Belize 100 1.5 0.0
Bermudab 12 2.3 0.0
British Virgin Islandsb 5 3.5 0.0
Canada 5,557 14.7 24.0 26.3 21.7 8.4
Cayman Islandsb 9 2.3 0.0
Dominicab 18 5.7 0.0
Grenadab 30 2.0 0.0
Guyana 216 0.1 0.0
Haiti 3,235 16.8 3.4
Jamaica 808 2.3 0.1
Mexico 32,621 0.5 2.0 1.1 1.5 2.7
Saint Kitts and Nevisb 11 3.5 0.0
Saint Vincent and the Grenadines 34 2.0 0.0
United States of America 62,136 9.5 16.9 22.0 16.1 62.6

NA Total 105,453 • • • • 77.3

b. Population estimates extracted from CIA World Factbook 2005

Table 2.9
Data sources: estimates of type 1 diabetes in children - North American Region


Anguilla Antigua and Barbuda (Tull et al, 1997)a, 79
Antigua and Barbuda Antigua and Barbuda (Tull et al, 1997)a, 79 1989-1993
Aruba Venezuela (Karvonen et al, 2000)51
Bahamas Bahamas (Peter et al, 2005)80 2001-2002
Barbados Barbados (Karvonen et al, 2000)51 1990-1993
Belize Mexico (Karvonen et al, 2000)51
Bermuda Cuba (DIAMOND, 2006)53
British Virgin Islands Antigua and Barbuda (Tull et al, 1997) a, 79
Canada Canada (DIAMOND, 2006)53 1990-1999
Cayman Islands Cuba (DIAMOND, 2006)53
Dominica Dominica (Karvonen et al, 2000)51 1990-1993
Grenada Barbados (Karvonen et al, 2000)51
Guadeloupe Dominica (Karvonen et al, 2000)51
Guyana Venezuela (Karvonen et al, 2000)51
Haiti Puerto Rico (DIAMOND, 2006)53
Jamaica Cuba (DIAMOND, 2006)53
Martinique Barbados (Karvonen et al, 2000)51
Mexico Mexico (Karvonen et al, 2000)51 1990-1993
Saint Kitts and Nevis Antigua and Barbuda (Tull et al, 1997) a, 79
Saint Lucia Barbados (Karvonen et al, 2000)51
Saint Vincent and the Grenadines Barbados (Karvonen et al, 2000)51
Trinidad and Tobago Barbados (Karvonen et al, 2000)51
United States of America USA (DIAMOND, 2006)53 1990-1999
US Virgin Islands US Virgin Islands (DIAMOND, 2006)53 1990-1996
B Other studies from the country in question, provided population denominators were given to enable rates to be calculated (excludes case-series studies
which provided no population denominator).
X Extrapolation using rates from a different country

a. Relates to 0 -19 years age range
N/A Not available


X
Antigua 4 100% A
X
X
X
X
Edmonton, Calgary, Prince Edward Island 636 75-100% A/B
X
X
X
X
X
X
X
Veracruz 9 100% B
X
X
X
X
Allegheny, Chicago, Jefferson 1,185 51-100% A/B

Table 2.10
Estimates of type 1 diabetes in children - South and Central American Region

Argentina 10,211 3.3 9.1 7.9 6.8 4.4

Bolivia 3,545 0.5 0.1
Brazil 52,451 4.9 8.4 9.8 7.7 25.4
Chile 3,947 5.9 1.4
Colombia 14,144 0.9 1.4 1.6 1.3 1.2
Costa Rica 1,215 1.3 0.1
Cuba 2,080 1.1 2.7 3.2 2.3 0.3
Dominican Republic 2,925 0.5 0.5 0.5 0.5 0.1
Ecuador 4,295 1.3 0.3
El Salvador 2,363 1.5 0.
French Guiana 65 0.1 0.
Guatemala 5,643 1.5 0.5
Honduras 2,863 1.5 0.3
Nicaragua 2,156 1.5 0.2
Panama 997 1.3 0.1
Paraguay 2,372 0.6 0.9 1.3 0.9 0.1
Peru 8,999 0.3 0.5 0.8 0.5 0.3
Puerto Rico 865 16.8 0.9
Uruguay 840 1.0 9.2 14.6 8.3 0.4
Venezuela 8,413 0.1 0.2 0.1 0.1 0.1

SACA Total 130,563 • • • • 36.5

Table 2.11
Data sources: estimates of type 1 diabetes in children - South and Central American Region


Argentina Argentina (DIAMOND, 2006)53 1990-1999
Bolivia Peru (DIAMOND, 2006)53
Brazil Brazil (DIAMOND, 2006)53 1990-1999
Chile Chile (Carrasco et al, 2006)81 1999-2003
Colombia Colombia (DIAMOND, 2006)53 1990-1999
Costa Rica Colombia (DIAMOND, 2006)53
Cuba Cuba (DIAMOND, 2006)53 1990-1999
Dominican Republic Dominican Republic (DIAMOND, 2006)53 1995-1999
Ecuador Colombia (DIAMOND, 2006)53
El Salvador Mexico (Karvonen et al, 2000)51
French Guiana Venezuela (Karvonen et al, 2000)51
Guatemala Mexico (Karvonen et al, 2000)51
Honduras Mexico (Karvonen et al, 2000)51
Netherlands Antilles Venezuela (Karvonen et al, 2000)51
Nicaragua Mexico (Karvonen et al, 2000)51
Panama Colombia (DIAMOND, 2006)53
Paraguay Paraguay (DIAMOND, 2006)53 1990-1999
Peru Peru (DIAMOND, 2006)53 1990-1994
Puerto Rico Puerto Rico (DIAMOND, 2006)53 1990-1999
Suriname Venezuela (Karvonen et al, 2000)51
Uruguay Uruguay (Karvonen et al, 2000)51 1992
Venezuela Venezuela (Karvonen et al, 2000)51 1992

N/A Not available


Avellaneda, Cordoba, Corrientes, Tierra del Fuego 141 88-100% A/B
X
Sao Paulo, Passo Fundo 47 70-100% A/B
Santiago approx 440 100% A
Cali, Santafé de Bogotá 76 N/A, 97% A/B
X
X
X
X
X
X
X
X
X
Lima 53 35-100% B
Whole country 1,625 90-97% A
X
Montevideo 26 97% A
Caracas 43 N/A B

Table 2.12
Estimates of type 1 diabetes in children - South-East Asian Region

Bangladesh 50,790 4.2 13.2

Bhutan 844 0.6 0.0
India 354,299 4.2 92.3
Maldives 137 4.2 0.0
Mauritius 302 0.8 0.9 2.4 1.4 0.0
Nepal 10,720 0.6 0.4
Sri Lanka 4,926 4.2 1.3

SEA Total 422,018 • • • • 107.3
Table 2.13
Data sources: estimates of type 1 diabetes in children - South-East Asian Region

Bangladesh India (Ramachandran et al, 1992)82
Bhutan China (DIAMOND, 2006)53
India India (Ramachandran et al, 1992)82 1991
Maldives India (Ramachandran et al, 1992)82
Mauritius Mauritius (Karvonen et al, 2000)51 1990-1994
Nepal China (DIAMOND, 2006)53
Sri Lanka India (Ramachandran et al, 1992)82

N/A not available

X
X
Madras 30 N/A B
X
X
X

Table 2.14
Estimates of type 1 diabetes in children - Western Pacific Region

Australia 3,914 13.7 20.1 28.7 20.9 5.2

Cambodia 5,270 0.3 0.1
China 272,242 0.3 0.6 0.9 0.6 9.3
China, Hong Kong 999 2.0 0.1
China, Macao 67 2.0 0.0
Cook Islandsb 8 0.1 0.0
Fiji 266 0.1 0.0
Guam 52 0.1 0.0
Indonesia 63,136 0.3 1.2
Japan 17,819 1.2 1.4 2.7 1.7 1.9
Kiribatib 39 0.1 0.0
Korea, Republic of 8,426 0.6 0.9 2.0 1.1 0.6
Malaysia 8,226 0.3 0.2
Marshall Islandsb 23 0.1 0.0
Micronesia, Federated States of 44 0.1 0.0
Mongolia 792 0.6 0.0
Myanmar 14,418 0.3 0.3
Naurub 5 0.1 0.0
New Zealand 850 11.5 19.4 23.3 18.0 1.0
Niueb 1 0.1 0.0
Palaub 5 0.1 0.0
Samoa 75 0.1 0.0
Singapore 799 2.4 1.6 3.3 2.5 0.1
Taiwanb 4,506 2.0 0.6
Thailand 15,118 0.3 0.3
Tokelaub 1 0.1 0.0
Tonga 36 0.1 0.0
Tuvalub 4 0.1 0.0
Vanuatu 86 0.1 0.0
Viet Nam 24,258 0.3 0.5

WP Total 481,957 • • • • 22.8

b. Population estimates extracted from CIA World Factbook 2005

Table 2.15
Data sources: estimates of type 1 diabetes in children - Western Pacific Region


Australia Australia (Taplin et al, 2005)83 1997-2002
Brunei Darussalam Thailand (Tuchinda et al, 2002)84
Cambodia Thailand (Tuchinda et al, 2002)84
China China (DIAMOND, 2006)53 1990-1996
China, Hong Kong Hong Kong (Huen et al, 2000)85 1992-1996
China, Macao Hong Kong (Huen et al, 2000)85
Cook Islands Papua New Guinea (Ogle et al, 2001)86
Fiji Papua New Guinea (Ogle et al, 2001)86
French Polynesia Papua New Guinea (Ogle et al, 2001)86
Guam Papua New Guinea (Ogle et al, 2001)86
Indonesia Thailand (Tuchinda et al, 2002)84
Japan Japan (Karvonen et al, 2000)51 1990-1993
Kiribati Papua New Guinea (Ogle et al, 2001)86
Korea, Democratic People’s Republic of Republic of Korea (Karvonen et al, 2000)51
Korea, Republic of Republic of Korea (Karvonen et al, 2000)51 1990-1991
Lao People’s Democratic Republic Thailand (Tuchinda et al, 2002)84
Malaysia Thailand (Tuchinda et al, 2002)84
Marshall Islands Papua New Guinea (Ogle et al, 2001)86
Micronesia, Federated States of Papua New Guinea (Ogle et al, 2001)86
Mongolia China (DIAMOND, 2006)53
Myanmar Thailand (Tuchinda et al, 2002)84
Nauru Papua New Guinea (Ogle et al, 2001)86
New Caledonia Papua New Guinea (Ogle et al, 2001)86
New Zealand New Zealand (Campbell-Stokes et al, 2005)87 1999-2000
Niue Papua New Guinea (Ogle et al, 2001)86
Palau Papua New Guinea (Ogle et al, 2001)86
Papua New Guinea Papua New Guinea (Ogle et al, 2001)86 1996-2000
Philippines China (DIAMOND, 2006)53
Samoa Papua New Guinea (Ogle et al, 2001)86
Singapore Singapore (Lee et al, 1998)a, 88 1992-1994
Solomon Islands Papua New Guinea (Ogle et al, 2001)86
Taiwan Hong Kong (Huen et al, 2000)85
Thailand Thailand (Tuchinda et al, 2002)84 1991-1995
Timor-Leste Thailand (Tuchinda et al, 2002)84
Tokelau Papua New Guinea (Ogle et al, 2001)86
Tonga Papua New Guinea (Ogle et al, 2001)86
Tuvalu Papua New Guinea (Ogle et al, 2001)86
Vanuatu Papua New Guinea (Ogle et al, 2001)86
Viet Nam Thailand (Tuchinda et al, 2002)84
provided no population denominator)
a. Only up to age 12 years
N/A Not available

New South Wales approx 1,500 99% A
X
X
22 regions 500 69-100% A/B
X
X
X
X
X
X
Chiba, Hokkaido, Okinawa 167 77-100% A/B
X
X
Seoul 61 N/A B
X
X
X
X
X
X
X
X
X
X
X
X
X
X
North, north-east, south and central regions 191 N/A B
X
X
X
X
X
X

Table 2.16
Mortality among children with type 1 diabetes in 10 European centres
Centre Cases Registration Person Observed Expected SMR =O/E

period years deaths (O) deaths (E) (95%CI)
Lithuania 1,006 1989-2003 7,568 15 5.2 2.9 (1.6,4.7)

Bulgaria (Eastern) 443 1989-1999 4,069 10 2.1 4.7 (2.3,8.7)
Hungary 1,968 1989-2002 13,432 6 4.6 1.3 (0.5,2.9)
Austria 1,989 1989-2002 14,744 6 4.9 1.2 (0.5,2.6)
Spain (Catalonia) 1,806 1989-2002 13,316 3 4.7 0.6 (0.1,1.9)
Germany (Düsseldorf ) 764 1989-2001 3,778 2 0.9 2.2 (0.3,8.0)
Iceland 151 1989-2004 1,160 0 0.5 0.0 ( - , - )
Denmark 2,287 1989-2002 13,104 12 3.3 3.6 (1.9,6.3)
United Kingdom (N Ireland) 1,311 1989-2002 9,622 10 3.2 3.1 (1.5,5.7)
Sweden 7,094 1989-2002 45,158 14 9.7 1.4 (0.8,2.4)

18,819 125,951 78 39.2
CI confidence interval
SMR standardized mortality ratio
Source: Patterson et al, 200527

CHAPTER 2.2
Type 2 Diabetes IN THE YOUNG
Type 2 diabetes in children and adolescents is on the

increase, and affects children in both developed and
developing nations. Many of these children risk developing
diabetic complications at an early age, which would place
a significant burden on the individual, national health
budgets as well as society as a whole.
Introduction Compared to adults there is little information on type 2

diabetes incidence and prevalence in the young with many
It is well recognized that the global burden of type 2 diabetes surveys being clinic based or case series with a paucity of
is both significant and rising, with most of the increase population-based surveys, particularly outside North
registered in the last two decades. From 2007 to 2025 the America91, Japan94 and Taiwan95. Similarly, information on the
worldwide prevalence of diabetes in adults is expected to natural history and aetiology of type 2 diabetes in the
increase from 5.9% to 7.1% of the adult population, or from paediatric age range is also sparse. Other deficiencies include
246 million to 380 million people (see Chapter 1). The largest a lack of uniformity in case definition, data collection and
proportional and absolute increases will occur in developing follow-up, with the diagnosis often made retrospectively96.
countries. In India and China, the number of adults with
diabetes is expected to increase by 50-70% between 2007 There are, however, ever increasing reports of type 2 diabetes
and 2025, to reach 70 million in India and 59 million in China in children worldwide, with some as young as eight years of
by 2025. age being affected97. These are mostly in ethnic groups
known to be at high risk of type 2 diabetes. There are now
In 1990 it was estimated that 0.2% of the total global diabetic also reports of type 2 diabetes occurring amongst Europid
population of 118 million was under 15 years of age89. The (White Caucasoid) teenagers98. In Japan, the prevalence of
prevalence of type 2 diabetes increases with age and affects type 2 diabetes amongst junior high school children has
some 17% of all 65-74 year olds in the USA, and a similar doubled from 7.3 per 100,000 in 1976-80 to 13.9 per 100,000
proportion in Australia90-92. Amongst the young, type 2 in 1991-95, with type 2 diabetes now outnumbering type 1
diabetes is thought to account for 2-3% of all types of diabetes in that country94.
diabetes. This however, may be an underestimate, as
depending on the study, 8-45% of recently diagnosed Despite the paucity of information, it is now becoming
diabetes in the young in the USA is due to type 2 recognized that type 2 diabetes in children is becoming a global
diabetes93. public health issue with potentially serious health outcomes99.
TYPE 2 DIABETES IN THE TOUNG CHAPTER 2 193

In response to this the American Diabetes Association (ADA) has type 2 diabetes. That is, they have elevated C-peptide and an
issued a consensus statement on the screening, diagnosis and absence of islet cell or anti-GAD antibodies91. This type of
treatment of children with type 2 diabetes93. presentation has also been termed Flatbush100,101, or atypical
diabetes mellitus (ADM)102.
As with adults, it is expected that youth with type 2 diabetes
will also develop diabetes-related micro- and macrovascular Unlike type 1 diabetes, most children with type 2 diabetes are
complications. Studies on youth with diabetic complications asymptomatic. However, approximately a third present with
have important implications in that they highlight the risk of ketonuria, an excess of ketones in the urine103. One study
complications occurring at a relatively young age and that found DKA occurred in 4.2% of all patients attending their
these complications can occur relatively soon after diagnosis. paediatric clinic, all of whom were of Canadian aboriginal
This will place a significant burden on health budgets as well descent104. A case series examining African Americans
as society as a whole, as many of these people would be adolescents found that up to 42% presented with ketonuria
entering their peak working and earning capacity. Early and 25% with DKA105. Similarly another report has shown that
detection and intervention is therefore essential to reduce some 30% of Hispanic youth with type 2 diabetes can present
the risk of future complications. with ketosis106. Why type 2 diabetes can present with ketosis
and in particular why this presentation is more likely to occur
The impact of misclassification in African Americans or Hispanics is not clear107.
There may be underestimation in type 2 diabetes rates due

to a misclassification of the type of diabetes at initial Factors in the development of type 2
presentation. The presence of diabetic ketoacidosis (DKA) is diabetes
classically a manifestation of type 1 diabetes. However, a
number of reports have shown that DKA may occur at initial There are several possible factors in the development of type
presentation in people who are eventually found to have 2 diabetes. Major factors include:

Figure 2.4
Annual incidence of type 2 diabetes and prevalence of obesity among
Japanese school children
Incidence of type 2 diabetes per

100,000 population per year
8.0
7.0
6.0
5.0
Obesity (%)
4.0 8.0
3.0 7.0
2.0 6.0
1.0 5.0
1975 1980 1985 1990 1995
Type 2 diabetes
Obesity Source: Kitagawa et al, 199894
• Ethnicity Obesity has been linked to changing patterns in diet and

• Obesity, diet and activity physical activity levels112,113. Allied to this are studies from
• Insulin resistance Japan which have demonstrated a parallel rise in type 2
• Family history diabetes incidence in children and levels of obesity from
• Intrauterine environment 1975 to 199594 (see Figure 2.4). Of note is that over this time
period there have also been significant increases in fat and
Ethnicity animal protein intake among Japanese youth, now mirroring
Ethnicity is an important factor in type 2 diabetes the kind of westernized diets consumed by Japanese-
development in both adults and children with higher rates Americans114.
being reported in Asians, Hispanics, indigenous peoples
(USA, Canada, Australia) and African Americans, with some Dietary changes are not only confined to the home
of the highest rates in the world being observed amongst environment. A survey of Californian public schools found
Pima Indians108,109. For instance from the period 1967-76 to that 85% sold fast food, which in turn accounted for 70% of
1987-96 the prevalence of type 2 diabetes in Pimas increased all food sales115. Of concern is that almost 70% of school
four to six-fold, reaching a prevalence of 22.3 per 1,000 for districts allowed advertising on campus, with 24% allowing
10-14 year olds and 50.9 per 1,000 for 15-19 year olds by advertising in exchange for cash or equipment.
1992-96103.
The prevalence of obesity among Japanese children has
Obesity, diet and activity increased from 5% to 8% from 1976 to 1992 and is similar to
On a global basis the rise in type 2 diabetes rates seems to data reported from the United States116 . In the USA, the
mirror the growth in urbanization and economic National Longitudinal Survey of Youth, which is a prospective
development, and may be due to mal-adaptation to a rapidly cohort study conducted from 1986 to 1998, showed that
changing environment110,111. Closely associated with this is over this time period the overweight prevalence increased
the increase in overweight and obesity. annually by 3.2% in non-Hispanic whites, 5.8% in African

Americans and 4.3% in Hispanics. Thus by 1998, 21.5% of A lifestyle predisposing to obesity and type 2 diabetes seems
African Americans, 21.8% of Hispanics and 12.3% of non- to characterize families with adolescents who have type 2
Hispanic whites were overweight117. A more recent study of diabetes. Specifically they have shown that members of such
nearly 5,000 children in the USA has shown that during 1999- families tend to be overweight, inactive and have a tendency
2000, 15% of 6-19 year olds were overweight, compared to to high fat intake and even binge eating125. Overall in the
11% in 1994-98. The biggest rises were recorded in African USA, only 50% of young people aged 12-21 years are regularly
American and Mexican American adolescents118. This study involved in physical activity, with some 25% admitting to no
also showed that the prevalence of being overweight (BMI physical activity at all. Even in schools there is a decline in
≥25) reached a staggering 65% in US adults. Increasing obesity physical education, with participation rates down from 41.6%
is also a problem in Australia, with a recent study examining in 1991 to 24.5% in 1995126.
children aged 7-15 years reporting that the prevalence of
obesity has increased two to four-fold from 1985 to 1997119. Insulin resistance
The onset of type 2 diabetes is frequently reported around
The problem of obesity also extends to developing nations, puberty and is thought to coincide with a physiological rise
particularly in the more affluent urban areas. In India, a recent in insulin resistance (IR) associated with puberty, where
study found that the age adjusted prevalence of being insulin sensitivity may be reduced by as much as 30%96 .
overweight among 13-18 year olds was around 18%. Healthy young adolescents compensate for the peri-pubertal
Prevalence rates increased with age and decreasing physical rise in IR by increasing insulin secretion as they have normal
activity and with higher socioeconomic status120 . Other pancreatic beta cell function. This is not the case with
factors also thought to be important amongst Indian Asians adolescents with type 2 diabetes, where both insulin action
are low birth weight and insulin resistance111. and eventually beta cell function are impaired93.
Obesity is also being increasingly observed in indigenous There appear to be ethnic differences in IR, with African
populations, such as the Objiwa-Cree community in Canada, American children being more hyperinsulinemic (having
where a study found that 48-51% of children aged 4-19 years high levels of insulin in the blood) and insulin resistant than
have a weight more than the 90th percentile121. Europids127. Similarly, the Bogalusa Heart Study has shown
that compared to Europids, African Americans, especially
Changes in traditional lifestyles among indigenous girls, had higher insulin levels and insulin:glucose ratios128.
communities such as a reduction in hunting and gathering
as well as the adoption of a more sedentary life with a Both African American and Hispanic children have been
westernized diet are thought to contribute to rising obesity shown to have greater insulin resistance than Europid
levels122. Currently some 85% of children with type 2 diabetes children129. In another study, the hyperinsulinaemia seen in
are either overweight or obese at diagnosis93. African-American children has been shown to be due to a
combination of lower insulin clearance (the rate at which
Inactivity is one of the major contributors to being insulin is removed from the circulation) and higher insulin
overweight. In the developed world, use of computers and secretion130.
increasing time spent in front of the television are some of
the factors impacting on activity113,118. Insulin resistance may be lowered by simple means such as
increasing activity levels. This has been demonstrated in
A recent longitudinal study showed a marked decline in physical obese children and more recently in non-diabetic, normal
activity in adolescent girls with 56% of black and 31% of white weight children131, where the more active children had lower
girls aged 16-17 years having no habitual leisure-time physical fasting insulin and greater insulin sensitivity.
activity123. Pregnancy, cigarette smoking, higher body mass
index (BMI) and lower parental education at baseline were all Acanthosis nigricans
associated with a subsequent decline in physical activity. Acanthosis nigricans (AN) is thought to be a physical marker of
Another study highlighting racial differences in physical activity IR and is reported to occur in up to 60-90% of young people
levels found that white students in the US have generally higher with type 2 diabetes108. This seems to be especially true for
physical activity levels than other ethnic groups, with boys African Americans and some Native Americans, but so far not
usually more active than girls, whatever the race124. demonstrated in other populations such as in Japan114. However,

despite its ubiquitous occurrence in some populations with (AFI) measured at 33-38 weeks gestation was a strong
type 2 diabetes, it should not exclusively be used as a reliable predictor of later IGT143. AFI is also thought to correlate with
marker of hyperinsulinemia and insulin resistance. later childhood obesity144, which in turn may lead to later
type 2 diabetes development.
A study has shown that only 35% of obese children with
hyperinsulinemia had AN, whether African American or Birth weight is strongly influenced by the intrauterine
white132. Similarly a recent survey of obese Hispanic children environment, particularly in diabetic pregnancies, which can
(BMI ≥95th percentile) found that there was no association be associated with high birth weight145. Conversely there is
between AN and markers of insulin resistance. In contrast, also evidence that low birth weight can result in later adult
AN was positively associated with BMI but negatively with type 2 diabetes development146. This is most likely due to
birth weight133. poor maternal nutrition leading to impaired islet cell
development145,147, but may also occur in a number of other
Polycystic ovary syndrome conditions such as pregnancies complicated by hypertension/
Polycystic ovary syndrome (PCOS) is associated with pre-eclampsia, which is not an uncommon condition
menstrual irregularities, hyperandrogenism and IR134. It is also complicating up to 3-5% of all pregnancies148.
said to affect up to 5-10% of females in their reproductive
years135 and is thought to predispose to glucose intolerance, There is a hypothesis that insulin resistance is a product of
with studies showing up to 30-40% being affected by IGT fetal programming and that gestational metabolic
and up to 7-10% with type 2 diabetes134,136,137. It may explain perturbations affect fetal size, leading to low birth weight
the female preponderance in type 2 diabetes rates amongst and hence later development of IR149-152.
adolescents96,134.
Two recent studies challenge this. First, a study examining
Family history 300 five-year old British children found that girls were
Many studies show a strong family history among affected more insulin resistant than boys, and insulin resistance
youth with 45-80% having at least one parent with diabetes was not related to birth weight153 . The second is a study
and 74-100% having a first or second degree relative with from Belgium154, which examined twins aged 18-35 years
type 2 diabetes93,138 . Children with diabetes are also more and found that among twin pairs discordant for birth
likely to have a family history of cardiovascular disease (CVD), weight, there was little evidence that the lighter twin had
with one study showing that up to 28% have a positive family abnormal glucose-insulin metabolism in adult life. Low
history of CVD139. pre-pregnancy maternal BMI and older maternal age at
delivery were independently associated with IR in the
The Bogalusa Heart Study140 has shown that children of offspring. These findings suggest that maternal factors
individuals with type 2 diabetes were more likely to be obese may be more important than feto-placental factors in
and have higher blood pressures, fasting insulin, glucose and determining glucose-insulin metabolism in the
triglycerides. In a study among Pima Indians, it was shown offspring.
that the cumulative incidence of type 2 diabetes was highest
in offspring if both parents had diabetes141. Methods
Intrauterine environment A Medline search was conducted using Ovid of papers

Apart from genes, the intrauterine environment may be written in the English language from 1965-2006.
important as there is evidence of higher rates of type 2
diabetes in offspring of mothers who develop gestational Key words used were: Diabetes, diabetics, non-insulin
diabetes (GDM)142. dependent diabetes, type II diabetes, impaired glucose
tolerance, insulin resistance, child, childhood, young,
A prospective study143 found that the prevalence of IGT in the adolescence, overweight, obesity and polycystic ovary
children of mothers with a diabetic pregnancy increased syndrome. The keywords related to diabetes were combined
with time from 1.2% at less than five years of age to 19.3% at with those related to children and then further combined
10-16 years of age. This was compared to 2.5% in control with terms related to obesity and then finally with polycystic
subjects. In addition, higher levels of amniotic fluid insulin ovary syndrome.

All available studies with relevant data have been included taking into account the current information on type 2
and have been grouped by study type (population based, diabetes rates around the world, the results for Africa are
case series and clinic based). These have further been divided probably an underestimate and may not represent the
into the IDF regions of Africa (AFR), Europe (EUR), North contemporary situation.
America (NA), Eastern Mediterranean and Middle East
(EMME), South and Central America (SACA), South-East Asia Eastern Mediterranean and Middle East
(SEA) and Western Pacific (WP). A large study of some 25,000 individuals aged 2-77 years
old was carried out in Saudi Arabia173. The figures for those
Studies which include young people 20 years of age and less than 29 years of age have been selected. In the under-
under have been selected. However, data are presented for 14 year age group, IGT prevalence was double that of type
studies which have given higher age ranges but which 2 diabetes (0.25% vs 0.12%). The opposite was true for the
include subjects less than 20 years of age within those 14-29 year age group, where type 2 diabetes outnumbered
ranges. In these cases it has not been possible to separate IGT almost 3:1 (0.79% for type 2 diabetes vs 0.21% for
those under 20 from the information given. IGT).
Results Europe
Two recent studies have provided the first population-based
Results are reported as presented in the original papers, data for European countries. A study of Turkish adolescents174
unlike in the adult diabetes and childhood type 1 diabetes found no cases of diabetes, although 2% had impaired
sections (Chapters 1.1 and 2.1), in which figures have been fasting glucose (IFG), and a very large study of 17-year old
calculated for the national population. Israeli military conscripts175 reported type 2 diabetes in
0.036% of males and in 0.01% of females.
In some of the studies used, the prevalence of type 2
diabetes in the general population (child and adolescent) North America
has been determined from a representative population- Compared to other regions, data from North America on
based sample 155 . However, many studies have simply type 2 diabetes and IGT prevalence are relatively extensive
reported a series of cases (sometimes supplemented by a and recent. The ethnicity of the study subjects is diverse with
calculation of the prevalence in the general population, many including African Americans, Mexican Americans and
using estimated figures for the size of the population from non-Hispanic white Americans in the same study.
which the cases were drawn)156, or examined only a specific
sub-population, such as from a diabetes registry157-160 or an In the USA, national data from 1988-94176, and data from a
obesity clinic161-165. single school district177 collected approximately 10 years later
showed diabetes prevalences of 0.13% and 0.4% respectively.
Population-based studies A study from Texas in 1981 examining 15-24 year-old Mexican
Americans found no type 2 diabetes in males and only a low
In general, it is very difficult to compare the studies due to prevalence of 0.4% in females178. By 2002, a study surveying
wide differences in study design. Population-based studies Mexican American fourth graders found not only an overall
were found from all regions except South and Central type 2 diabetes prevalence of 0.3%, but also cases of IGT
America (see Table 2.17). The size of the studies were very (0.14%) as well as IFG (0.14%)179. In contrast, another study
variable, ranging from less than 100166 to over eight million reported relatively high rates of type 2 diabetes (1.5%) and
participants167. In the case of Africa168-171, studies found are IFG (10.8%) in a population of Europids and African
few and in most examples conducted some 20 years ago. Americans180.
Africa A study which examined Pima Indians since 1967

Five studies were found and included two from west demonstrated rising rates of glucose intolerance over time,
Africa168,170 and three from east Africa169,171,172. All but one, as well as a female preponderance181. From 1967-76 to 1987-
which looked only at Indians172, showed a zero or low 96 the prevalence of type 2 diabetes markedly increased
prevalence of diabetes. Apart from the study examining from 2.4% in males and 2.7% in females to 3.8% in males and
Indians, all the others were conducted in the 1980s. Therefore 5.3% in females. A female preponderance of type 2 diabetes

of almost 4:1 among Navajo adolescents was also found in Clinic/ register-based studies
another study182.
Clinic and register-based studies make up the largest group
A study of American Indian and Alaskan Native adolescents of studies conducted on youth IGT and type 2 diabetes (see
reported that the type 2 diabetes prevalence increased by Tables 2.18 and 2.19). They reveal type 2 diabetes occurring in
68% from 1990 to 1998 among those aged 15-19 years children as young as under the age of five years189. In addition,
(0.32% to 0.54%)109. In addition although the prevalence of they have demonstrated a female preponderance158,159,190,191,
type 2 diabetes was higher among females, the relative strong family history158,192,193, obesity97,155,158,192,193, and AN97,155,193.
increase over this time period was greater among males
(0.23% to 0.41% for males vs 0.42% to 0.68% for females). These studies have also shown an increase in incidence rates,
Even though the overall prevalence among under-15 year with one study157 finding that type 2 diabetes incidence rates
olds remained the same at 0.12%, there was regional rose by 9% per year from 1985 to 1994 in the USA, reaching
variation, and Alaska recorded the biggest rise of 114% 3.8 per 100,000 per year by 1990-94, while another American
(0.04% to 0.09%). study193 found a 10-fold increase in type 2 diabetes incidence
rates from 0.7 per 100,000 per year in 1982 to 7.2 per 100,000
From Canada, a study among Cree-Objiway children found per year in 1994. Yet another American study194 reported that
greater rates for IFG (2.6%) compared to type 2 diabetes in 1994, 9.4% of new cases of diabetes were due to type 2
(1.1%), but no female preponderance183. diabetes, rising to 20% by 1998. Similarly, a study in Thailand155
reported a rise in the proportion with type 2 diabetes referred
South-East Asia to a diabetic clinic from 5% during 1986-95 to 17.9% during
Studies in the South-East Asian Region were identified from 1996-99.
India184 and Bangladesh185,186 . The study from Chennai in
south India184 was conducted in the early 1990s and found A study from a clinic in Hungary195 from 1989-2001 also
a zero prevalence rate for type 2 diabetes. This may no reported rising incidence rates over time with 57% of all type
longer be the case, given the recent worldwide rise in type 2 diabetes and 77% of all IGT being diagnosed in the last six
2 diabetes in children, and a case series report in 2003 from years of the 13-year study.
the same city, noting 18 cases of childhood type 2
diabetes187. While, there has been much evidence of type 2 diabetes
becoming a major problem, and perhaps the dominant form
Western Pacific of diabetes among youth in the USA and Asia, a series of
Two very large studies involving the mass screening of studies from Europe indicate that it remains a rarity in these
schoolchildren in Japan94,167 and Taiwan95 were identified in populations. Well-designed studies from Germany, Austria,
the Western Pacific area. The largest study reported is from France and the UK196-198 all show type 2 diabetes accounting
Japan167, with over eight million youth being studied between for only 1-2% of all cases of diabetes.
1974 and 2002. Over this time, type 2 diabetes incidence
increased from 1.73 per 100,000 per year in the period 1974- Incidence rates rise with age, with one study189 demonstrating
80 to 2.76 per 100,000 per year in the period 1981-2002. that 15-19 year olds with rates of 5.9 per 100,000 per year
have three times the rate of 10-14 year olds with rates of 1.8
A cohort of indigenous Australian children aged 7-18 years per 100,000 per year.
was surveyed in 1989 and again in 1994. Over the five years,
the prevalence of type 2 diabetes almost doubled to 1.3%, A number of studies have pre-selected subjects for obesity,
while that for IGT increased almost seven-fold to 8.1%188. By 18 AN or PCOS. One study162 in 1965 found an IGT prevalence of
years of age, 18% of the population were overweight or obese. 23% in subjects pre-selected for obesity. More recently,
In addition one-third of the children had elevated cholesterol another study164 selected children and adolescents whose
levels, with almost half reporting alcohol use and smoking. weight was more than the 95th percentile for age and sex
attending an obesity clinic and found similar rates of IGT:
In contrast to the Australian study, the Tongan study 166 25% in 4-10 year olds and 21% in 11-18 year olds.
examining 15-19 year olds found no glucose intolerance in
that population. A study165 from Italy also reported an IGT prevalence of 12.6%,

but other studies of obese youth from the US163, Germany199, duration of type 2 diabetes, nephropathy was present in all
and another from Italy200 have reported lower IGT prevalences age groups (incidence/1,000 person years: 13/1,000 youth,
of 4.1%, 7.5% and 4.5% respectively. Another study from 8/1,000 young adults and 7/1,000 older). However,
Singapore also found lower rates of IGT (4.3%) in young retinopathy only appeared among those with youth onset
obese children161. diabetes after 5-10 years duration (incidence/1,000 person
years: 10/1,000 youth, 29/1,000 young adults and 35/1,000
The cause for the discrepancy in results is uncertain, but it older).
has been suggested that for at least one of the high
prevalence studies164, it may be due to the study population Discussion
being enriched with children with extreme obesity, with
PCOS, and having a high proportion of children from high- Compared to adults there is a paucity of information on both
risk ethnic groups (non-Hispanic Black or Hispanic). the epidemiology and natural history of type 2 diabetes in
the young. This needs to be urgently addressed given the
Studies pre-selecting for PCOS have demonstrated significant potential threat of an explosion in childhood type 2
rates of glucose intolerance. One study135 reported an IGT diabetes.
prevalence of 26.9% while another201 found a rate of 13%.
However, both studies report lower prevalences of type 2 There are only a few large scale population-based studies
diabetes of 3.7% and 0% respectively. focusing on youth with type 2 diabetes. Most of the
information available comes from case series or clinic-based
One of the few studies pre-selecting for the presence of studies. On a global basis, the majority of data come from
AN202 reported an IGT prevalence of 24% in subjects with developed countries, particularly North America and Japan,
AN. The authors of the study suggest that children with AN with a distinct lack of information from many regions in the
may benefit from diabetes screening and early intervention. world, particularly from Africa and South America.
However, AN is not a universal phenomenon in children
with type 2 diabetes, and has so far not been noted to any Notably, there is also a lack of standardization in study
degree among the large studies surveying Japanese methods, with many surveys only examining small numbers
youth94. of people, as well as using different diagnostic methods and
criteria. In addition some studies have only looked at very
Diabetic complications high risk subjects, such as those with PCOS135, presence of
AN202, or obesity164. This can make comparisons between
As with adults it is expected that youth with type 2 diabetes studies difficult.
will also develop diabetes- related micro- and macrovascular
complications. This was reported recently in a study from Conclusion
Canada, where subjects who developed type 2 diabetes as
children were then surveyed as young adults, aged between Despite apparent deficiencies in research, some valid
18 and 33 years. Of the 51 adults, 9% had died, 6% were on conclusions can still be made regarding type 2 diabetes in
dialysis, while one had a toe amputation and one was the young:
blind203.
1. It is a global phenomenon, which is on the increase.
Another follow-up study from Japan compared those with
type 1 and type 2 diabetes diagnosed at under 30 years of 2. Children are being affected in both developed and
age for development of nephropathy204. After 30 years of developing nations.
diabetes, 44% of those with type 2 and 20.2% of those with
type 1 had nephropathy. 3. Reports are appearing that show its existence in
populations hitherto thought not to be at risk, such as
Yet another study205 looked at incidence of retinopathy and British Europids.
nephropathy among Pima Indians diagnosed with type 2
diabetes at under 20 years of age (youth), 20-39 years (young 4. The risk of type 2 diabetes is clearly linked to an increasing
adults) and 40-59 years of age (older). At less than five years prevalence of obesity. This in turn is associated with

changing dietary and lifestyle patterns. In particular an The increasing prevalence of type 2 diabetes in the young
increase in fatty foods as well as a reduction in activity may be blunted by encouraging increasing physical activity,
levels both at home and in the school. The change in and changing dietary habits. Interventional programmes
lifestyle is a worldwide phenomenon, occurring in both should be considered to address the underlying cause, with
developed and emerging nations, where it is most an emphasis on diet, weight, exercise and lifestyle issues.
prevalent in urban areas. In these nations as well as among
indigenous communities residing in developed nations, It is recognized that in an ideal world it would be possible to
there seems to be a gradual abandonment of traditional implement the proposed recommendations. In reality this
ways of living in favour of a ‘westernized’ lifestyle. may be difficult given the poor economic condition that
many have to endure and the already tight health budgets
5. A number of studies have noted an association between governments have to deal with. However, many regions of
type 2 diabetes and PCOS. Not all studies look for this the world are progressing economically and hence becoming
condition and it is possible that it may partly explain the more urbanized.
female preponderance in youth onset type 2 diabetes.
Future work may need to address the issue of PCOS, A consequence of urbanization is the parallel emergence
especially since it is amenable to treatment. of cardiovascular disease and diabetes, which hitherto, was
mainly a problem of the developed world. Therefore,
6. Studies have shown that youth with type 2 diabetes will governments will be forced to deal with the problem of
also develop diabetes-related micro- and macrovascular type 2 diabetes in children. As such, it would be better to
complications, as with adults. These studies have address the problem as a public health issue under the
important implications in that they highlight the risk of heading of primary care and prevention, rather than dealing
complications occurring at a relatively early age, which with the consequences of an entrenched condition and its
will place a significant burden on health budgets as well complications in a young population.
as society as a whole.

Table 2.17
Type 2 diabetes and impaired glucose tolerance in the young - population-based studies
REGION COUNTRY/TERRITORY AUTHOR YEAR OF STUDY ETHNICITY

AFR Mali Fisch et al, 1987170 1984-1985 Mixed tribal

Tanzania, United Republic of McLarty et al, 1989171 1988 African
Ahren et al, 1984169 1982-1983 African
Ramaiya et al, 1991172 • Indian

Togo Teuscher et al, 1987168 1987 Mixed tribal
EMME Saudi Arabia el-Hazmi et al, 2000173 1998 Arab

EUR Israel Bar Dayan et al, 2005175 • Mixed

Turkey Uckun-Kitapci et al, 2004174 • Mixed
NA Canada Dean et al, 1998183 1996-1997 Cree-Ojibway
Delisle et al, 1993206 1989 Algonquin
Harris et al, 1997207 1996 Cree-Ojibway
United States of America Harrell et al, 2002180 2001-2002 Caucasian 69%
African American 24%
Hale et al, 2002179 2002 Mostly Mexican American
Hanis et al, 1996178 1981-2002 Mexican American

Chavez et al, 2002208 2002 N/A
Freedman et al, 1997182 1991-1992 Navajo

Dabelea et al, 1998181 1987-1996 Pimas

Acton et al, 2002109 1990-1998 American Indian and Alaskan native

Kim et al, 1999209 1999 Navajo
Dolan et al, 2005177 2002 Non-Hispanic white 50%
Fagot-Campagna et al, 2001176 1988-1994 Mixed
Lee et al, 2004210 • Cherokee
SEA Bangladesh Abutt Sayeed et al, 1995186 1995 South Asian rural
Sayeed et al, 1997185 1997 South Asian urban
India Bai et al, 1995184 1994 South Asian
WP Australia Braun et al, 1996188 1989 Indigenous
Daniel et al, 1999211 1987-1995 Indigenous
Japan Urakami et al, 2005167 1974-2002 Japanese

Taiwan Wei et al, 200395 1993-1999 South-East Asian

Tonga Colagiuri et al, 2002166 1998-2000 Polynesian
DM type 2 diabetes
FBG fasting blood glucose
FCG fasting capillary glucose
FPG fasting plasma glucose
IFG Impaired fasting glucose
IGT impaired glucose tolerance
N/A not available
OGT Toral glucose tolerance test
RBG random blood glucose

AGE (YRS) DIAGNOSTIC METHOD SOURCE OF CASES TYPE 2 CASES PREVALENCE DM INCIDENCE
(NO.) (%) per 100,000 per year
15-24 FCG 2,558 0.39 • •

15-24 OGTT 1,178 0.40 6.70 •
≤19 OGTT 1,327 0.15 • •
15-24 OGTT 156 Male 0.00 Male 2.30 •
Female 0.00 Female 4.20
<20 OGTT 864 0.00 • •
2-29 OGTT 9,917 <14 years: 0.12 <14 years: 0.25
(<14) 14-29 years: 0.79 14-29 years: 0.21 •
17 FBG or RBG or OGTT 76,732 Male 0.036 • •
<14 Female 0.01
• FBG 1,647 0.00 IFG 1.96
4-19 FBG 717 1.10 2.60 •
15-20 OGTT 106 • 1.90 •
10-19 OGTT 244 3.00 10.00 •
10-15 FPG 668 1.50 10.80 •

4th grade OGTT 1,417 0.30 0.14 •
15-24 OGTT 729 Male 0.00 • •
Female 0.40
15-19 RBG 778 0.13 • •
12-19 OGTT 160 Male 3.00 Male 3.00 •
Female 13.00 Female 13.00
5-19 OGTT 3,098 5-9 years: Male 0.00 • •
Female 0.00
10-14 years: Male 1.50
Female 2.90
15-19 years: Male 3.80
Female 5.30
≤19 Chart review <15 years: 0.12 • •
15-19 years: 0.54
Male: 0.41
Female: 0.68
13-20 OGTT 234 0.42 3.40 •

9-20 OGTT if risk factor positive 2,501 0.40 0.30 •
12-19 FBG 2,867 0.13 IFG 1.76
5-19 FBG 989 1.00 IFG 0.70 •
15-29 OGTT 371 0.50 5.70 •
15-19 OGTT 271 0.06 0.04 •
5-19 OGTT 3,515 0.00 • •
7-18 OGTT 74 1.30 8.10 •
15-24 OGTT • • • 1,070
6-15 Annual urinalysis. 8,812,356 • • 1974-1980 : 1.73
If glycosuria x2, then OGTT 1981-2002 : 2.76
6-18 Urinalysis.If glycosuria, 3x106 Male 0.009 • •
then OGTT Female 0.015 • •
15-19 OGTT 59 0.00 • •

Table 2.18
Type 2 diabetes in the young - case series

REGION COUNTRY/TERRITORY AUTHOR YEAR OF STUDY ETHNICITY AGE (YRS)

EMME Libyan Arab Republic Kadiki et al, 1996189 1981-1990 Arab ≤19

United Arab Emirates Punnose et al, 2002212 1990-1998 Arab ≤18

EUR United Kingdom Ehtisham et al, 2001159 1999-2000 Mixed <18
Ehtisham et al, 2004213 2000 Mixed <16
NA Canada Harris et al, 1996158 1978-1994 Cree-Ojibway <16

Dean, 1998214 1996 First Nation 5-14
United States of America Jones, 1998215 1993-1998 Mexican American 67% 5-17

Lipton et al, 2002216 1985-1994 African American ≤17
Latino
Pihoker et al, 199897 1995-1998 African American 8-21
Caucasian
Hispanic
Macaluso et al, 2002194 1994-1998 Hispanic 5-19
African American
SEA India Ramachandran et al, 2002120 2002-2003 Indian Asian 9-15
WP Australia McMahon et al, 2004190 1990-2002 Mixed <17

Sinha et al, 2000138 1999-2000 Indigenous 6-16
New Zealand Campbell-Stokes et al, 200587 1999-2000 Mixed <15
* Prevalence and incidence rates are calculated using an estimate of the total at-risk population.
DM Type 2 diabetes
N/A Not available
OGTT Oral glucose tolerance test

DIAGNOSTIC METHOD SOURCE OF CASES TYPE 2 CASES PREVALENCE* DM INCIDENCE*
(NO.) (%) per 100,000 per year
Chart review Diabetes register and hospital clinic 0-4 years: 0 N/A 5-9 years: 0.10
5-9 years: 1 10-14 years: 1.80
10-14 years: 11 15-19 years: 5.90
15-19 years: 30
Chart review Hospital clinic Male 1 N/A •
Female 4
Chart review Paediatric clinics 10 0.004 DM 1.52
Questionnaire of paediatric centres Paediatric diabetes centres in UK 25 0.0002 •
Chart review Diabetes register Male 1 Male 0.07 N/A
Female 14 Female 0.42
Total 0.25
Chart review Diabetes register 15 0.77 N/A
OGTT or Sustacal Medical centre and clinics 18 N/A N/A
challenge test
Chart review Diabetes register N/A N/A DM 3.80

Chart review Diabetes clinic 37 N/A N/A
12
1
Chart review Diabetes clinic 92 14 N/A

Chart review Diabetes clinic 18 N/A •
Chart review Paediatric centre Male 15 N/A N/A
Female 28
Chart review / OGTT Diabetes clinic 20 N/A N/A
Chart review Diabetes register 12 • 0.72

Table 2.19
Type 2 diabetes and impaired glucose tolerance in the young - clinic-based studies
REGION COUNTRY/TERRITORY AUTHOR YEAR OF STUDY ETHNICITY AGE (YRS)

EUR Austria Rami et al, 2003217 1999-2001 Mixed European <15

France Ortega-Rodriguez et al, 2001197 1993-1998 Mixed <17
Germany Wiegand et al, 2004199 2000-2002 Mixed European 7-18
Wabitsch et al, 2004218 • Caucasian 9-20
Germany and Austria Schober et al, 2005196 1991-2004 Mixed <20
Hungary Korner, 2002195 1989-2001 Caucasian ≤19
Italy Invitti et al, 2003200 1994-2001 Caucasian 6-18
Ciampalini et al, 2002165 N/A Caucasian 3-19
United Kingdom Feltbower et al, 2003198 2000 Mixed <20
NA Canada Zdravkovic et al, 2004219 1994-2002 Mixed <18
United States of America Paulsen et al, 1968162 1965 Mixed 4-16
Legro et al, 1999201 1983-1991 Mixed 14-20
Pinhas-Hamiel et al, 1996193 1984-1994 African American 68% ≤19
White 32%
Neufeld et al, 1998106 1990-1994 Mexican American <17
Uwaifo et al, 2002163 1996-2002 Caucasian 6-11
African American
Sinha et al, 2002164 1999-2001 Caucasian 58% 4-18
Hispanic 19%
Brickman et al, 2002202 1999-2002 Mixed Mean 11.9; +/- 2.9
Palmert et al, 2002135 2001 Mixed 13-19
Oeltmann et al, 2003220 1999 Mixed <19
SACA Puerto Rico Perez-Perdomo et al, 2005221 1995-2003 Mixed <20
WP China, Hong Kong Huen et al, 200085 1984-1996 Chinese <15
New Zealand McGrath et al, 1999160 1978-1998 Maori DM onset before 30
Hotu et al, 2004222 1996-2002 Mixed 14-20

Singapore Lee et al, 1999161 1999 Malay 42% ≤15
Indian 28%
Chinese 33%
Thailand Likitmaskul et al, 2003155 1996-1999 South-East Asian <15
* prevalence of type 2 diabetes within the specific population (e.g. within an obesity clinic or within the total diabetic population)
** incidence (or prevalence if stated) of type 2 diabetes within the general population
AN acanthosis nigricans
DM type 2 diabetes
OGTT oral glucose tolerance test
BMI body mass index (kg/m2)
N/A not available
PCOS polycystic ovary syndrome

POPULATION DIAGNOSTIC METHOD SAMPLE SIZE PREVALENCE* (%) DM INCIDENCE
DM IGT per 100,000 per year **
Diabetes register Chart review 529 1.50 • 0.25

Diabetes clinic Chart review 382 2.00 • •
Obese OGTT if risk factor positive 491 1.20 7.50 N/A
Obese OGTT 520 1.50 2.10 •
Diabetes register Chart review 25,706 0.90 • •
Diabetic clinic Chart review 524 10.70 • N/A
Obese OGTT 710 0.10 4.50 N/A
Obese OGTT 191 0.50 12.60 N/A
Diabetes clinics Chart review 280 1.80 • Prevalence 1/105
Diabetes clinic Chart review 1,020 4.30 • •
Obese OGTT 66 0.00 23.00 N/A
PCOS - all female OGTT 16 0.00 13.00 N/A
N/A N/A N/A • • 7.20

Diabetic clinic Chart review 55 31.00 • N/A
Overweight BMI at <95th percentile OGTT Overweight 121 0.00 4.10 N/A
Not overweight 104 0.00 0
Obesity clinic OGTT 4-10 years: 55 0.00 25.00 N/A
11-18 years: 112 3.60 21.00

Presence of AN OGTT 33 3.00 24.00 N/A
PCOS - all female OGTT 27 3.70 26.90 N/A
Diabetes register Chart review 181 19.10 • N/A
Diabetes clinics Chart review 2,800 3.30 • Prevalence 13.5/105
Diabetes register Chart review 255 7.10 • 0.10
Diabetes register Chart review 51 55.00 • N/A
Diabetes clinic Chart review 1996: 110 1.80 • N/A
2002: 163 11.00
Obese children in a paediatric clinic OGTT 23 17.00 4.30 N/A

Diabetes clinic Chart review 39 17.90 • N/A

CHAPTER 3
GESTATIONAL DIABETES MELLITUS

A disciplined life, exercise, a
healthy diet and close monitoring
of blood glucose is the secret for a
successful outcome of pregnancy
with GDM.
3.0
Gestational Diabetes Mellitus
Women with previous gestational diabetes mellitus are an

appropriate population in which to direct efforts at diabetes
prevention because of the increased risk of developing
type 2 diabetes in later years. GDM is also associated with
increased risk of obesity and abnormal glucose metabolism
during childhood and adult life in the offspring.
Introduction mellitus is “carbohydrate intolerance of varying degrees of

severity with onset or first recognition during pregnancy”2,3.
G estational diabetes mellitus (GDM) is common and, like

obesity and type 2 diabetes that are related conditions,
is increasing in frequency throughout the world. The risk of
The definition applies regardless of treatment method or
whether the condition persists after pregnancy. It does not
exclude the possibility that unrecognized glucose
developing diabetes after GDM is very high. Recently intolerance may have antedated the pregnancy. Though
completed research studies as well as ongoing studies the definition is simple, there is much controversy
promise important advances in the diagnosis and treatment concerning the diagnostic methods and criteria as well as
of GDM. In addition, the risk of progressing to diabetes after the appropriate therapy.
GDM can be greatly reduced or delayed by moderate,
sustained improvement in lifestyle or with medication in Consequences of GDM
women who have impaired glucose tolerance (IGT).
During the interval of more than four decades that GDM has
Women with previous GDM are an appropriate population in been viewed as a distinct entity, many approaches to
which to direct efforts at diabetes prevention because of the detection and diagnosis have been proposed. The criteria for
increased risk of developing type 2 diabetes in later years. GDM were originally set based on the power to detect
Results reported recently from a randomized clinical trial women at risk for development of diabetes mellitus outside
(RCT) confirm that treating ‘mild GDM’ decreases the risk of of pregnancy in later years4. Some of the criteria that have
adverse perinatal outcome1. Studies currently in progress been proposed subsequently are based on the distribution
hold much hope of providing the data from which ‘outcome of glucose values from oral glucose tolerance tests performed
based’ diagnostic criteria and appropriate strategies for the in other population samples of women during the last half of
detection of GDM can be developed. gestation. The high risk of progression to diabetes mellitus
following GDM has been confirmed extensively among many
The most widely accepted definition of gestational diabetes different racial/ethnic groups.
GESTATIONAL DIABETES MELLITUS CHAPTER 3 211

Diabetes begets diabetes Increasing incidence of GDM in Northern California, USA, 1991 – 2000
Incidence (%)
MATERNAL 12
FUELS
PGDM 11 11
10 9.8
GDM 9.7
9
8.3
8 8.3
8 8.1
Impaired Adult Altered Fetal 7.4
Islet Function Islet Function 7.2
7 6.9
7.2
6.9 6.2 6.4
Child 6 5.8
Obesity 5.4 5.7
5.1 5.1 5.1 5.7
5
4.1 4.7
4 3.9 4.1
PUBERTAL IGT
3
1991 1993 1995 1997 2000
All ethnic groups ‡ Values presented = mean ± standard error

White (Non Hispanic) † ‡ Adjusted for age and race-ethnicity
PGDM pre-gestational diabetes mellitus
African American † † Adjusted for age
Hispanic † Adapted from Ferrara et al, 20048
Asian †
In recent years, several important studies have demonstrated major source of controversy about GDM derives from
that the development of type 2 diabetes can be prevented uncertainty about what level of maternal hyperglycaemia is
or delayed by intervention with lifestyle changes or associated with a significant risk of adverse pregnancy
medications. Importantly, women with GDM were included outcome.
among those recruited as subjects for the Diabetes Prevention
Program5 in the USA. Women with previous GDM represented There is general agreement that overt diabetes, diagnosed
the target population that was used for the Troglitazone in prior to pregnancy, clearly increases the risk of adverse
the Prevention of Diabetes (TRIPOD) intervention trial6, also pregnancy outcome. What is yet to be established is the level
in the USA. of glucose intolerance short of diabetes that is associated
with significantly increased risk. The currently ongoing
It is also recognized that intrauterine exposure to the altered multicentre, international Hyperglycemia and Adverse
metabolic environment of diabetes or GDM is associated Pregnancy Outcome (HAPO) study is designed to address
with increased risk of obesity and abnormal glucose this issue7. It is anticipated that the collection of clinical data
metabolism during childhood and adult life in the offspring, in the HAPO study will be completed in 2006 and the analysis
thus, contributing to the progressive increase of obesity, of outcomes will begin early in 2007.
GDM and type 2 diabetes in the population (see Figure 3.1).
However, to date, the extent to which GDM adds to the risk In the meantime it is recommended that clinicians and
of diabetes has been estimated in only one population, the investigators who currently have programmes in place for
Pima Indians of Arizona. the diagnosis and treatment of GDM continue to use their
present paradigms or adopt the recommendations that were
Interest in the detection of GDM for the purpose of identifying made by the participants in the Fourth International
pregnancies in which there may be increased risk of adverse Workshop Conference on Gestational Diabetes Mellitus2 and
perinatal outcome, for the most part, developed after the recently endorsed by the Fifth International Workshop
diagnostic criteria had been established. Consequently, one Conference on GDM3.

Table 3.1
Treatment of GDM reduces adverse outcomes
Outcome Routine Care Intervention Relative Risk p

(N = 510) (N = 490) (95% CI)
Serious complications 4% 1% 0.33 (0.14-0.75) 0.01

Neonatal nursery care 61% 71% 1.13 (1.03-1.23) 0.01
Induction of labour 29% 39% 1.36 (1.15-1.62) < .001
Caesarean delivery 32% 31% 0.97 (0.81-1.16) ns
EPDS Score >12 17% 8% 0.46 (0.29-0.73) 0.001
Adjusted Treatment
Effect (95% CI)
Birth weight (BW) 3,482 ± 660 3,335 ± 551 -145 (-219 to -70) < .001
LGA 22% 13% 0.62 (0.47-0.81) < .001
Macrosomia (BW > 4 kg) 21% 10% 0.47 (0.34-0.64) < .001
SGA 7% 7% 0.88 (0.56-1.39) ns
CI Confidence Interval
EPDS Score Edinburgh Postnatal Depression Scale (3 months postpartum)
LGA Large for gestational age;
SGA Small for gestational age
ns not significant
Adapted from Crowther et al, 20051
Prevalence African American, Hispanic and Asian populations, as shown

in Figure 3.2.
The reported prevalence of GDM has varied widely among
different populations around the world. Much of this The increase in GDM has paralleled the increase in obesity
variability results from the differences in diagnostic criteria within the population in the reproductive age. The increase
and methods for detection that are used in different centres. in overweight and obesity among adolescents and young
Recent data from Australia and the USA confirm earlier adults is of major concern. Further investigation is required
findings that the incidence of GDM varies among ethnic and to establish if this weight increase is either causal for or a
racial groups. It is important to note that within each ethnic concomitant of GDM.
group, GDM prevalence has increased over time. For any
given maternal age, the frequency of GDM has exhibited a Benefits of treating GDM
similar increase. Large population-based studies in the United
States that have controlled for maternal age and ethnicity The lack of convincing evidence for benefit from treating
have found a substantial increase in the overall incidence of ‘mild GDM’ has also been a source of controversy concerning
GDM over the past decade, particularly in populations in the value of efforts to identify women with GDM. However,
rapid transition. the results of a randomized clinical trial conducted in
Australia and reported recently help to clarify this issue1.
While GDM is probably increasing globally, well designed, Some of the key findings from this report are summarized
population-based studies to confirm this assumption are not in Table 3.1.
presently available outside of the USA. Data from a report
drawn from the data of the Kaiser Permanente Medical Care The RCT demonstrated that treating GDM (diagnosed when
Program in Northern California 8 illustrate the points the fasting plasma glucose was 4.8 + 0.7 mmol/L and the
mentioned above very well. In this study, it was possible to two-hour value after a 75 gm oral glucose load was from 7.8-
compare trends in yearly incidence of GDM among Caucasian, 11.0 mmol/L) significantly reduced the likelihood of serious.

IN TOUCH WITH: SAMINA FAISAL
Every woman desires a normal and healthy child and Samina Faisal delivered her
gestational diabetes mellitus should not come in the way first child, a normal baby girl,
of achieving this goal. A disciplined life, exercise, a healthy nine years after her marriage to
diet and close monitoring of blood glucose is the secret for a a fellow banker in Pakistan. It
successful outcome of pregnancy with GDM. Educating the was an uneventful pregnancy
woman on diabetes is the most important factor. after two sad experiences
of an abortion and a tubal
pregnancy. Samina had enjoyed
her food throughout her
pregnancy, especially sweets,
which resulted in an increase of 27 kgs in weight. After
delivery, she found it difficult to shed those extra kilos.
Four years later she conceived again and, on screening

in her sixth month, was diagnosed as having gestational
diabetes mellitus (GDM). In these six months she had had a
weight gain of some 11 kgs. “I felt so very hungry and I love
sweets,” Samina recalled. She was advised an appropriate
neonatal morbidity (complications) compared to outcomes Medical nutrition therapy remains the initial and primary
in those receiving routine prenatal care. Birth weight and modality for treatment of GDM. When optimal glycaemia is
the frequency of delivering babies that were large for not achieved or maintained, additional treatment with
gestational age (LGA) or macrosomic (> 4.0 kg birth weight) biosynthetic human insulin has been used globally for many
were also less in the treatment/intervention group. years. Following the demonstration that the sulfonylurea,
Treatment included individualized medical nutrition glyburide (glibenclamide), crosses the placenta to a very
therapy, daily self-monitoring of blood glucose and insulin limited extent9, a randomized clinical trial was carried out
when needed (20% of cases). Other RCT studies of similar comparing glycaemic control and outcomes in women
design are in progress. with GDM treated with human insulin or glyburide
(glibenclamide)10. Comparable results were found in the two
New approaches to treatment groups. Additional reports with smaller numbers of subjects
have been published subsequently that in general confirm
As pointed out above, there is uncertainty about “the level of the results of the original study.
hyperglycaemia, short of overt diabetes that conveys increased
perinatal risk”7. However, there is general consensus that in The participants of the Fifth International Workshop
women with a diagnosis of GDM that have clearly elevated Conference on GDM cautioned that the findings with
fasting and/or one or two hours after meal blood glucose glyburide (glibenclamide) could not be extrapolated to
concentrations at diagnosis, lowering the maternal blood other sulfonylurea agents or other classes of oral medication.
glucose levels to near normal concentrations may reduce the They further emphasized the need for continued close
risk of excessive fetal growth to approximate the risk in the surveillance of maternal glycaemia during all forms of
general population2,3 and a major objective of treating GDM is treatment of GDM to assure that treatment goals are met
to reduce adverse perinatal events, primarily those associated and sustained3.
with excess weight or adiposity of the newborn (Caesarean
delivery, birth trauma, neonatal morbidities).

diet along with insulin injections to control her blood An elective Caesarian section was performed on completing
sugar. Samina eventually underwent a Caesarian section 37 weeks, delivering another baby girl weighing 3 kgs.
as the baby was under stress, and delivered another baby
girl. After delivery, Samina no longer had diabetes but her Samina and her husband Faisal are proud parents of three
blood glucose levels did not revert back to normal; she had healthy and beautiful girls. She is nursing the little one
impaired glucose tolerance (IGT). She was then careful with and has to be very attentive to the middle one who had
her diet and in a period of two years lost about 7 kgs. demanded more attention after the birth of her sister. “It is a
Samina became pregnant with her third child and this time, very difficult task”, said Samina, “but I manage alright.”
she was monitored from the very beginning. She continued
with her professional responsibilities along with the work Samina has understood gestational diabetes very well. “My
at home with her two girls. The blood glucose remained in case can be taken as an example for other women,” she
the normal range with a an appropriate diet; insulin was offered. With a family history of diabetes, it is mandatory
not required. She maintained regular meal timings and to acquire a healthy lifestyle to prevent the onset of
had a daily walk. Throughout the pregnancy she was extra the metabolic disorder. When a woman marries she
careful, and the baby grew beautifully as was seen on the should take extra care to avoid obesity as that is a major
ultrasonography pictures. contributor to the risk of GDM. If GDM develops, a very
strict diet regime, insulin if advised, exercise and close
In this pregnancy, Samina had a weight gain of the normal monitoring of blood glucose are the tools to eventually
10 kgs. She felt well and truly enjoyed her baby within her. hold a normal smiling baby in one’s arms.
Prevention
As indicated above, risk of developing diabetes following

GDM in women with IGT can be reduced greatly by moderate,
sustained changes in lifestyle, or by taking medication to
improve insulin sensitivity. There have not been randomized
clinical trials to determine if GDM can be prevented in women
at ‘high risk’ for its development during pregnancy (obese,
strong family history of type 2 diabetes, member of an ethnic
group with a high prevalence of type 2 diabetes). However,
epidemiological data suggest that sustaining a healthy
lifestyle would also reduce the risk of GDM in `high risk´
individuals.

Chapter4Fin.indd Sek1:216 27/10/06 4:19:04
CHAPTER 4
DIABETES MORTALITY

In India, an
estimated 15.5% of
all deaths in adult
women are
attributable to
diabetes.

Routine health statistics based upon death certification DisMod II, a software programme, was used to estimate the
seriously underestimate mortality from diabetes1. This is number of deaths attributable to diabetes in the year 2007 in
because only a minority of persons with diabetes die from a persons 20-79 years old. The programme was developed for
cause uniquely related to the condition, such as diabetic the Global Burden of Disease 2000 study5, and is based on a
ketoacidosis or hypoglycaemia. About 50% of persons with set of differential equations that describe age-specific
diabetes die of cardiovascular disease, and 10-20% die of incidence, remission, case fatality (or relative risk on total
renal failure2. mortality), ‘all other causes’ mortality, prevalence and disease-
specific mortality. DisMod II implements exact mathematical
A study of death certificate coding practices in nine European solutions of these equations. The input data in this study were:
countries demonstrated that much of the reported variation
in diabetes mortality was due to variations in certification • Number of persons by 10-year age and sex groups for each
practices and in the national coding procedures for assigning country for the year 2007 (UN population projections).
the ‘underlying cause of death’3. Most of the variations
concerned the coding of co-morbidity involving diabetes • Expected number of all deaths in each country, by 10-year age
and ischaemic heart disease or stroke. Analysing all the stratum and gender (by applying the age and sex-specific
conditions mentioned on the certificate was shown to mortality rate for the year 2001 to the population of the year 2007).
overcome some of these problems4. However, multiple-
cause encoding is not likely to become generally available, • Estimates of diabetes prevalence by 10-year age and sex
even in industrialized countries, because of the cost involved. groups for each country for the year 2007 (see Chapter 1).
Another problem is that only some 30% of deaths worldwide
are medically certified, and alternative sources of information • Remission (equal to zero) and age and sex-specific
have to be identified to obtain information on causation. relative risks of mortality.
DIABETES MORTALITY CHAPTER 4 219

FIGURE 4.1 FIGURE 4.2
Number of deaths attributable to diabetes (20-79 age group) by Deaths attributable to diabetes as percentage of all deaths (20-79 age
region, 2007 group) by region, 2007
Number of deaths Percentage of all deaths (%)

14
600,000
12
500,000
10
400,000
300,000
6
200,000
4
100,000
2
0 0
Males
Females
• Remission of diabetes (equal to zero). 79 years old in the year 2007 is estimated at 3.8 million deaths
(1.8 million men and 2 million women). Since most deaths
• Relative risk of dying for persons with diabetes compared attributable to diabetes occur in persons 20-79 years old,
to those without diabetes, from population-based follow- these 3.8 million deaths account for more than 6% of total
up studies (see Table 4.1). The published studies were world mortality. The total number of deaths attributable to
from USA6 and Taiwan7. The unpublished relative risks of diabetes in adults 20-79 years old, as well as the percentage
death by age and sex were obtained by personal of deaths attributable to diabetes in this particular age group
communication from investigators of the DECODE and are shown in Table 4.2.
DECODA studies8,9.
Tables 4.3 - 4.16 show the number of deaths attributable to
DisMod was used to calculate the number of excess deaths diabetes in the year 2007 for 193 countries. The number of
that could be attributed to diabetes in each region, i.e. the deaths attributable to diabetes in each IDF region is shown
number of deaths among those with diabetes over and above in Figure 4.1, and the percentage of all deaths that are due
those expected according to underlying mortality rates. Given to diabetes is shown in Figure 4.2. Figure 4.3 shows the
that the diabetes-specific variables in the computer model are percentage of all deaths that are due to diabetes in the top
the prevalence, remission and relative risk of death, DisMod II 10 countries with the highest diabetes prevalence in 2007.
smoothes out the age-specific relative risks of death available
from the different studies (see Table 4.1) and calculates what The percentage of excess deaths was lowest in the poorest
proportion of all deaths is attributable to diabetes using a African countries, and in Mongolia, Chile, Paraguay, Iceland,
simple formula for population-attributable fraction10. and highest in North America, the Eastern Mediterranean
and Middle East, Mauritius and in the small Western Pacific
island countries. However, even in poor African countries
diabetes accounts for about 5% of all mortality in the
Global excess mortality attributable to diabetes in adults 20- productive age group of 30-60 year olds. Over two-thirds of

FIGURE 4.3
Deaths attributable to diabetes as percentage of all deaths in the top 10 countries for diabetes prevalence (20-79 age group), 2007
Nauru
United Arab
Emirates
Saudi Arabia
Bahrain
Kuwait
Oman
Tonga
Mauritius
Egypt
Mexico
0 10 20 30 40 50
Percentage of all deaths (%)
Males
Females
deaths attributable to diabetes occur in developing this study is three to four times greater than those given in
countries. the conventional international statistical reports largely
based on diabetes given as an underlying cause on death
In countries with a high prevalence of diabetes in younger certificates11. The number of excess deaths attributable to
age groups (in South-East Asia, Eastern Mediterranean, North diabetes is similar in magnitude to those reported for HIV/
America and Western Pacific islands), the percentage of AIDS in the year 200211.
excess deaths peaked at 50-59 years of age. In the rest of the
world, where the prevalence is higher in older age groups The higher proportion of excess deaths in females compared
the percentage of excess deaths due to diabetes was highest to males is explained by their lower background mortality
in persons 60-69 years old. In almost all countries the levels, and the larger increase in the absolute risks of dying
proportion of deaths due to diabetes was higher in females in women compared with men if diabetic, in almost all age
than in males. groups. Although diabetes is often perceived as a disease of
affluent countries, the proportion of all deaths that are
attributable to diabetes in developing countries is not
negligible. This issue of considerable preventable mortality
Although many studies of mortality in persons with diabetes due to diabetes has been recognized for type 1 diabetes12,
have demonstrated the deceptive character of routinely but the vast majority of persons have type 2 diabetes.
collected mortality statistics on diabetes, they are,
nevertheless, widely used in national and international A potential source of error in this study is that relative risks of
health reports. Such underestimation has potentially dying in persons with diabetes, compared to those without
undesirable consequences, since mortality rates are often diabetes, were obtained from studies conducted in a
used as a basis for priority setting and resource allocation. relatively small number of countries, most of them developed.
Because little data from developing countries has been
The number of deaths attributable to diabetes calculated in published in a format suitable for this study, unpublished

MAP 4.1
Deaths attributable to diabetes as percentage of all deaths in males (20-79 age group), 2007
>20%
14% - 20%
10% - 14%
8% - 10%
6% - 8%
4% - 6%
<4%
no data
data from the DECODE and DECODA studies have been used prevalence have not been conducted for more than one-
(Jaakko Tuomilehto, personal communication). third of the countries of the world, so the diabetes prevalence
for many countries was obtained by extrapolation, and error
This is unlikely to have overestimated the burden of diabetes is possible. The prevalence estimates include both diagnosed
mortality in developing countries, as available studies from and undiagnosed diabetes.
Mauritius and Brazil show that the risk of death is about three
times higher in persons with known diabetes, compared to The relative risks of dying were derived from cohort studies
individuals with normal blood glucose, or the general of patients with diabetes. The proportion of undiagnosed
population13,14. This is consistent with the sparse information diabetes varies between populations, but is rarely lower than
available from low-income countries indicating a poor 30%, and is often higher than 50%, even in developed
prognosis for persons with diabetes15. countries. The relative risk of dying may not be the same for
diagnosed and undiagnosed diabetes, but published data
The latest validated available country-specific mortality rates from the DECODE study show that mortality in people with
were for the year 2001 and it is possible that the overall undiagnosed diabetes is as high as in people with previously
number of deaths in each country has not been accurately diagnosed diabetes8. Moreover, people with a lesser degree
estimated because these mortality rates, rather than those of hyperglycaemia, impaired glucose tolerance (IGT), have a
for the year 2007, were applied to the estimated population 40% increased mortality, regardless whether they progress
size in the year 2007. It is unlikely, however, that the country- to diabetes or not16.
specific adult mortality rates have changed substantially
since 2001. One of the reasons for non-diagnosis of diabetes could be
lack of symptoms, which could reflect a milder metabolic
The age and sex-specific prevalence of diabetes by country disturbance and possibly a better prognosis. If so, the
used in this study was estimated from population-based calculated 3.8 million deaths could be an overestimate of the
surveys. However, population-based studies of diabetes true number. The results of the DECODE study indicate that

MAP 4.2
Deaths attributable to diabetes as percentage of all deaths in females (20-79 age group), 2007
>20%
14% - 20%
10% - 14%
8% - 10%
6% - 8%
4% - 6%
<4%
no data
risk of death is not significantly different between previously

and newly diagnosed persons with diabetes, when
unrecognized diabetes is defined by the two-hour post-load
glucose value rather than by fasting glucose8.
Although these mortality estimates are unlikely to be

accurate, given the assumptions on which the calculations
are based, they do provide a more realistic estimate of
diabetes-attributable mortality than currently exist. The
number of deaths related to hyperglycaemia would likely be
even higher if mortality attributable to IGT were taken into
account17.

TABLE 4.1
Age and sex-specific relative risks of death used to estimate the proportion of all deaths attributable to diabetes
a b c d e
DECODE STUDY DECODA STUDY DECODA STUDY TAIWAN STUDY NHANES
(Indians in Mauritius and Fiji) (All)
Age group Males Females Males Females Males Females Males Females Males Females
20-29 3.66 6.05 3.40 5.12 3.70 5.95 5.42 4.68 3.08 3.20
30-39 3.38 5.41 3.50 4.98 3.30 5.61 5.26 4.64 4.60 3.10
40-49 1.85 3.14 2.60 3.65 1.95 3.41 4.24 4.25 2.80 2.80
50-59 1.63 2.64 2.30 3.29 1.65 2.73 3.02 3.44 2.00 2.60
60-69 1.60 2.04 1.60 2.51 1.62 2.08 2.22 2.58 1.65 2.10
70-79 1.39 1.79 1.50 2.42 1.40 1.78 1.46 1.61 1.40 1.60
a. Used for Europe, Australia and New Zealand

b. Used for South Asia
c. Used for Africa and Eastern Mediterranean
d. Used for Western Pacific (except Australia and New Zealand)
e. Used for North and South America and the Caribbean
TABLE 4.2
Regional estimates of death attributable to diabetes in males and females (20-79 age group), 2007
REGION MALE FEMALE TOTAL DM AS % OF

ALL DEATHS
AFR 133,055 204,322 337,377 5.4
EMME 115,933 181,531 297,464 11.5
EUR 329,423 391,873 721,296 11.1
NA 122,505 119,129 241,634 11.8
SACA 90,461 98,192 188,653 9.4
SEA 430,109 587,100 1,017,209 12.1
WP 544,719 432,918 977,637 8.6
Total 1,766,205 2,015,065 3,781,270 9.6

TABLE 4.3
Number of deaths attributable to diabetes in males (20-79 age group), 2007 - African Region
COUNTRY AGE GROUPS (YRS) TOTAL DM AS % OF

20-29 30-39 40-49 50-59 60-69 70-79 ALL DEATHS
Angola 540 1,131 662 449 402 222 3,406 3.6

Benin 171 346 243 244 260 155 1,418 5.1
Botswana 31 138 102 66 49 35 421 3.4
Burkina Faso 333 791 427 333 467 284 2,635 4.3
Burundi 216 330 148 90 65 51 901 1.8
Cameroon 723 1,145 512 416 594 540 3,930 5.7
Cape Verde 5 8 5 3 7 12 40 5.4
Central African Republic 153 333 187 148 162 119 1,104 5.1
Chad 2 67 177 268 285 104 905 2.7
Comoros 7 12 10 12 15 9 64 3.4
Congo 95 228 116 91 119 85 734 5.8
Congo, Democratic Republic of 1,272 2,787 1,577 1,235 1,292 770 8,935 3.3
Côte d’Ivoire 660 1,506 889 759 864 531 5,209 5.3
Djibouti 0 6 18 32 38 13 108 4.3
Equatorial Guinea 8 15 12 15 21 15 86 5.2
Eritrea 53 126 54 41 63 39 376 2.3
Ethiopia 928 2,150 1,304 1,112 1,351 976 7,822 2.6
Gabon 20 41 36 52 78 52 279 5.4
Gambia 19 38 35 42 57 35 226 4.7
Ghana 206 670 571 664 884 527 3,522 4.7
Guinea 173 341 246 274 390 241 1,664 4.7
Guinea-Bissau 25 54 37 36 44 27 222 4.1
Kenya 887 2,365 1,164 725 632 560 6,332 3.9
Lesotho 67 192 123 93 78 59 613 4.1
Liberia 130 187 88 101 122 71 698 5.3
Madagascar 154 315 287 345 441 331 1,873 3.5
Malawi 316 653 326 221 228 164 1,907 2.6
Mali 302 579 352 325 487 411 2,457 4.6
Mauritania 1 19 62 101 124 37 343 3.6
Mozambique 452 1,160 696 642 696 441 4,086 4.3
Namibia 31 123 84 56 57 47 398 4.1
Niger 323 612 415 365 345 181 2,240 4.4
Nigeria 2,865 5,305 3,508 3,626 4,563 2,960 22,825 5.2
Rwanda 263 331 136 95 114 104 1,041 1.8
Sao Tome and Principe 2 3 1 1 2 3 12 5.0
Senegal 149 245 175 212 282 172 1,235 5.2
Seychelles 1 3 5 9 12 8 37 11.8
Sierra Leone 256 556 370 271 275 146 1,875 5.0
Somalia 207 481 269 213 204 130 1,503 3.4
South Africa 785 3,610 2,903 2,194 1,976 1,198 12,666 4.2
Swaziland 589 2,051 1,536 1,338 1,471 982 7,969 4.2
Tanzania, United Republic of 810 2,053 1,129 840 878 553 6,262 3.3
Togo 140 289 174 156 190 130 1,079 4..8
Uganda 494 999 445 336 396 346 3,016 2..5
Zambia 527 1,619 718 390 344 231 3,830 4.6
Zimbabwe 564 1,868 1,008 551 433 329 4,754 4.0
AFR Total - males 15,958 37,880 23,339 19,586 21,857 14,434 133,055 •

TABLE 4.4
Number of deaths attributable to diabetes in females (20-79 age group), 2007 - African Region

20-29 30-39 40-49 50-59 60-69 70-79 ALL DEATHS
Angola 943 1,380 794 679 507 404 4,708 6.2

Benin 444 485 272 310 324 362 2,196 8.5
Botswana 151 426 267 160 104 125 1,233 9.1
Burkina Faso 1,171 1,277 476 408 433 530 4,297 7.5
Burundi 294 452 230 171 129 145 1,421 3.2
Cameroon 2,022 1,984 773 634 641 722 6,776 10.2
Cape Verde 5 8 8 7 13 32 74 8.9
Central African Republic 527 537 229 198 199 247 1,938 8.7
Chad 99 477 445 455 446 431 2,354 7.6
Comoros 8 15 15 17 18 16 88 5.8
Congo 297 361 143 121 136 174 1,232 9.8
Congo. Democratic Republic of 2,190 3,664 2,005 1,865 1,725 1,546 12,995 5.6
Côte d’Ivoire 2,055 2,188 865 737 722 787 7,354 9.1
Djibouti 7 52 69 79 75 59 341 11.9
Equatorial Guinea 21 23 15 20 24 29 131 8.6
Eritrea 114 208 95 101 99 92 709 4.4
Ethiopia 1,920 3,286 1,866 1,777 1,643 1,575 12,067 4.3
Gabon 48 68 46 71 75 102 410 8.9
Gambia 33 47 39 47 54 58 278 7.7
Ghana 579 925 612 735 862 1,006 4,718 7.4
Guinea 358 433 268 319 398 423 2,200 7.8
Guinea-Bissau 67 82 47 52 55 61 364 7.4
Kenya 2,347 3,552 1,477 976 652 726 9,731 6.3
Lesotho 211 428 265 210 158 164 1,436 8.8
Liberia 316 235 88 118 129 136 1,022 8.9
Madagascar 270 459 405 494 472 450 2,550 5.5
Malawi 672 945 445 364 295 243 2,963 4.0
Mali 807 827 420 458 604 801 3,917 7.7
Mauritania 34 111 145 190 210 195 885 10.0
Mozambique 1,024 1,794 958 867 760 646 6,049 7.0
Namibia 103 277 179 129 102 113 902 9.5
Niger 828 833 458 466 412 344 3,341 7.5
Nigeria 7,360 7,683 4,194 4,677 5,066 5,551 34,530 8.6
Rwanda 281 403 173 142 133 148 1,278 2.7
Sao Tome and Principe 3 5 3 3 6 8 28 8.3
Senegal 323 379 258 339 338 291 1,927 8.6
Seychelles 0 2 3 8 10 15 39 22.7
Sierra Leone 639 706 372 336 316 282 2,651 8.4
Somalia 338 628 330 281 212 172 1,960 5.5
South Africa 2,561 8,480 5,912 4,319 3,436 3,507 28,216 10.0
Swaziland 96 182 112 83 58 56 587 8.7
Tanzania. United Republic of 1,922 3,059 1,578 1,400 1,234 1,107 10,300 5.5
Togo 403 455 215 201 212 255 1,742 8.1
Uganda 855 1,362 570 511 452 464 4,215 3.8
Zambia 1,565 2,397 800 487 362 321 5,933 7.3
Zimbabwe 1,899 3,771 1,917 1,173 746 730 10,237 8.5
AFR Total - females 38,212 57,348 30,858 27,194 25,058 25,651 204,322 •

TABLE 4.5
Number of deaths attributable to diabetes in males (20-79 age group), 2007 - Eastern Mediterranean and Middle East Region

20-29 30-39 40-49 50-59 60-69 70-79 ALL DEATHS
Afghanistan 1,111 3,312 2,842 2,738 2,630 1,030 13,662 9.5

Algeria 398 548 553 899 1,391 1,539 5,327 8.0
Armenia 5 22 80 205 397 554 1,263 7.6
Bahrain 2 14 55 74 55 29 230 13.3
Egypt 811 1,858 2,629 4,201 4,707 2,807 17,013 8.4
Iran. Islamic Republic of 203 630 1,284 3,106 3,761 3,291 12,276 7.5
Iraq 125 591 886 1,368 1,937 1,067 5,974 9.4
Jordan 17 87 128 188 364 214 999 9.4
Kuwait 14 18 52 114 257 173 628 14.6
Lebanon 4 26 62 154 357 405 1,008 9.1
Libyan Arab Jamahiriya 36 46 41 85 186 182 576 4.0
Morocco 171 376 401 790 1,191 1,015 3,944 7.5
Oman 29 52 103 154 153 114 604 11.3
Pakistan 1,225 3,525 5,504 8,801 10,062 5,243 34,360 8.7
Qatar 8 46 79 107 64 11 315 14.7
Saudi Arabia 91 270 867 1,720 1,815 1,106 5,869 10.9
Sudan 15 243 591 1,176 1,470 471 3,966 3.0
Syrian Arab Republic 307 373 312 474 981 1,238 3,686 11.0
Tunisia 48 98 137 224 308 255 1,070 4.0
United Arab Emirates 29 121 358 540 654 266 1,967 17.3
Yemen 188 297 133 178 256 144 1,196 3.0
EMME Total - males 4,839 12,554 17,096 27,296 32,996 21,153 115,933 •
TABLE 4.6
Number of deaths attributable to diabetes in females (20-79 age group), 2007 - Eastern Mediterranean and Middle East Region

20-29 30-39 40-49 50-59 60-69 70-79 ALL DEATHS
Afghanistan 1,741 3,345 2,926 3,462 3,066 1,990 16,530 15.9

Algeria 404 843 1,072 1,582 1,847 2,732 8,480 15.1
Armenia 5 31 138 356 595 1,137 2,261 16.6
Bahrain 1 9 41 51 81 71 254 25.0
Egypt 767 1,742 3,520 8,402 11,834 14,872 41,136 21.6
Iran, Islamic Republic of 191 775 1,796 4,207 4,575 5,557 17,100 14.9
Iraq 157 766 1,244 1,959 2,326 1,909 8,362 17.4
Jordan 14 86 161 249 333 272 1,117 17.6
Kuwait 7 13 39 98 158 151 466 25.8
Lebanon 1 15 93 278 467 642 1,496 16.8
Libyan Arab Jamahiriya 51 83 90 151 199 286 861 10.9
Morocco 111 451 681 1,265 1,350 1,836 5,694 14.0
Oman 23 48 74 119 152 156 572 21.7
Pakistan 2,869 6,066 7,681 11,678 12,782 12,042 53,118 15.9
Qatar 2 17 37 40 23 11 130 26.9
Saudi Arabia 93 276 644 1,029 1,375 1,121 4,539 18.8
Sudan 319 1,162 1,361 2,089 2,325 1,966 9,222 8.9
Syrian Arab Republic 227 390 464 756 1,140 1,822 4,799 20.4
Tunisia 57 152 269 450 521 785 2,234 11.6
United Arab Emirates 18 58 180 213 189 133 791 31.6
Yemen 299 450 391 504 432 292 2,368 6.0
EMME Total - females 7,357 16,778 22,902 38,938 45,771 49,783 181,531 •

TABLE 4.7
Number of deaths attributable to diabetes in males (20-79 age group), 2007 - European Region

20-29 30-39 40-49 50-59 60-69 70-79 ALL DEATHS
Albania 13 25 33 73 204 240 587 4.4

Andorra 0 0 1 2 6 9 18 8.3
Austria 5 27 90 306 1,006 1,394 2,828 10.8
Azerbaijan 27 79 193 449 699 968 2,415 7.0
Belarus 149 388 569 1,082 1,475 1,615 5,279 8.6
Belgium 2 17 64 298 919 1,817 3,117 8.5
Bosnia and Herzegovina 10 37 70 199 502 576 1,394 7.3
Bulgaria 11 66 169 572 1,147 1,357 3,323 7.6
Croatia 7 29 115 258 749 934 2,091 7.4
Cyprus 5 8 18 39 86 89 244 10.8
Czech Republic 41 113 191 661 1,418 1,587 4,010 9.0
Denmark 1 14 57 210 562 472 1,317 7.0
Estonia 13 39 59 121 215 227 674 8.8
Finland 10 29 58 195 500 883 1,676 9.0
France 54 158 470 2,055 4,786 7,593 15,116 8.1
Georgia 11 57 122 256 609 752 1,808 7.3
Germany 45 283 1,017 3,077 12,737 17,602 34,761 11.1
Greece 17 53 79 267 829 1,907 3,153 8.5
Hungary 42 211 382 995 1,749 1,779 5,157 8..9
Iceland 0 0 0 2 4 9 16 2.8
Ireland 10 23 30 87 253 386 789 6.4
Israel 11 37 53 217 515 947 1,780 13.1
Italy 22 175 396 1,591 5,843 9,250 17,277 8.6
Kazakhstan 74 370 763 1,382 1,576 937 5,101 6.6
Kyrgyzstan 11 74 158 310 369 243 1,165 6.2
Latvia 18 55 69 172 337 434 1,085 8.9
Liechtenstein 0 0 0 1 3 5 9 10..7
Lithuania 35 94 142 241 471 543 1,526 8.8
Luxembourg 0 1 3 12 41 65 122 8.3
Macedonia, the Former Yugoslav Republic of 9 23 33 100 216 248 629 7.1
Malta 0 0 2 11 40 59 112 9.2
Moldova 40 111 178 383 568 600 1,880 8.7
Monaco 0 0 0 1 2 4 7 8.0
Netherlands 2 17 77 393 1,411 2,302 4,202 8.6
Norway 6 16 23 72 218 391 726 5.6
Poland 224 608 1,104 2,933 4,455 5,612 14,937 8.8
Portugal 7 55 120 352 1,104 1,869 3,505 8.3
Romania 116 458 642 1,609 2,975 4,002 9,802 8.9
Russian Federation 3,586 7,055 9,909 19,783 26,818 26,936 94,087 8.6
San Marino 0 0 0 1 2 3 6 8.5
Serbia and Montenegroa 16 65 168 635 1,320 1,681 3,886 7.4
Slovakia 29 79 146 406 693 1,701 3,054 12.9
Slovenia 9 25 44 114 250 310 753 9.0
Spain 18 173 358 1,137 3,585 6,294 11,565 8.4
Sweden 7 23 45 149 526 813 1,563 6.3
Switzerland 4 21 60 210 686 1,044 2,025 1.8
Tajikistan 15 69 139 189 304 197 914 5.4
Turkey 125 590 1,417 3,365 5,520 4,306 15,323 7.4
Turkmenistan 16 84 179 290 346 213 1,128 6.1
Ukraine 597 1,787 2,667 4,915 9,151 9,238 28,354 8.8
United Kingdom 2 35 178 943 3,386 3,973 8,517 4.2
Uzbekistan 52 276 600 1,122 1,565 994 4,609 6.2
EUR Total - males 5,524 14,034 23,462 54,241 104,750 127,412 329,423 •
a. Estimates made prior to the establishment of Serbia and Montenegro as independent countries

TABLE 4.8
Number of deaths attributable to diabetes in females (20-79 age group), 2007 - European Region

20-29 30-39 40-49 50-59 60-69 70-79 ALL DEATHS
Albania 24 23 35 60 154 508 805 10.6
Andorra 0 0 0 2 4 11 17 15.0
Austria 7 30 115 318 711 1,926 3,107 19.6
Azerbaijan 24 104 308 730 1,129 2,579 4,873 15.8
Belarus 15 74 272 921 1,641 4,063 6,986 16.4
Belgium 1 11 69 316 680 2,181 3,259 14.9
Bosnia and Herzegovina 6 34 96 276 563 1,024 1,998 15.5
Bulgaria 11 74 207 744 1,369 2,945 5,351 16.5
Croatia 4 24 118 286 626 1,692 2,750 15.6
Cyprus 1 3 9 19 40 122 194 12.9
Czech Republic 5 30 119 593 1,200 2,867 4,814 16.8
Denmark 6 24 63 205 486 899 1,683 12.3
Estonia 1 8 30 105 204 466 813 16.6
Finland 7 18 48 151 285 910 1,420 13.5
France 34 132 513 2,155 3,319 8,899 15,052 15.2
Georgia 9 46 149 375 931 1,754 3,264 16.1
Germany 69 308 1,174 3,283 9,178 22,584 36,595 19.7
Greece 6 26 66 235 679 3,110 4,123 17.5
Hungary 5 58 231 902 1,672 3,645 6,514 16.6
Iceland 0 0 0 2 4 13 20 4.7
Ireland 10 33 41 94 162 378 718 9.4
Israel 1 11 35 183 382 1,013 1,624 16.6
Italy 9 94 379 1,547 4,060 11,301 17,390 14.5
Kazakhstan 4 63 437 1,594 2,198 1,939 6,234 9.9
Kyrgyzstan 1 15 87 286 353 427 1,169 8.6
Latvia 2 10 34 134 242 580 1,003 16.5
Liechtenstein 0 0 0 1 2 6 10 19.4
Lithuania 3 19 75 197 427 1,055 1,776 16.4
Luxembourg 0 0 3 13 28 84 128 14.8
Macedonia, the Former Yugoslav Republic of 3 15 50 142 278 532 1,020 15.7
Malta 0 0 2 17 49 97 165 20.2
Moldova 6 29 121 454 774 1,425 2,807 16.2
Monaco 0 0 0 1 2 5 8 15.2
Netherlands 1 17 112 522 1,176 2,828 4,656 14.6
Norway 3 11 21 68 138 402 642 8.1
Poland 24 130 610 2,524 3,815 10,098 17,201 16.6
Portugal 1 15 80 334 853 2,494 3,777 15.1
Romania 18 144 415 1,587 3,177 8,013 13,354 16.6
Russian Federation 321 1,410 4,777 16,215 25,724 58,655 107,103 16.2
San Marino 0 0 0 1 1 4 6 14.4
Serbia and Montenegroa 12 77 238 924 1,644 3,665 6,562 15.7
Slovakia 3 17 78 312 616 1,490 2,516 16.7
Slovenia 1 6 29 105 188 506 834 16.7
Spain 3 48 225 872 2,300 7,574 11,022 15.1
Sweden 9 24 53 202 511 1,574 2,373 14.8
Switzerland 7 26 77 274 572 1,287 2,244 19,.3
Tajikistan 2 23 111 239 260 245 880 7.6
Turkey 176 848 2,167 4,969 8,155 10,454 26,769 16.9
Turkmenistan 1 18 90 305 343 358 1,115 8.7
Ukraine 67 394 1,313 4,435 10,117 21,047 37,374 16.5
United Kingdom 34 141 377 1,150 2,594 6,696 10,992 7.7
Uzbekistan 6 72 387 1,191 1,523 1,585 4,763 8.5
EUR Total - females 962 4,740 16,048 52,570 97,539 220,013 391,873 •
a. Estimates made prior to the establishment of Serbia and Montenegro as independent countries

TABLE 4.9
Number of deaths attributable to diabetes in males (20-79 age group), 2007 - North American Region
COUNTRY AGE GROUPS (YRS) TOTAL DM AS %

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Antigua and Barbuda 0 1 2 4 5 5 17 8.2
Bahamas 1 14 21 23 23 15 96 10.3
Barbados 1 6 14 19 16 11 66 7.8
Belize 1 5 9 13 11 5 43 8.2
Canada 29 224 687 1,650 3,002 3,987 9,579 11.4
Dominica 0 2 5 5 4 2 18 10.3
Grenada 0 3 6 9 7 3 29 8.3
Guyana 3 31 53 60 42 18 206 8.5
Haiti 133 1,499 1,231 788 514 184 4,350 8.4
Jamaica 4 40 100 144 152 85 525 8.0
Mexico 545 3,138 3,733 4,823 5,777 5,066 23,082 11.2
Saint Kitts and Nevis 0 1 2 3 3 1 9 7.8
Saint Lucia 0 3 8 10 8 4 34 8.1
Saint Vincent and the Grenadines 0 4 9 9 10 7 40 10.9
Trinidad and Tobago 4 46 97 145 119 38 449 9.5
United States of America 1,078 2,332 15,578 16,747 26,976 21,250 83,962 10.0
NA Total - males 1,800 7,348 21,555 24,454 36,669 30,679 122,505 •
TABLE 4.10
Number of deaths attributable to diabetes in females (20-79 age group), 2007 - North American Region

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Antigua and Barbuda 0 0 2 5 7 8 21 13.7
Bahamas 1 6 18 27 36 29 117 17.4
Barbados 0 2 9 20 26 30 87 14..9
Belize 1 3 8 14 17 17 58 17.1
Canada 13 67 377 1,276 2,241 3,164 7,137 13.2
Dominica 0 1 3 6 7 7 25 20.1
Grenada 0 2 7 15 16 13 54 17.6
Guyana 4 19 52 90 99 88 352 16.9
Haiti 167 586 865 1,245 1,251 840 4,955 14.3
Jamaica 5 29 112 198 273 344 960 18.4
Mexico 224 927 2,712 6,860 9,884 9,123 29,731 20.2
Saint Kitts and Nevis 0 0 2 4 5 4 16 17.1
Saint Lucia 0 2 10 15 20 15 62 17.6
Saint Vincent and the Grenadines 0 2 9 13 15 12 51 17.0
Trinidad and Tobago 5 21 80 190 259 180 736 21.2
United States of America 610 1,099 5,618 10,343 28,312 28,786 74,768 12.4
NA Total - females 1,031 2,766 9,884 20,320 42,469 42,660 119,129 •

TABLE 4.11
Number of deaths attributable to diabetes in males (20-79 age group), 2007 - South and Central American Region

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Argentina 35 347 998 2,230 2,998 2,062 8,669 7.1
Bolivia 27 183 306 456 497 316 1,784 7.1
Brazil 862 4,397 7,595 10,171 11,555 9,786 44,367 7.8
Chile 23 194 431 652 816 615 2,731 7.0
Colombia 120 844 1,302 1,625 1,969 1,307 7,167 5.7
Costa Rica 16 64 124 166 217 236 823 9.9
Cuba 11 216 515 658 715 316 2,431 7.8
Dominican Republic 36 344 518 520 425 169 2,012 7.7
Ecuador 46 299 415 544 533 448 2,284 6.7
El Salvador 67 332 287 294 323 327 1,629 9.2
Guatemala 101 384 402 470 546 664 2,566 8.8
Honduras 55 263 264 302 375 381 1,641 9.4
Nicaragua 34 153 185 202 219 195 988 10.4
Panama 16 81 96 113 164 175 646 10.1
Paraguay 9 63 134 192 141 51 589 5.1
Peru 79 618 889 1,151 1,290 1,069 5,096 7.2
Suriname 4 21 40 39 34 21 158 9.7
Uruguay 2 26 59 149 231 188 654 6.9
Venezuela 140 472 672 881 1,103 958 4,225 7.5
SACA Total - males 1,683 9,301 15,230 20,814 24,149 19,284 90,461 •
TABLE 4.12
Number of deaths attributable to diabetes in females (20-79 age group), 2007 - South and Central American Region

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Argentina 14 106 549 1,712 2,477 2,285 7,143 9.7
Bolivia 18 88 257 593 766 577 2,301 10.3
Brazil 219 1,005 4,170 10,799 16,063 15,534 47,790 12.6
Chile 7 42 220 558 797 671 2,296 9.6
Colombia 20 162 760 2,078 2,779 1,473 7,272 9.7
Costa Rica 9 23 85 201 317 363 996 18.1
Cuba 11 98 410 878 1,480 1,235 4,112 18.2
Dominican Republic 38 146 354 597 762 549 2,445 15.8
Ecuador 15 74 258 628 758 623 2,356 10.4
El Salvador 23 88 192 475 636 661 2,074 17.1
Guatemala 52 142 330 753 1,088 1,317 3,682 16.1
Honduras 33 94 188 359 529 642 1,846 1.3
Nicaragua 21 64 167 313 401 372 1,337 18.2
Panama 7 30 63 142 229 211 682 18.2
Paraguay 9 25 75 179 270 356 914 10.3
Peru 38 182 653 1,427 1,819 1,555 5,674 10.8
Suriname 2 8 27 46 58 48 189 16.9
Uruguay 1 6 34 115 174 162 492 9.8
Venezuela 29 109 412 979 1,563 1,499 4,591 12.6
SACA Total - females 566 2,492 9,205 22,832 32,967 30,131 98,192 •

TABLE 4.13
Number of deaths attributable to diabetes in males (20-79 age group), 2007 - South-East Asian Region

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Bangladesh 1,819 3,286 4,467 6,492 3,905 3,603 23,573 6.2
Bhutan 16 41 62 123 119 151 511 7.9
India 10,533 32,458 58,432 110,831 88,131 94,043 394,427 9.7
Maldives 3 5 11 23 17 7 65 7.7
Mauritius 5 29 101 176 115 84 510 11.8
Nepal 24 85 234 2,040 1,191 296 3,869 5.1
Sri Lanka 654 882 1,267 1,988 1,286 1,078 7,154 8.8
SEA Total - males 13,054 36,786 64,574 121,672 94,762 99,262 430,109 •
TABLE 4.14
Number of deaths attributable to diabetes in females (20-79 age group), 2007 - South-East Asian Region

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Bangladesh 3,702 6,283 7,408 9,849 9,791 12,697 49,729 13.6
Bhutan 29 38 65 138 194 269 732 13.4
India 18,254 24,566 49,497 106,537 144,264 171,386 514,505 15.5
Maldives 3 8 8 27 38 49 133 16.9
Mauritius 4 14 50 140 169 256 633 23.5
Nepal 413 752 1,037 1,934 2,711 4,235 11,082 13.6
Sri Lanka 210 430 830 1,594 2,432 4,791 10,287 22.1
SEA Total - females 22,615 32,090 58,895 120,219 159,598 193,683 587,100 •
TABLE 4.15
Number of deaths attributable to diabetes in males (20-79 age group), 2007 - Western Pacific Region

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Australia 7 47 101 403 1,224 1,867 3,648 7.9
Brunei Darussalam 0 5 25 57 54 21 163 24.5
Cambodia 303 870 1,246 1,279 820 213 4,731 10.1
China 6,343 20,648 51,194 97,676 99,086 48,598 323,544 8.0
Cook Islands 0 0 1 1 1 1 4 7.9
Fiji 3 19 80 131 107 23 363 17.5
Indonesia 142 1,297 6,029 12,090 13,268 4,449 37,274 5.1
Japan 127 813 2,991 9,933 16,865 11,340 42,068 10.6
Kiribati 1 4 9 15 14 6 51 12.2
Korea, Democratic People’s Republic of 169 834 2,053 2,701 3,766 1,072 10,595 12.3
Korea, Republic of 271 1,557 5,324 7,198 8,346 3,866 26,562 15.7
Lao People’s Democratic Republic 43 118 225 279 265 126 1,056 5.8
Malaysia 53 368 1,559 3,488 4,284 2,094 11,846 17.9
Marshall Islands 1 4 11 16 13 5 52 17.0
Micronesia, Federated States of 2 6 13 30 28 15 95 28.8
Mongolia 9 40 103 79 78 13 323 4.1
Myanmar 655 1,932 2,527 3,341 3,186 1,440 13,081 5.9
Nauru 1 4 9 11 8 3 37 40.6

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
New Zealand 9 20 33 100 248 338 748 7.4
Niue 0 0 0 0 0 0 1 11.1
Palau 0 1 2 4 4 2 12 16.3
Papua New Guinea 3 18 103 285 285 71 766 5.4
Philippines 441 2,178 5,460 7,366 6,027 1,544 23,016 10.1
Samoa 0 2 10 17 19 8 56 13.8
Singapore 7 46 228 535 746 507 2,068 20.9
Solomon Islands 0 1 4 16 23 6 51 6.1
Thailand 1,249 4,425 6,330 7,803 7,489 3,698 30,994 13.1
Timor-Leste 0 3 16 31 33 8 91 4.0
Tonga 0 1 2 3 3 1 10 19.4
Tuvalu 0 1 2 3 3 1 10 19.6
Vanuatu 0 1 3 9 13 4 29 5.9
Viet Nam 319 822 2,024 2,920 3,089 2,199 11,372 5.3
WP Total - males 10,159 36,087 87,719 157,820 169,395 83,538 544,719 •
TABLE 4.16
Number of deaths attributable to diabetes in females (20-79 age group), 2007 - Western Pacific Region

20-29 30-39 40-49 50-59 60-69 70-79 OF ALL DEATHS
Australia 10 47 130 433 783 1,807 3,210 11.4
Brunei Darussalam 1 5 11 37 28 42 124 27.7
Cambodia 143 256 346 970 791 753 3,259 7.6
China 1,033 5,021 10,633 54,225 62,388 113,488 246,787 8.3
Cook Islands 0 0 0 1 1 2 4 10.7
Fiji 7 12 23 73 65 60 240 15.1
Indonesia 317 807 1,515 6,683 10,116 18,223 37,659 5.7
Japan 32 285 772 4,251 7,480 19,930 32,750 15.8
Kiribati 1 2 2 8 9 15 37 10.6
Korea, Democratic People’s Republic of 98 247 345 1,074 1,855 2,253 5,872 8.4
Korea, Republic 126 78 356 1,779 3,494 9,773 15,606 16.8
Lao People’s Democratic Republic 31 52 69 250 312 495 1,209 6.9
Malaysia 43 174 466 2,170 2,970 4,876 10,699 22.9
Marshall Islands 1 2 3 10 9 13 38 14.6
Micronesia, Federated States of 2 3 4 16 17 26 69 25.8
Mongolia 3 10 20 50 61 46 190 3.6
Myanmar 257 477 612 2,604 3,182 5,503 12,636 7.5
Nauru 0 1 3 6 5 4 19 32.6
New Zealand 5 20 60 161 264 401 911 13.3
Niue 0 0 0 0 0 0 0 10.3
Palau 0 0 1 2 2 4 9 15.0
Papua New Guinea 11 26 47 205 210 247 745 6.4
Philippines 467 1,080 1,699 5,471 6,600 8,814 24,130 18.0
Samoa 0 1 3 11 15 24 54 16.3
Singapore 2 13 49 284 463 1,028 1,840 27.6
Solomon Islands 1 1 2 10 14 15 44 7.4
Thailand 804 1,070 1,262 4,413 5,256 8,984 21,789 13.2
Timor-Leste 1 1 4 16 21 28 72 3.9
Tonga 0 0 1 2 2 3 9 19.7
Tuvalu 0 0 1 2 2 3 9 19.8
Vanuatu 0 1 1 6 8 9 26 7.2
Viet Nam 103 251 494 2,004 2,652 7,368 12,873 8.1
WP Total - females 3,500 9,945 18,936 87,230 109,074 204,234 432,918 •

CHAPTER 5
THE ECONOMIC IMPACTS OF DIABETES

In 2007, the mean health
expenditure for a person with
diabetes in Fiji is estimated to be
at least USD142.
5.0
THE ECONOMIC IMPACTS OF DIABETES
Diabetes costs hundreds of billions of dollars to treat each

year. World treatment costs are growing more quickly than
world population. However, the larger costs of diabetes arise
from disability and loss of life caused by its preventable
complications, including heart, kidney, eye and foot disease.
Introduction Higher-income countries spend large sums to treat diabetic

complications. In these countries, even expensive
G lobal health expenditures to treat and prevent diabetes

and its complications will total at least USD232.0 billion
in 2007. By 2025, this number will exceed USD302.5 billion.
interventions to prevent these complications can be cost-
effective. However, a long list of diabetes interventions is
cost-effective around the globe, in both developing and
Expressed in international dollars (ID), which correct for developed locales. Some of these treatments can save further
differences in purchasing power, at least ID286.1 billion of medical expenditures.
goods and services will be consumed by diabetes in 2007,
and at least ID381.1 billion in 2025. The world suffers huge losses in the form of foregone
economic growth as a result of diabetes. Lost economic
More than 80% of expenditures for medical care for diabetes growth may be a relatively greater problem in poorer
are made in the world’s economically richest countries, not countries. Between 2005 and 2015, the World Health
in the low- and middle-income countries where 80% of Organization (WHO) predicts net losses in national income
persons with diabetes will soon live. In the world’s poorest from diabetes and cardiovascular disease of ID557.7 billion
countries, not enough is spent to provide even the least in China, ID303.2 billion in the Russian Federation, ID336.6
expensive lifesaving diabetes drugs. billion in India, ID49.2 billion in Brazil and ID2.5 billion in the
United Republic of Tanzania (2005 ID).
In poor and middle-income countries, medical care purchases
primarily go towards preventing the immediate life- These losses arise from the premature death and disability
threatening diabetic complication, high blood sugar. Little is that untreated diabetes causes. Perhaps 25 million years of
spent to prevent cardiovascular disease, the predominant life are lost annually to mortality caused by diabetes. Reduced
cause of death from diabetes, and little is available to treat quality of life may reach a similar magnitude among the
complications when they appear. living.
THE ECONOMIC IMPACTS OF DIABETES CHAPTER 5 237

Health expenditures for diabetes capita health spending into estimates of spending caused
by diabetes. Based on current evidence, which is very limited,
we think that R rarely falls below 2.0 in any country and rarely
New estimates for 2007 and 2025 exceeds 3.0. In the industrialized countries of North America,
Europe and the Western Pacific, R has probably been falling
In 2003, the second edition of the Diabetes Atlas presented and a value closer to 2.0 should be assumed3. In other
the first worldwide Tables of country-specific estimates of countries, it is impossible as yet to recommend a ratio (see
expenditures for health and medical care caused by diabetes. Appendix 3 for details).
These estimates were generated using a formula that
combines estimates of total national health spending, the Annual total health expenditures for diabetes in 2007
prevalence of diabetes by country, and the ratio of diabetic The annual global health expenditure for diabetes in 2007
to non-diabetic medical care expenses (‘R’)1. For this edition is estimated to fall between USD232.0 billion (assuming
of the Atlas, a more complex version of this formula was R=2) and USD421.7 billion (assuming R=3). One country,
used. Instead of relying on one value for R and one value for the United States of America (USA), will spend more than
countrywide per capita health expenditures, the expanded half of this amount (USD119.4 billion assuming R=2, or
formula used different values for each of 42 different 52%). The European Region (EUR, Table 5.5) will spend
subgroups, according to age and sex within each country. about half of the US amount (USD64.0 billion, R=2) and the
Expenditure estimates nearly doubled using the more Western Pacific Region (WP, Table 5.9), which includes
precise formula. Appendix 3 details and critiques the formula Australia, China, Japan and Korea, will spend slightly less
and the data. than half the European total (USD28.8 billion, 12.5% of
global spending).
How to read the Tables of health expenditures
Table 5.1 provides a summary of the global health expenditure The remaining 9.2% of global spending will be divided
in the years 2007 and 2025. Table 5.2 summarizes the new among South-East Asia, the Eastern Mediterranean and
estimates by region, age and sex. Tables 5.3 - 5.9 display total Middle East, South and Central America, Africa and the
estimated national health expenditures caused by diabetes remainder of North America. India, the country with the
for 193 countries in the years 2007 and 2025. For 2007, these largest population of persons living with diabetes, will spend
Tables also show the estimated per person expenditure for an estimated USD2.0 billion (R=2). The 47 countries in the
diabetes for each person with diabetes. These are not total African Region (AFR, Table 5.3) will spend, in total, USD0.7
expenditures per person with diabetes; they are only the billion for diabetes (R=2, 0.3% of the global total). Figure 5.1
expenditures caused by diabetes. They include expenditures graphs expected 2007 expenditures for diabetes by IDF
for public health programmes as well as payments for region, assuming R=2.
medical care (see Appendix 3).
Three-quarters of global expenditures for the care of diabetes
Estimates are shown in both United States dollars (USD) and in 2007 will be used for persons who are between 50 and 80
international dollars (ID). US dollars are best used to compare years of age. This is because the prevalence of diabetes is
currency prices or expenditures for diabetes care. much higher in older age groups, and because persons who
International dollars are corrected for differences in prices have lived with diabetes for many years have higher rates of
among countries (see explanatory note). Estimates in ID are complications, which are expensive to treat. Also, the
best used to compare the amount of diabetes care that countries that spend the most per capita for diabetes have
countries produce. Amounts in both USD and ID are older populations. In countries and regions with younger
expressed as of their value in 2002, the most recent year for populations, such as Africa, the Eastern Mediterranean and
which national health expenditure estimates have been Middle East, and South-East Asia, younger persons consume
published2. larger shares of spending.
Estimates are shown at two values of the diabetes expenditure More money is expected to be spent on diabetes care for
ratio, R. R is the ratio of medical care expenditures for persons women than for men (about 9% more, USD121.0 billion vs
with diabetes to age- and sex-matched persons without USD111.0 billion assuming R=2, Table 5.2). In these
diabetes. R is the key parameter in the conversion of per calculations, per capita diabetes-care expenditures are higher

Figure 5.1
Health expenditures for diabetes in 2007 (USD) by region, assuming R=2
INTERNATIONAL DOLLAR (ID)

-ILLIONS53$
The international dollar (ID) is a hypothetical unit of currency that has the
same purchasing power in every country. Conversions from local currencies
to international dollars are calculated using tables of purchasing power

parities (PPP), which are taken from studies of prices for the same basket of
goods and services in different countries.

!&2 %--% %52 .! 3!#! 3%! 70
for women than for men, especially at younger ages, buys more in these countries. Estimates adjusted for
mirroring the US data that was used to calculate age- and purchasing power are shown in international dollars (ID).
sex-specific values for R. For the countries just listed, ID estimates are ID30 in
Burundi, ID72 in Iraq, ID81 in Tajikistan, ID334 in Guyana,
Expenditures per person ID137 in Haiti, ID94 in Bangladesh, and ID80 in the
Countries vary widely in the resources they spend on Democratic People’s Republic of Korea.
diabetes. In 2007 (R=2), the IDF formula predicts that the
US will spend an average of USD6,231 for diabetes for each Figure 5.2 compares the number of persons living with
person who has the condition, Norway will spend USD4,714 diabetes to annual ID health expenditures for diabetes (R=2),
and Switzerland will spend USD4,430. However, spending in the 25 countries with the largest populations of persons
at this level is uncommon. Globally, the mean of each with diabetes. This figure shows that the need for medical
country’s average 2007 expenditure will be USD505 (ID725) care is not the primary determinant of spending for medical
at R=2. care. The great majority of spending in 2007 will occur in the
world’s largest industrialized countries.
In each IDF region, some countries are predicted to spend
very little for the prevention and treatment of diabetes in Less than 20% of global spending will occur in low- and
2007: USD6 in Burundi, USD18 in Iraq, USD10 in Tajikistan, middle-income countries, where the large majority of
USD78 in Guyana, USD48 in Haiti, US19 in Bangladesh, and persons with diabetes live. By 2025, if the resources devoted
almost nothing in the Democratic People’s Republic of to diabetes in low- and middle-income countries are not
Korea. Most of these amounts could not cover the annual increased, this disparity will widen.
wholesale price of a generic oral agent capable of
preventing acute, life-threatening hyperglycaemia. Projections to 2025
Fortunately, poorer countries provide more medical care Tables 5.3 - 5.9 also show projected 2025 aggregate health
than these estimates in USD imply, because the US dollar expenditures for diabetes in 2002 dollars. The 2025

Figure 5.2
Annual health expenditure for diabetes (ID) vs persons with diabetes in the 25 countries with the largest numbers of persons with diabetes in 2007
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estimates differ from the 2007 estimates only as a result of China, and in the countries where medical care spending is
predicted changes in population size, age, sex and degree highest, such as the United States and Europe.
of urbanization4. Age- and sex-specific diabetes prevalences
are assumed to remain the same — for example, no Comparisons to other estimates
specific increase in diabetes prevalence due to increased Despite the many difficulties that accompany international
obesity (apart from the increase that will be reflected by comparisons of economic studies5, the estimates presented
increased urbanization) is factored in, despite the near here are largely confirmed by independent estimates
certainty that this will occur. In addition, health obtained from industrialized countries where direct studies
expenditures per capita remain in 2002 dollars and take of diabetes expenditures have been conducted. Because
the same values they had when estimated by WHO for these are the countries in which the great bulk of medical
20022. Given these assumptions, the annual global direct care spending for diabetes occurs, these studies also suggest
expenditure for diabetes for 2025 is projected to fall that, at R=2, the estimates presented here of global health
between USD302.5 billion (assuming R=2) and USD558.6 expenditures for diabetes are roughly accurate. For example,
billion (assuming R=3). The international dollar projection a recently published study of the expenditure burden of
falls between ID381.1 billion (assuming R=2) and ID701.2 diabetes in Germany in 2001 (CoDiM) reported net per capita
billion (assuming R=3) (see Table 5.1). expenditures of EUR2,507, quite similar to the estimate here
of USD2,713 in 2002 dollars (R=2)3. CoDiM also observed an
These figures indicate that health expenditures for diabetes overall R for direct medical care of 2.0.
will grow by 30% to 35% between 2007 and 2025, somewhat
more than assumed global population growth among Earlier, the CODE-2 Study estimated annual per capita type
persons 20-80 years of age over the same period, which is 2 diabetes expenditures at EUR2,834 in Western Europe in
27.6%. Expenditures are estimated to grow more quickly 1999. CODE-2 estimated expenditures that ranged from
than population because populations are becoming older in EUR1,305 +/-2,197 in Spain to EUR3,576 +/-920 in Germany6.
the countries where diabetes will be most prevalent, such as For Spain, IDF’s formula-based per capita estimate for 2007

(in 2002 USD) is very similar: USD1,276, assuming R=2. (In estimate for India (USD47 per person a year) is somewhat
1999 and 2002, the exchange rate between euros and US lower than a report from Madras, a large city in southern
dollars was approximately 1.0.) India11.
In Australia, the DiabCo$t Study7 estimated a direct medical What do medical care expenditures
care expenditure per person with diabetes (including for diabetes buy?
expenditures for treating both diabetes and other health
conditions) of AUD4,260 (in 2001 AUD). This equals In industrialized countries, about a quarter of the medical
approximately USD2,179 at mid-2001 exchange rates, similar expenditures for diabetes is spent for the control of
to IDF’s formula-based estimate for 2007 of USD2,369 in 2002 elevated blood sugar. Another quarter goes to treat long-
dollars. However, the IDF estimate omits expenditures not term complications (largely cardiovascular disease), and
caused by diabetes, so these estimates do not confirm each half is consumed by the additional general medical care
other. that accompanies diabetes and diabetic complications,
including intensified efforts to prevent cardiovascular and
The American Diabetes Association’s most recent estimate microvascular complications12. In these countries, persons
expenditures for medical care for diabetes over all age groups with major complications of diabetes incur much higher
in the USA is USD91.8 billion in 2002 (USD 5,642 per person)8. medical care expenditures than persons without major
The IDF formula-based estimate for the USA in 2007 is complications 13-16 . For example, published estimates of
somewhat higher, USD119.4 billion (USD6,537 per person) at expenditures for diabetic foot ulceration not requiring
R=2. However, the IDF per capita estimate includes more amputation range from USD993 to USD30,724 (1998
diabetes-caused medical care than the ADA’s study was able USD)17. Expenditures for ulceration requiring amputation
to capture, and includes more health expenditures than are even higher, USD16,488 to USD60,215 (1998 USD) 17.
those used for medical care. Some of these additional Total expenditures of diabetic foot ulceration and
expenditures, such as payments for medical research, are amputation totalled USD10.9 billion in 200117,18 . Because
substantial in the US. For a more precise comparison, the of amounts like these, in the USA, acute hospitalization
ADA’s aggregate estimate also should be adjusted to account consumes 44% of diabetes-attributable expenditures,
for undiagnosed diabetes and for the increase in US diabetes followed by outpatient care (22%), drugs and supplies
prevalence since 2002. (19%), and nursing home care (15%)8 . Similar proportions
are reported from other high-income countries such as
Published studies of expenditures for diabetes are nearly all Finland19.
from developed countries. Therefore, confirmation of
estimates for developing countries remains uncertain. The In middle-income countries, a higher proportion of
IDF per capita estimate appears similar to a recently published expenditures — half — goes for blood sugar control, which
estimate for the publicly supported medical care systems in is essential for the prevention of acute life-threatening
Mexico, after removing indirect costs and adjusting for hyperglycaemia. The remainder is split between general
inflation9. medical care and chronic complications20. In Latin America
and the Caribbean, anti-hyperglycaemic drugs alone are
In China, a 2002 study of patients of endocrinologists from believed to account for about half of all spending20 . In
11 different provincial capitals, including Beijing and Bangladesh, even among patients with diabetes sampled
Shanghai, estimated that patients with type 2 diabetes from a tertiary diabetes care hospital, 52% of annual medical
without diabetic complications consumed USD450 per year care expenditures were consumed by drugs21. These data
in direct medical expenditures, while patients with both confirm anecdotal reports from IDF member associations
microvascular and macrovascular complications consumed indicating that most persons in these countries do not
USD4,66510. IDF’s countrywide estimate for China based on receive a great deal of medical care once complications
formula is much lower, USD89 and ID351 per person, but it appear, and many may not survive acute hyperglycaemic
encompasses nearly a billion rural Chinese who have no crises to develop longer term sequellae.
health insurance, and tens of millions of urban residents who
cannot afford treatment by the endocrine specialists who Finally, it is significant to note that diabetes increases medical
contributed the Chinese data. Similarly, IDF’s countrywide care expenditures even before it is diagnosed. Researchers in

the USA found that persons destined to have diabetes their own pockets20. In the poorest countries, people with
incurred an extra USD1,205 per year (1993 USD) during the diabetes and their families bear almost the whole cost of
eight years preceding diagnosis22. In 2004 dollars, this adds whatever medical care they can afford. In India, for example,
up to USD14,896 over all eight pre-diagnosis years. Increased the poorest persons with diabetes spend an average of
utilization before diagnosis has also been reported from the 25% of their total income on private care 11. In low- and
United Kingdom23. middle-income countries, illness, injury and death is one of
the main causes, possibly the main cause, of household
Out-of-pocket expenditures impoverishment25,26 .
The expenditures for medical care described above impose Other direct economic effects of
different demands on people with diabetes and their families, diabetes
depending on their economic status and the social insurance
policies of the countries in which they live. Although The direct economic impact of diabetes includes non-
expenditures for the medical care of diabetes are much monetary as well as monetary effects. Non-monetary effects
higher in industrialized countries, nearly all these countries include changes in quality of life (or disability) and length of
have organized systems of medical care insurance and/or life. Disability, pain, and lost years of life are as important as
governmental provision of medical services. This allows financial loses.
families to survive financially when diabetes strikes. The
exception is the United States, which lacks a comprehensive Reduced years of life
national medical care service or insurance system24.
Diabetes dramatically reduces life expectancy when glucose,
In 2025, however, 80% of all cases of diabetes will be in blood pressure and lipids are not aggressively controlled.
low- and middle-income countries25,26 . In Latin America, Chapter 4 describes global mortality attributable to diabetes,
families pay 40-60% of expenditures for medical care from providing estimates for every country. Diabetes is expected

Figure 5.3
Projected foregone national income due to heart disease, stroke and diabetes in selected countries, 2005-2015
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Billions (ID)

)NTERNATIONALBILLIONS
Source: WHO, 200526
to cause 3.8 million deaths worldwide in 2007, about 6% of sometimes tax it heavily), or because insulin is not available at
total world mortality, about the same as HIV/AIDS27. any price, or is of very low quality (see Chapter 6). In these
From an economic point of view, the cost associated with locations, untreated type 1 diabetes can be particularly costly in
these deaths is conceptualized as the years of life lost terms of life years lost, because it attacks children and younger
because death came sooner by diabetes rather than later by adults who would otherwise live for many additional decades.
something else. For 2002, the WHO Burden of Disease project
estimated that 8.59 million years of life were lost because of Disability and reduced quality of life
diabetes28. This is undoubtedly an underestimate because it
is based on mortality rates obtained from death certificates, Quality of life effects may be as deleterious as premature
which under-report diabetes as a cause of death27,29. The true mortality to persons living with diabetes. Studies indicate
estimate is probably at least three times higher — 25 million that persons in perfect health would willingly give up 2.76-
years of life lost annually. 3.73 months of life to avoid a year of living with diabetes30,31.
Interestingly, however, persons who actually have diabetes
Underestimation of diabetes mortality is less of a concern without complications rate their quality of life only slightly
when diabetes is combined with cardiovascular disease, below similarly aged persons in the general population32.
because CVD accounts for half of diabetes-cased death
worldwide (see Chapter 4). WHO estimates that, if the value But quality of life decreases when complications appear32.
of a year of life is set country by country at 100 times GDP Persons with diabetes say they would sacrifice about two
per capita, then diabetes, heart disease and stroke cost about months of life per year to avoid a year of diabetes-caused
ID250 billion in China, ID225 billion in the Russian Federation, blindness, about one month per year to avoid kidney dialysis,
and ID210 billion in India in 200526. one to 3.3 months per year to avoid amputation, three weeks
per year to avoid painful diabetic neuropathy, one to two
In poor countries, many children die because access to life- months per year to avoid a stroke, and three weeks per year to
saving insulin is not subsidized by governments (who instead avoid a history of heart attack30,31. Disability and reduced quality

IN TOUCH WITH: KM Haridas
The story of Mr KM Haridas highlights the importance of early of diabetology, vascular surgery and plastic surgery. As a
diagnosis and aggressive treatment of people with diabetes result, Mr Haridas had to undergo angiography followed by
to prevent complications. Through self-management, people peripheral bypass surgery in both lower limbs in a multi-
with diabetes can substantially reduce their costs of diabetes superspeciality hospital.
care. Substantial savings can be achieved by motivating
people with diabetes to realize the importance of self- During his working years as a cargo officer in the United
management of diabetes through well–conducted education Arab Emirates, Mr Haridas neglected his health which
sessions. subsequently led to the development of his various
complications. He ate irregularly, and also did not
Mr KM Haridas, 50, from Kerala, India, has lived with type exercise nor take his medication regularly. He incurred
2 diabetes for almost half his life. He was diagnosed at 27 high expenditures due to repeated hospitalization and
years old, and retired early from government service two therapeutic procedures including repeated laser treatment
years ago because of his diabetes-related illnesses. He bears for retinopathy. He spent about 20% of his salary on
the total cost of his diabetes care with about 70% of his medical care.
pension being spent on medical expenses.
In addition to the direct costs of diabetes medical care, Mr
In 2003, Mr Haridas entered hospital and was diagnosed with Haridas has incurred indirect costs due to frequent travel
hypertension, peripheral vascular disease and an ulcer in his from Kerala to Chennai for treatment. His wife and two
right foot. Apart from ensuring better diabetic control, he children have been subjected to intangible costs such as
had to be investigated and treated for his complications. He stress and anxiety caused by frequent hospitalization of
was examined by a team of superspecialists in the disciplines their husband and father.
of life may be a proportionately larger problem in low-income is to calculate the impact of diabetes on economic growth.
countries33. WHO assumes that diabetes-caused blindness No studies have yet done this for diabetes, alone, but in 2005
reduces the value of a year of life by more than half34. WHO used econometric models to estimate that diabetes,
heart disease, and stroke together would cost ID557.7 billion
Using estimates like these, the World Health Report 2004 in lost national income in China between 2005 and 2015,
calculated that the equivalent of 7.6 million years of life were ID303.2 billion in the Russian Federation, ID236.6 billion in
lost to diabetes-caused disability in 200228 . This estimate India, ID49.2 billion in Brazil and ID2.5 billion even in a very
omits the effects of complications such as heart attack, stroke poor country, United Republic of Tanzania (see Figure 5.3)26.
and other cardiovascular complications, though. These are very large losses. WHO limited its calculations to
the effects of premature death. Accounting for disability
Impact of diabetes on national might increase these estimates.
economies
Economic value of diabetes
Diabetes affects all persons living in society, not just those who prevention and treatment
live with diabetes. Many studies have tried to measure this
larger societal impact by adding a category of effects called
indirect costs. The ADA estimated that the US economy lost Cost-effectiveness in developed countries
USD39.8 billion or USD3,290 per person with diabetes in 2002,
as a result of lost earnings due to lost work days, restricted Elevated HbA1c15 and other risk factors21 are associated with
activity days, mortality and permanent disability caused by higher medical care expenditures. Studies indicate that the
diabetes8. Indirect costs of diabetes in Germany have been prevention and treatment of diabetes can be highly cost-
estimated at EUR1,328 per person for the year 20013. effective. Often, in fact, treatment is cost-saving, because
medical care expenditures are avoided when therapy stops
One way to create more comprehensive national estimates complications35,36.

Computer simulation models have predicted that blood very low price of aspirin, its use is probably cost-effective or
pressure, blood sugar and lipid control actually save money cost-saving for everyone with diabetes45.
in industrialized countries, because they prevent open heart
surgery, renal dialysis, and the need for many other expensive The cost-effectiveness of screening for type 2 diabetes is less
interventions37-39. Foot care for persons with diabetes who clear. The CDC group calculated that, in persons without risk
are at high risk of ulcers, and preconception care for women factors for diabetes, screening for diabetes, at least in the USA,
with diabetes also are predicted to save money40. The Centers may not be cost-effective46. A European modelling study
for Disease Control and Prevention (CDC) Diabetes Cost- recently concluded that the cost-effectiveness of diabetes
Effectiveness Group41 recently calculated that intensified screening depends on the presumed benefit of treatment47. A
hypertension control would save USD1,957 per person with simulation study in Taiwan concluded that mass screening for
type 2 diabetes (1997 USD). type 2 diabetes would be cost-effective there48.
Other interventions that appear cost-effective in developed Cost-effectiveness in developing countries

countries according to economic studies include lifestyle
improvement and possibly metformin to prevent type 2 Developing countries cannot justify paying for all the
diabetes, smoking cessation programmes, annual eye treatments that high-income countries use. Still, many low-
examinations to detect retinal disease, ACE-inhibitor use in cost treatments should be cost-effective or cost-saving
all persons with diabetes, and influenza vaccines in elderly everywhere, as the IDF Task Force on Diabetes Health
persons living with type 2 diabetes40. The cost-effectiveness Economics argued it its publication, Cost-effective approaches
of low-dose aspirin to prevent cardiovascular disease in all to diabetes care and prevention49.
persons with diabetes has not been formally assessed.
However, aspirin is cost-effective in persons with pre-existing In 2006, the World Bank systematically assessed the cost-
cardiovascular disease42 and risk-beneficial in others when, effectiveness and feasibility of diabetes interventions in
as in diabetes, cardiovascular risk is elevated43,44. Given the developing countries40. Their table of findings by region is

MAP 5.1
Mean health expenditure per person with diabetes (USD), R=2, 2007
5,000 - 7,000
3,000 - 5,000
1,000 - 3,000
500 - 1,000
100 - 500
50 - 100
<50
no data
reproduced here as Table 5.10. The World Bank classified result from recommendations like the World Bank’s, whether
cost-effective interventions into three levels of carried out in Bangladesh or Denmark50.
implementation priority, based on cost per quality-adjusted
life year (QALY, its measure of cost-effectiveness), technical Researchers are now debating and testing the use of
feasibility, and cultural feasibility. inexpensive and convenient ‘polypills’ that combine in a
single, once-a-day treatment, several compounds that
Level 1 interventions were predicted to be cost-saving and already have been judged cost-effective or risk-effective51.
highly feasible in all regions. Three interventions achieved This approach could increase the feasibility of diabetes
level 1: glycaemic control when HbA1c is higher than 9.0%, treatment in developing countries, and make it even more
hypertension control when blood pressure exceeds 160/95 cost-saving.
mmHg, and foot care for persons at high risk of ulcers. (As
explained above, low-dose aspirin also might be added to Finally, it is worth noting that although ‘Level 2’ activities like
this list.) Level 2 interventions (N=6) are usually highly cost- smoking cessation, increased physical activity, and more
effective but face some barriers to implementation. Level 3 prudent eating face administrative costs and implementation
(N=5) priorities all cost more than USD1,500 per QALY saved barriers when done as social programmes, individuals in
and were judged challenging to implement. developing countries who decide on their own to stop
smoking or increase their walking can do so very cheaply.
Although the World Bank assessment was not based on
actual effectiveness trials in developing countries — none Efficiency and equity
have been conducted — their work leaves little doubt that
many diabetes interventions could and should be pursued Analyses of cost-effectiveness usually assess the impact of
aggressively throughout the world. A recent high-level new programmes and policies under the assumption that
modelling analysis suggests that large gains for the entire they are implemented as designed, with little waste or
economy, as well as for individuals with diabetes, would corruption. Implicitly, analysts also assume that access will

be based on the ability to benefit, with no discrimination by towards agriculture, transportation, housing and land
class, race, or tribe. These assumptions do not always hold in drive patterns of eating and exercise. Perhaps even more
practice. Indeed, it has been estimated that if only 50% of importantly, countries with less egalitarian distributions
persons with diabetes are diagnosed, and 50% of these of income, wealth and power also have higher rates of
receive care, and 50% of these achieve treatment targets, insulin resistance, diabetes and cardiovascular disease.
and if treatment prevents complications 50% of the time, Much research now indicates that this relationship is
only 6% of persons with diabetes will have a successful causal, and that it operates in high- as well as low-income
outcome50. Increasing the efficiency of diabetes care can countries, independently of average levels of resources.
yield large improvements. If the reach of intervention were Feelings of shame, vulnerability, powerlessness and
increased to 75% in the calculation just described, the uncertainty trigger many of the same physiologic cascades
percentage of persons with successful outcomes would be that transmit the ill-effects of genes, obesity and lack of
five times larger. exercise53,54.
Many existing policies are ill-designed to operate efficiently and Conclusion

equitably. In the Northwest Frontier Province of Pakistan, for
instance, the government pays for insulin only when citizens are Diabetes is one of the world’s most important causes of
hospitalized. This causes multiple costly hospitalizations — expenditure, mortality, disability and lost economic growth.
patients become desperately sick when they lack insulin — and A long list of simple, cheap treatments can help prevent
leads to severe complications and premature loss of life. In these losses and many of these treatments will actually save
Pakistan, it would probably be cost-effective for government to hard money in countries, rich and poor. In fact, the returns to
buy insulin for all persons with diabetes52. better diabetes prevention and treatment are relatively
higher in the world’s low- and middle-income countries,
Finally, it is important to recognize that, just as diabetes where most persons with diabetes live but few are treated
harms economies, economies create diabetes. Policies cost-effectively.

Table 5.1
Global health expenditure for diabetes, 2007 and 2025

Health expenditure for diabetes in 2007 (‘000)

US Dollars (USD) International Dollars (ID) per

Region R=2 R=3 R=2 R=3
AFR 710,180 1,270,784 2,137,027 3,824,368
EMME 3,195,799 5,349,671 7,511,656 12,787,425
EUR 63,987,133 119,090,727 82,158,649 152,427,546
NA 128,691,947 230,344,260 132,163,097 236,460,803
SACA 4,503,248 8,049,214 12,555,309 22,511,523
SEA 2,067,942 3,664,551 6,811,580 12,070,481
WP 28,811,441 53,886,502 42,729,935 78,832,195

Global Total 231,967,689 421,655,708 286,067,252 518,914,340

R
is the ratio of all medical care expenditures for persons with diabetes to all medical care expenditures for age- and sex-matched persons who do not have diabetes.
Totals for expenditure per person are means of the mean per person expenditure per region.
Table 5.2
Health expenditure for diabetes (USD*) by sex, age and region, and the diabetes cost ratio, R, in 2007

Health expenditure for diabetes by age group (‘000 USD), both sexes, R=2

Age AFR EMME EUR
20-29 69,345 211,977 734,634
30-39 111,330 550,193 2,168,418
40-49 153,265 760,089 6,411,682
50-59 185,757 808,187 14,162,315
60-69 131,860 580,897 20,913,114
70-79 58,623 284,455 19,596,970
Total 710,180 3,195,799 63,987,133

Health expenditure for diabetes by age group (‘000 USD), both sexes, R=3

Age AFR EMME EUR
20-29 120,104 359,146 1,280,595
30-39 190,308 891,092 3,711,817
40-49 256,095 1,178,921 10,661,843
50-59 317,170 1,285,887 23,764,537
60-69 242,290 981,781 36,105,083
70-79 144,817 652,844 43,566,853
Total 1,270,784 5,349,671 119,090,727

Health expenditure for diabetes by age group (‘000 USD), women, R=2
Age AFR EMME EUR

20-29 39,107 104,375 433,356
30-39 62,104 238,297 1,157,740
40-49 88,068 344,070 3,263,932
50-59 110,352 411,226 7,443,472
60-69 76,742 309,432 10,648,774
70-79 39,108 169,440 12,106,195
Total 415,481 1,576,840 35,053,468
*2002 USD

Mean health expenditure
per person with diabetes in 2007 USD ID US Dollars (USD) International Dollars (ID)

R=2 R=2 R=2 R=3 R=2 R=3
71 180 922,542 1,672,591 2,754,377 5,001,165
334 514 6,191,714 10,366,100 13,982,139 23,825,035
1,288 1,561 76,258,302 143,136,315 97,909,474 183,064,381
973 1,188 174,485,018 319,487,464 179,903,410 329,140,328
265 625 7,196,796 13,007,973 19,969,324 36,192,479
73 233 3,239,120 5,790,771 10,676,508 19,087,682
439 684 34,187,702 65,105,388 55,857,411 104,880,442

492 712 302,481,194 558,566,601 381,052,643 701,191,512

NA SACA SEA WP TotaL
6,316,745 136,380 146,331 455,382 8,070,795
6,584,148 389,745 254,668 1,648,413 11,706,915
25,512,851 826,549 413,759 3,682,128 37,760,322
27,822,654 1,308,579 562,643 7,630,543 52,480,678
39,418,186 1,193,073 467,321 9,098,972 71,803,424
23,037,364 648,921 223,219 6,296,003 50,145,555
128,691,947 4,503,248 2,067,942 28,811,441 231,967,689

NA SACA SEA WP TotaL
10,926,602 235,486 250,920 771,530 13,944,382
11,368,769 663,942 425,067 2,751,351 20,002,346
40,394,405 1,365,764 673,733 6,042,496 60,573,256
46,915,708 2,173,607 940,799 12,903,671 88,301,379
67,352,629 2,091,877 832,434 16,295,128 123,901,221
53,386,146 1,518,539 541,598 15,122,327 114,933,125
230,344,260 8,049,214 3,664,551 53,886,502 421,655,708

NA SACA SEA WP Total

4,000,473 70,838 77,309 182,480 4,907,938
4,169,990 211,009 115,885 639,358 6,594,382
11,197,125 465,993 205,001 1,668,860 17,233,049
12,741,220 780,290 294,938 3,907,324 25,688,821
19,835,457 692,085 233,753 4,717,882 36,514,125
13,148,723 426,909 116,392 4,006,894 30,013,661
65,092,988 2,647,124 1,043,277 15,122,798 120,951,975

Table 5.2
Health expenditure for diabetes (USD*) by sex, age and region, and the diabetes cost ratio, R, in 2007

Health expenditure for diabetes by age group (‘000 USD), women, R=3
Age AFR EMME EUR
20-29 72,190 190,750 802,720

30-39 113,229 420,943 2,124,221
40-49 156,240 580,379 5,846,219
50-59 185,744 647,677 12,391,504
60-69 138,093 512,471 18,149,124
70-79 91,353 364,834 25,453,931
Total 756,850 2,717,054 64,767,719
Health expenditure for diabetes by age group (‘000 USD), men, R=2
Age AFR EMME EUR
20-29 30,239 107,602 301,277
30-39 49,226 311,897 1,010,678
40-49 65,198 416,019 3,147,750
50-59 75,405 396,961 6,718,843
60-69 55,119 271,465 10,264,340
70-79 19,514 115,015 7,490,775
Total 294,700 1,618,959 28,933,664
Health expenditure for diabetes by age group (‘000 USD), men, R=3
Age AFR EMME EUR
20-29 47,914 168,396 477,875
30-39 77,079 470,149 1,587,596
40-49 99,855 598,541 4,815,624
50-59 131,426 638,210 11,373,033
60-69 104,196 469,310 17,955,958
70-79 53,464 288,010 18,112,922
Total 513,934 2,632,617 54,323,008
*2002 USD

7,278,930 131,330 142,068 338,171 8,956,159

7,574,501 384,363 210,532 1,176,768 12,004,558
19,581,867 819,162 360,647 2,989,348 30,333,863
21,560,216 1,276,651 488,510 6,564,294 43,114,596
33,627,319 1,184,468 411,516 8,318,100 62,341,090
28,957,460 939,432 268,221 9,071,831 65,147,062
118,580,293 4,735,406 1,881,495 28,458,512 221,897,328

2,316,272 65,542 69,023 272,902 3,162,857
2,414,158 178,736 138,784 1,009,055 5,112,533
14,315,725 360,555 208,757 2,013,268 20,527,273
15,081,434 528,289 267,705 3,723,219 26,791,857
19,582,729 500,989 233,569 4,381,090 35,289,300
9,888,641 222,012 106,828 2,289,108 20,131,894
63,598,959 1,856,124 1,024,665 13,688,643 111,015,714

3,647,672 104,155 108,851 433,359 4,988,223
3,794,269 279,578 214,535 1,574,582 7,997,788
20,812,538 546,601 313,086 3,053,148 30,239,393
25,355,492 896,956 452,289 6,339,377 45,186,783
33,725,310 907,409 420,918 7,977,028 61,560,130
24,428,687 579,107 273,377 6,050,496 49,786,063
111,763,967 3,313,808 1,783,056 25,427,990 199,758,380

Table 5.3
Health expenditure for diabetes, 2007 and 2025 - African Region

COUNTRY/TERRITORY R=2 R=3 R=2 R=3
Angola 13,313 23,887 32,232 57,831
Benin 5,433 9,659 11,953 21,251
Botswana 10,758 19,199 24,347 43,449
Burkina Faso 3,501 6,308 12,095 21,791
Burundi 265 489 1,416 2,609
Cameroon 4,825 9,232 10,585 20,250
Cape Verde 1,207 2,164 3,376 6,054
Central African Republic 1,338 2,416 6,082 10,980
Chad 2,972 5,415 9,979 18,179
Comoros 185 331 498 893
Congo 2,343 4,156 3,254 5,772
Congo, Democratic Republic of 4,646 8,367 17,421 31,376
Côte d’Ivoire 26,427 47,155 64,267 114,674
Djibouti 1,496 2,651 2,161 3,830
Equatorial Guinea 1,366 2,465 2,288 4,128
Eritrea 537 971 2,418 4,372
Ethiopia 6,160 11,254 25,873 47,268
Gabon 7,453 13,392 11,624 20,887
Gambia 879 1,583 4,054 7,300
Ghana 11,437 20,600 49,113 88,460
Guinea 3,900 7,215 18,614 34,436
Guinea-Bissau 353 638 1,492 2,695
Kenya 14,201 25,442 52,319 93,733
Lesotho 1,383 2,530 6,581 12,044
Liberia 376 666 1,034 1,832
Madagascar 2,013 3,646 7,246 13,126
Malawi 2,485 4,585 8,519 15,722
Mali 4,029 7,245 11,079 19,922
Mauritania 1,340 2,404 5,170 9,272
Mozambique 5,586 10,040 25,391 45,638
Namibia 6,650 11,903 22,233 39,796
Niger 2,422 4,307 9,341 16,612
Nigeria 78,250 139,892 177,093 316,597
Réunion • • • •
Rwanda 954 1,767 4,164 7,713
Sao Tome and Principe 189 342 567 1,027
Senegal 10,223 18,294 23,474 42,008
Seychelles 3,440 5,730 4,508 7,509
Sierra Leone 1,072 1,925 4,826 8,662
Somalia 1,061 1,928 2,299 4,178
South Africa 385,824 688,013 1,290,449 2,301,169
Swaziland 1,945 3,512 9,104 16,442
Tanzania, United Republic of 10,492 19,004 25,018 45,317
Togo 6,501 11,685 29,436 52,908
Uganda 6,357 11,682 27,194 49,973
Western Sahara • • • •
Zambia 5,621 10,068 14,333 25,674
Zimbabwe 46,972 84,626 60,506 109,009

AFR Total 710,180 1,270,784 2,137,027 3,824,368
Population data are from the UN 2004 revision (medium variant) of the World Population Prospects4 (for non-UN members, the CIA World Factbook55 was used).
Expenditure data are in 2002 USD and derived from the WHO World Health Report2.
Totals for expenditure per person are means of the mean per person expenditure per country.

Mean health expenditure Health expenditure for diabetes in 2025 (‘000)
R=2 R=2 R=2 R=3 R=2 R=3
70 169 22,565 40,464 54,632 97,966
36 79 9,987 17,865 21,972 39,304
292 660 9,647 17,951 21,833 40,626
20 69 6,336 11,292 21,887 39,010
6 30 457 844 2,439 4,501
56 122 7,206 13,742 15,806 30,143
110 308 2,278 4,025 6,372 11,257
19 85 1,794 3,221 8,153 14,639
26 86 4,607 8,369 15,465 28,097
18 48 349 628 943 1,697
32 44 4,093 7,214 5,685 10,020
8 28 7,868 14,113 29,506 52,923
76 184 40,931 73,117 99,537 177,806
94 136 2,487 4,422 3,592 6,387
140 235 1,790 3,237 2,997 5,421
14 65 979 1,763 4,405 7,935
9 38 10,136 18,547 42,570 77,896
249 389 11,099 20,024 17,312 31,233
30 137 1,450 2,627 6,685 12,114
29 123 19,091 34,470 81,978 148,018
39 188 6,298 11,660 30,057 55,651
15 65 586 1,052 2,472 4,440
34 125 26,033 46,537 95,912 171,451
41 194 1,261 2,322 6,003 11,055
7 19 627 1,111 1,724 3,055
9 32 3,520 6,397 12,672 23,028
26 88 3,717 6,829 12,745 23,415
21 58 7,288 12,940 20,043 35,585
25 95 2,369 4,226 9,139 16,300
19 88 7,997 14,336 36,350 65,165
170 569 8,988 16,256 30,052 54,351
13 51 4,573 8,155 17,640 31,456
33 75 124,149 221,620 280,970 501,561
• • • • • •
20 88 1,632 3,013 7,124 13,149
63 190 339 601 1,018 1,803
47 109 17,991 32,072 41,313 73,647
539 707 4,417 7,413 5,789 9,715
10 47 1,604 2,876 7,219 12,943
11 25 1,897 3,465 4,111 7,507
318 1,064 424,815 778,004 1,420,861 2,602,157
112 523 1,623 2,990 7,599 13,997
24 56 16,456 29,770 39,242 70,990
63 284 11,498 20,676 52,060 93,615
35 148 12,717 23,052 54,401 98,611
• • • • • •
37 93 8,219 14,619 20,958 37,279
212 273 56,776 102,663 73,135 132,244

71 180 922,542 1,672,591 2,754,377 5,001,165

Table 5.4
Health expenditure for diabetes, 2007 and 2025 - Eastern Mediterranean and Middle East Region

Afghanistan 25,602 43,089 62,175 104,644
Algeria 170,268 294,101 402,451 695,148
Armenia 10,757 19,420 55,459 100,121
Bahrain 48,137 75,454 73,742 115,589
Egypt 383,482 645,613 1,247,940 2,100,976
Iran, Islamic Republic of 459,796 808,621 1,909,921 3,358,888
Iraq 19,839 33,268 79,356 133,070
Jordan 65,273 110,408 165,357 279,700
Kuwait 158,005 253,092 159,449 255,405
Lebanon 142,952 254,081 175,418 311,786
Libyan Arab Jamahiriya 28,388 52,428 52,084 96,191
Morocco 114,432 198,084 386,987 669,884
Occupied Palestinian Territory • • • •
Oman 63,387 103,150 97,656 158,918
Pakistan 143,224 242,140 683,070 1,154,820
Qatar 99,205 152,287 94,854 145,609
Saudi Arabia 649,377 1,087,018 1,005,122 1,682,515
Sudan 20,544 37,280 62,713 113,802
Syrian Arab Republic 83,677 143,634 157,255 269,932
Tunisia 62,805 113,083 206,857 372,455
United Arab Emirates 436,507 665,232 408,205 622,100
Yemen 10,145 18,190 25,583 45,871
EMME Total 3,195,799 5,349,671 7,511,656 12,787,425
Table 5.5
Health expenditure for diabetes, 2007 and 2025 - European Region

Albania 13,864 26,196 44,541 84,160
Andorra 6,593 12,344 9,102 17,042
Austria 1,418,579 2,568,559 1,599,414 2,895,988
Azerbaijan 14,765 26,508 65,622 117,814
Belarus 72,337 131,171 453,466 822,284
Belgium 1,407,445 2,694,142 1,639,520 3,138,382
Bosnia and Herzegovina 43,883 80,461 108,695 199,296
Bulgaria 95,986 174,494 330,324 600,502
Channel Islands • • • •
Croatia 138,180 255,128 235,917 435,584
Cyprus 62,589 110,041 62,660 110,166
Czech Republic 421,616 762,676 935,252 1,691,808
Denmark 932,157 1,736,742 849,298 1,582,365
Estonia 28,930 52,711 66,439 121,055
Finland 662,712 1,250,674 695,275 1,312,127
France 9,512,269 17,860,020 11,084,143 20,811,335

R=2 R=2 R=2 R=3 R=2 R=3
23 56 45,913 77,162 111,502 187,393
115 273 291,948 505,816 690,059 1,195,564
60 309 13,310 23,809 68,618 122,751
683 1,047 88,649 143,660 135,802 220,075
88 286 623,930 1,058,541 2,030,415 3,444,744
179 744 877,240 1,540,378 3,643,919 6,398,491
18 72 40,018 67,047 160,073 268,189
281 711 137,225 230,271 347,637 583,353
798 806 371,078 603,195 374,470 608,708
856 1,050 227,350 398,805 278,985 489,379
209 384 49,878 93,407 91,512 171,375
84 285 192,031 333,924 649,413 1,129,269
• • • • • •
398 614 127,742 211,434 196,806 325,746
21 99 251,975 427,194 1,201,725 2,037,385
1,253 1,198 180,143 280,008 172,243 267,730
575 891 1,343,594 2,262,964 2,079,650 3,502,675
34 103 34,769 63,282 106,136 193,177
98 185 167,560 288,003 314,898 541,247
194 637 102,549 185,177 337,760 609,910
993 929 1,004,551 1,535,606 939,418 1,436,041
44 110 20,263 36,417 51,098 91,834
334 514 6,191,714 10,366,100 13,982,139 23,825,035

R=2 R=2 R=2 R=3 R=2 R=3
145 465 18,778 36,017 60,328 115,715
1,606 2,217 9,340 17,689 12,895 24,421
2,079 2,344 1,735,041 3,161,339 1,956,217 3,564,334
39 173 23,632 41,800 105,032 185,778
108 678 77,479 139,834 485,702 876,595
2,350 2,738 1,724,365 3,316,871 2,008,697 3,863,794
165 408 48,223 88,955 119,444 220,334
161 554 94,217 172,391 324,237 593,264
• • • • • •
420 718 145,022 269,671 247,598 460,414
1,008 1,009 86,196 153,838 86,294 154,012
557 1,236 487,655 907,877 1,081,743 2,013,902
3,207 2,922 1,077,735 2,058,791 981,936 1,875,788
297 683 29,790 54,368 68,416 124,860
2,060 2,161 808,920 1,576,982 848,668 1,654,469
2,630 3,065 11,890,384 22,681,853 13,855,234 26,429,961

Table 5.5
Health expenditure for diabetes, 2007 and 2025 - European Region

Country/territory R=2 R=3 R=2 R=3
Georgia 8,563 15,604 42,130 76,774
Germany 20,019,621 36,449,053 21,434,919 39,025,839
Greece 937,089 1,787,088 1,418,932 2,705,992
Hungary 412,936 747,059 897,471 1,623,649
Iceland 16,090 33,521 15,461 32,210
Ireland 481,278 905,264 505,181 950,226
Israel 662,298 1,212,229 836,727 1,531,492
Italy 6,976,071 13,212,424 8,699,004 16,475,596
Kazakhstan 44,462 79,107 207,224 368,696
Kyrgyzstan 2,909 5,265 24,315 43,997
Latvia 38,560 70,197 90,608 164,946
Liechtenstein • • • •
Lithuania 67,188 122,449 153,056 278,939
Luxembourg 80,048 151,858 83,168 157,776
Macedonia, the Former Yugoslav Republic of 19,320 35,016 53,131 96,294
Malta 31,887 57,376 32,153 57,856
Moldova 8,753 15,636 48,950 87,444
Monaco 6,954 12,964 8,100 15,098
Netherlands 2,313,400 4,360,145 2,581,183 4,864,844
Norway 718,277 1,410,691 607,143 1,192,424
Poland 942,223 1,705,287 2,043,037 3,697,603
Portugal 784,478 1,483,221 1,222,693 2,311,760
Romania 227,560 416,263 833,795 1,525,213
Russian Federation 1,688,443 3,039,210 6,022,115 10,839,848
San Marino 4,554 8,513 5,693 10,642
Serbia and Montenegroa 96,209 176,383 244,531 448,307
Slovakia 113,277 203,628 309,054 555,560
Slovenia 150,765 274,814 252,965 461,103
Spain 3,187,683 6,044,157 4,385,738 8,315,787
Sweden 1,278,965 2,443,814 1,290,783 2,466,396
Switzerland 2,645,206 4,779,729 2,160,554 3,903,993
Tajikistan 1,198 2,157 9,381 16,900
Turkey 844,059 1,485,155 2,061,074 3,626,541
Turkmenistan 15,452 27,578 35,597 63,534
Ukraine 152,316 276,314 799,660 1,450,650
United Kingdom 4,156,075 8,261,948 4,420,050 8,786,710
Uzbekistan 21,059 37,740 143,405 256,994

EUR Total 63,987,133 119,090,727 82,158,649 152,427,546
a. Estimates made prior to the establishment of Serbia and Montenegro as separate countries.


R=2 R=2 R=2 R=3 R=2 R=3
30 147 9,364 16,992 46,069 83,602
2,713 2,905 22,141,589 40,382,885 23,706,901 43,237,776
1,272 1,926 1,062,772 2,011,273 1,609,239 3,045,451
557 1,210 449,019 826,327 975,892 1,795,929
3,947 3,793 24,183 51,482 23,237 49,469
2,837 2,978 700,488 1,337,591 735,279 1,404,026
1,965 2,482 1,028,116 1,907,663 1,298,890 2,410,082
1,812 2,259 8,029,085 15,257,991 10,012,089 19,026,373
81 376 58,196 104,208 271,237 485,684
22 184 5,000 8,995 41,783 75,176
226 532 38,663 70,362 90,849 165,332
• • • • • •
280 638 72,161 130,777 164,383 297,911
3,385 3,517 115,514 218,318 120,015 226,826
161 442 23,813 43,556 65,485 119,779
1,113 1,123 41,207 76,602 41,551 77,243
35 196 10,770 19,450 60,233 108,778
3,616 4,212 8,882 16,752 10,344 19,510
2,653 2,960 3,130,062 6,012,829 3,492,375 6,708,831
4,714 3,985 941,213 1,904,070 795,585 1,609,466
361 783 1,153,034 2,127,252 2,500,143 4,612,557
1,210 1,886 972,470 1,839,374 1,515,699 2,866,863
149 547 247,834 453,262 908,080 1,660,781
175 625 1,822,801 3,305,982 6,501,323 11,791,336
2,690 3,363 6,788 12,849 8,486 16,062
143 362 106,173 196,000 269,858 498,166
321 875 144,733 265,376 394,874 724,025
1,013 1,699 176,029 326,275 295,354 547,448
1,276 1,756 4,121,387 7,724,658 5,670,365 10,627,886
2,736 2,761 1,508,291 2,943,833 1,522,229 2,971,036
4,430 3,619 3,227,608 5,921,278 2,636,250 4,836,388
10 81 2,345 4,184 18,373 32,777
257 627 1,409,251 2,482,645 3,441,194 6,062,273
134 308 29,418 52,318 67,774 120,529
46 239 145,073 264,130 761,634 1,386,684
2,431 2,586 4,997,164 10,067,385 5,314,561 10,706,820
35 237 41,031 73,113 279,401 497,866

1,288 1,561 76,258,302 143,136,315 97,909,474 183,064,381

Table 5.6
Health expenditure for diabetes, 2007 and 2025 - North American Region

Anguilla • • • •
Antigua and Barbuda 2,155 3,838 2,417 4,304
Aruba • • • •
Bahamas 32,458 55,319 30,932 52,717
Barbados 13,621 23,936 20,726 36,422
Belize 3,181 5,388 5,423 9,185
Bermuda • • • •
British Virgin Islands • • • •
Canada 5,719,191 10,341,843 7,544,081 13,641,738
Cayman Islands • • • •
Dominica 1,307 2,185 1,976 3,304
Grenada 2,519 4,307 4,110 7,028
Guadeloupe • • • •
Guyana 2,930 4,967 12,549 21,273
Haiti 15,073 25,656 43,141 73,430
Jamaica 38,209 64,941 49,672 84,423
Martinique • • • •
Mexico 3,461,699 5,925,755 5,023,574 8,599,381
Saint Kitts and Nevis 1,374 2,353 1,962 3,361
Saint Lucia 2,869 4,903 3,834 6,551
Saint Vincent and the Grenadines 1,533 2,645 2,897 4,996
Trinidad and Tobago 35,377 58,701 57,354 95,167
United States of America 119,358,449 213,817,522 119,358,449 213,817,522
US Virgin Islands • • • •
NA Total 128,691,947 230,344,260 132,163,097 236,460,803

R=2 R=2 R=2 R=3 R=2 R=3
• • • • • •
718 805 2,953 5,305 3,312 5,948
• • • • • •
1,605 1,530 53,482 91,999 50,967 87,673
835 1,271 20,086 36,029 30,564 54,824
285 485 6,080 10,271 10,363 17,508
• • • • • •
• • • • • •
2,581 3,405 8,091,559 14,985,105 10,673,430 19,766,581
• • • • • •
274 414 1,498 2,521 2,265 3,812
496 809 3,148 5,423 5,136 8,848
• • • • • •
78 334 4,284 7,290 18,348 31,223
48 137 23,430 39,834 67,060 114,009
252 328 52,014 88,069 67,618 114,490
• • • • • •
566 821 6,014,551 10,332,820 8,728,240 14,994,857
644 920 1,771 3,057 2,530 4,366
346 463 4,332 7,400 5,788 9,888
260 492 2,514 4,271 4,748 8,067
345 559 47,849 80,752 77,573 130,916
6,231 6,231 160,155,467 293,787,319 160,155,467 293,787,319
• • • • • •
973 1,188 174,485,018 319,487,464 179,903,410 329,140,328

Table 5.7
Health expenditure for diabetes, 2007 and 2025 - South and Central American Region

Argentina 490,972 894,039 1,972,140 3,591,181
Bolivia 26,377 47,085 74,943 133,782
Brazil 2,158,335 3,879,880 6,401,665 11,507,799
Chile 227,704 408,792 594,251 1,066,847
Colombia 311,767 558,855 1,106,669 1,983,750
Costa Rica 134,155 232,183 260,254 450,422
Cuba 202,104 345,698 242,114 414,136
Dominican Republic 91,126 154,756 174,560 296,449
Ecuador 58,140 104,210 125,863 225,597
El Salvador 85,634 149,950 178,966 313,378
French Guiana • • • •
Guatemala 70,608 124,377 151,086 266,140
Honduras 27,957 48,646 72,687 126,481
Netherlands Antilles • • • •
Nicaragua 22,042 37,703 75,676 129,447
Panama 93,402 161,689 151,548 262,347
Paraguay 19,376 34,674 81,049 145,037
Peru 128,818 228,975 313,042 556,435
Puerto Rico • • • •
Suriname 7,618 12,938 14,889 25,285
Uruguay 67,562 124,323 150,657 277,229
Venezuela 279,552 500,441 413,251 739,782
SACA Total 4,503,248 8,049,214 12,555,309 22,511,523
Population data are from the UN 2004 revision (medium variant) of the World Population Prospects4 (for non-UN members, the CIA World Factbook55 was used),
Table 5.8
Health expenditure for diabetes, 2007 and 2025 - South-East Asian Region

Bangladesh 73,321 129,815 359,941 637,275
Bhutan 1,165 2,120 7,377 13,429
India 1,916,123 3,397,767 6,131,592 10,872,854
Maldives 2,187 3,803 5,594 9,731
Mauritius 11,173 19,037 31,345 53,405
Nepal 11,166 20,373 59,549 108,659
Sri Lanka 52,808 91,634 216,181 375,128

SEA Total 2,067,942 3,664,551 6,811,580 12,070,481

R=2 R=2 R=2 R=3 R=2 R=3
330 1,326 657,474 1,201,380 2,640,944 4,825,712
106 302 43,647 78,173 124,013 222,111
312 926 3,508,468 6,391,837 10,406,185 18,958,314
353 921 337,970 618,411 882,020 1,613,903
244 866 542,514 988,113 1,925,744 3,507,472
574 1,113 238,977 418,747 463,603 812,348
239 287 260,304 450,766 311,836 540,004
238 455 153,916 262,837 294,839 503,486
144 311 96,434 174,623 208,764 378,030
278 582 145,687 253,849 304,469 530,515
• • • • • •
162 347 121,042 212,562 259,005 454,838
104 271 52,423 91,158 136,301 237,010
• • • • • •
102 349 42,955 73,497 147,477 252,338
518 840 158,540 276,466 257,236 448,575
146 611 35,882 65,040 150,093 272,059
144 350 216,464 387,454 526,030 941,556
• • • • • •
286 559 10,820 18,430 21,145 36,018
462 1,029 82,702 151,607 184,417 338,071
297 439 490,578 893,023 725,203 1,320,121
265 625 7,196,796 13,007,973 19,969,324 36,192,479

R=2 R=2 R=2 R=3 R=2 R=3
19 94 122,269 218,683 600,227 1,073,534
21 136 1,941 3,522 12,290 22,304
47 150 3,003,613 5,371,754 9,611,562 17,189,613
211 540 4,121 7,167 10,542 18,336
146 409 15,958 27,797 44,767 77,980
22 120 19,114 34,973 101,941 186,520
45 182 72,105 126,875 295,179 519,395

73 233 3,239,120 5,790,771 10,676,508 19,087,682

Table 5.9
Health expenditure for diabetes, 2007 and 2025 - Western Pacific Region

Australia 2,193,190 4,135,956 2,967,127 5,595,461
Brunei Darussalam 16,743 26,842 25,425 40,762
Cambodia 19,094 33,686 114,567 202,114
China 3,561,507 6,488,040 14,754,816 26,879,023
China, Hong Kong • • • •
China, Macau • • • •
Cook Islands 273 491 744 1,338
Fiji 6,197 10,440 15,822 26,655
French Polynesia • • • •
Guam • • • •
Indonesia 126,606 240,857 535,641 1,019,011
Japan 18,380,947 34,998,795 15,834,637 30,150,416
Kiribati 361 645 1,038 1,856
Korea, Democratic People’s Republic of 338 606 64,245 115,141
Korea, Republic of 2,277,727 4,017,903 3,876,478 6,838,094
Lao People’s Democratic Republic 1,393 2,603 6,828 12,753
Malaysia 341,050 572,305 798,834 1,340,499
Marshall Islands 647 1,104 1,279 2,181
Micronesia, Federated States of 1,685 2,713 3,664 5,901
Mongolia 1,180 2,150 5,594 10,193
Myanmara 466,371 864,669 44,416 82,349
Nauru 2,230 3,347 4,534 6,806
New Caledonia • • • •
New Zealand 328,735 601,609 486,423 890,189
Niue 33 58 13 23
Palau 716 1,245 1,191 2,071
Papua New Guinea 2,581 4,791 15,957 29,620
Philippines 141,974 245,286 775,788 1,340,312
Samoa 897 1,577 2,425 4,266
Singapore 470,288 789,054 578,695 970,940
Solomon Islands 301 560 862 1,602
Taiwan • • • •
Thailand 416,729 741,642 1,486,332 2,645,189
Timor-Leste 625 1,181 2,592 4,901
Tokelau • • • •
Tonga 932 1,561 2,989 5,008
Tuvalu 105 174 104 172
Vanuatu 212 399 584 1,096
Viet Nam 49,775 94,215 320,292 606,251
WP Total 28,811,441 53,886,502 42,729,935 78,832,195
Expenditure data are in 2002 USD and derived from the WHO World Health Report.2
a. Conversion between USD and ID based on official exchange rates in 2002.

R=2 R=2 R=2 R=3 R=2 R=3
2,369 3,205 3,178,633 6,130,269 4,300,317 8,293,532
577 876 33,535 54,241 50,926 82,370
59 351 31,764 56,669 190,586 340,013
89 371 5,175,082 9,658,294 21,439,625 40,012,932
• • • • • •
• • • • • •
372 1,014 393 715 1,071 1,947
142 363 8,885 15,194 22,686 38,794
• • • • • •
• • • • • •
44 185 208,057 396,667 880,240 1,678,206
2,634 2,269 18,799,147 36,654,941 16,194,904 31,577,137
85 245 644 1,164 1,852 3,350
0 80 438 788 83,249 149,709
741 1,261 3,182,402 5,732,761 5,416,151 9,756,623
19 93 2,477 4,622 12,136 22,650
223 522 596,702 1,016,024 1,397,644 2,379,815
354 700 841 1,435 1,663 2,836
217 472 2,411 3,912 5,244 8,508
47 221 2,253 4,126 10,681 19,559
534 51 769,478 1,446,903 73,284 137,800
869 1,768 3,626 5,485 7,374 11,153
• • • • • •
1,521 2,251 436,634 818,961 646,079 1,211,801
549 219 40 71 16 28
626 1,041 1,102 1,935 1,833 3,218
44 270 5,026 9,342 31,071 57,753
46 254 249,455 433,976 1,363,094 2,371,368
152 412 1,362 2,389 3,684 6,461
1,058 1,302 804,791 1,391,185 990,305 1,711,870
60 171 605 1,124 1,733 3,216
• • • • • •
132 470 597,424 1,083,762 2,130,814 3,865,419
95 395 1,155 2,207 4,790 9,156
• • • • • •
143 459 1,207 2,021 3,874 6,485
109 107 167 279 165 275
87 239 391 736 1,076 2,025
38 247 91,572 173,188 589,244 1,114,430
439 684 34,187,702 65,105,388 55,857,411 104,880,442

Table 5.10
Cost-effectiveness of interventions for preventing and treating diabetes and its complications in developing regions

Cost/QALY (2001 USD)
East Asia and Europe and Latin America and
Intervention the Pacific Central Asia the Caribbean
Level 1
Glycaemic control in people with HbA1c higher than 9 percent Cost saving Cost saving Cost saving
Blood pressure control in people with pressure higher than 160/95 mmHg Cost saving Cost saving Cost saving
Foot care in people with a high risk of ulcers Cost saving Cost saving Cost saving

Level 2
Preconception care for women of reproductive age Cost saving Cost saving Cost saving
Lifestyle interventions for preventing type 2 diabetes 80 100 130
Influenza vaccinations among the elderly for type 2 diabetes 220 290 360
Annual eye examination 420 560 700
Smoking cessation 870 1,170 1,450
ACE inhibitor use for people with diabetes 620 830 1,020

Level 3
Metformin intervention for preventing type 2 diabetes 2,180 2,930 3,630
Cholesterol control for people with total cholesterol
higher than 200 milligrams/decilitre 4,420 5,940 7,350
Intensive glycaemic control for people with HbA1c higher than 8 percent 2,410 3,230 4,000
Screening for undiagnosed diabetes 5,140 6,910 8,550
Annual screening for microalbuminuria 3,310 4,450 5,510

a. Feasibility was assessed based on difficulty of reaching the intervention population (the capacity of the healthcare system to deliver an intervention to the targeted
population), technical complexity (the level of medical technologies or expertise needed for implementing an intervention), capital intensity (the amount of capital
required for an intervention), and cultural acceptability (appropriateness of an intervention in terms of social norms and/or religious beliefs). ++++ indicates feasible
for all four aspects, +++ indicates feasible for three of the four, ++ indicates feasible for two of the four, and + indicates feasible for one of the four.
b. Implementing priority was assessed by combining the cost-effectiveness of an intervention and its implementation feasibility; 1 represents the highest priority and 3
represents the lowest priority.

Source: World Bank, 200640

Cost/QALY (2001 USD)
Middle East and South Asia Sub-Saharan Africa
North Africa Feasibilitya Implementing priorityb

Cost saving Cost saving Cost saving ++++ 1

Cost saving Cost saving Cost saving ++ 2
110 60 60 ++ 2
310 180 160 ++++ 2
590 350 320 ++ 2
1,230 730 660 ++ 2
870 510 460 +++ 2

3,080 1,820 1,640 ++ 3

6,240 3,680 3,330 +++ 3
3,400 2,000 1,810 ++ 3
7,260 4,280 3,870 ++ 3
4,680 2,760 2,500 ++ 3

Chapter6Fin.indd 266 27/10/06 4:15:54
hapter 6 presents a description of the pattern of use of and a link between depression and diabetes has been
diabetes therapies, both pharmacological and dietary, recognized.
in as many countries as data are available. There appears to
be a very wide range of prescribing habits across the world. Chapter 8 discusses the metabolic syndrome and the IDF
Whilst some of these differences are easily explicable in definition of this condition. The metabolic syndrome is now
terms of different prevalences of type 1 and type 2 diabetes, thought to be a key driver of the modern day epidemics of
and others are attributable to differences in study diabetes and CVD. Its cause is uncertain, but lifestyle change,
methodology, there is a clear need to investigate further focussing on increased physical activity and healthy eating
how prescribing habits can be brought into closer alignment to achieve weight loss, is an essential component of its
with treatment guidelines. treatment.
This chapter also looks at the barriers to insulin access and

diabetes care in three sub-Saharan African countries and
identifies the factors that have to be present for a solution to
succeed.
Chapter 7 focuses on the association between mental health,

antipsychotic drugs and hyperglycaemia. The chronically
mentally ill are a high-risk population for diseases such as
diabetes and cardiovascular disease due to a number of
factors. These include suboptimal access to medical services,
a propensity to smoking, poor diet, sedentary lifestyle and
obesity. Evidence is mounting for the association between
antipsychotic medication and the development of diabetes,
THE CHALLENGES CHAPTER 6 267
Chapter6Fin.indd 267 27/10/06 4:15:57

Chapter6Fin.indd 268 27/10/06 4:15:58
CHAPTER 6
ACCESS TO INSULIN, MEDICATION, AND DIABETES SUPPLIES
Chapter6Fin.indd 269 27/10/06 4:15:58

Continuous accessibility to
insulin and other diabetes
supplies is still a major problem
in many developing countries.
Chapter6Fin.indd 270 27/10/06 4:15:59

and socio-economic differences, and as it was felt that they
were representative countries for sub-Saharan Africa. An
ne of the major breakthroughs in medical sciences of assessment was carried out in these three countries to see
the last century was the discovery of insulin in 1921. how a sustainable solution could be found to the issues of
This discovery meant that people with diabetes who were access to insulin and proper diabetes care under extreme
insulin-treated survived the acute effects of the disease. conditions of scarce resources in the health sector.
Eighty-five years after its discovery, people around the world
are still dying because they cannot access insulin, which is
classified by WHO as an essential drug. Continuous
accessibility to insulin is still a major problem in many
developing countries especially those in sub-Saharan Africa
such that there are reports of premature deaths due to the
chronic lack of access to insulin in some of these countries.
Chapter 6.1 captures the pattern of use of diabetes therapies,

both pharmacological and dietary, in countries where there
are data. Describing the use of hypoglycaemic treatments is
valuable in gaining an understanding of how therapies are
actually used in practice, as against the advice given in
various published guidelines.
Chapter 6.2 examines the barriers to insulin access and

diabetes care in Mali, Mozambique and Zambia. These
countries were chosen due to their geographical, historical
ACCESS TO INSULIN, MEDICATION, AND DIABETES SUPPLIES CHAPTER 6 271
Chapter6Fin.indd 271 27/10/06 4:16:07

Chapter6Fin.indd 272 27/10/06 4:16:08
The aim of this report is to present a description of the pattern
of use of diabetes therapies, both pharmacological and
he treatment of diabetes includes both lifestyle changes dietary, in as many countries as data are available.
and pharmacological therapy. Whilst type 1 diabetes
mandates insulin use from the time of diagnosis, the
management of type 2 diabetes begins with lifestyle advice.
If glycaemic control is inadequate, oral hypoglycaemic The data have been collected from a variety of sources,
medication is added, and insulin is added for those in whom including published articles, government and institution
oral therapy is insufficient to achieve glycaemic targets. reports, national pharmacy databases and personally
communicated information. Searches of Medline were
Each drug can be used alone or in a variety of combinations with undertaken using the major Medical Subject Headings (MeSH)
others. The patterns of use of different therapies within a categories of ‘diabetes mellitus (epidemiology)’, ‘diabetes
population can be influenced by many factors including the mellitus (diet therapy)’, ‘diabetes mellitus (drug therapy)’.
availability of medication, beliefs among healthcare professionals Further articles were accessed in Medline using ‘related articles’.
about the value, efficacy and practicality of different therapies,
the phenotype of the person with diabetes (particularly in regard
to obesity), and the costs, which include not only the drug cost,
but also the costs of associated education for the person with The studies were grouped into six main types. Each study
diabetes (specifically with regard to insulin use). type has its specific advantages and limitations.
Describing the use of hypoglycaemic treatments is valuable 1. National prescription databases

in gaining an understanding of how therapies are actually A number of countries maintain databases of all prescriptions
used in practice, as against the advice given in various that are presented to pharmacists through national or
published guidelines. government health schemes. These provide very accurate
DIABETES MEDICATION USE: INTERNATIONAL PRESCRIPTION PATTERNS CHAPTER 6 273
Chapter6Fin.indd 273 27/10/06 4:16:09

data covering large numbers of individuals. National use. The Finnish data for 1995 have been previously
prescription databases generally include the vast majority of published, briefly noting therapy category according to
prescriptions for oral hypoglycaemic agents (OHAs) and type 1 or 2 diabetes2, although type was not classified for a
insulin used for a whole country in a given time period. quarter of those on treatment.
There are two principal types of database: the first has linkage In most of the studies based on counting numbers of
to individual persons, so that numbers of people using any prescriptions for each drug (without linking to individuals), the
specific single medication, or combination of drugs can be data are reported as the defined daily dose per 1,000 persons
ascertained. The second type of prescription database is not in the general population per day (ddd/1000 persons/day).
linked to persons, but indicates the number of prescriptions This system is based on a definition for each drug of the usual
that have been presented for each drug, or the overall daily dose, and its accuracy will depend on the applicability of
amount of drug provided/prescribed, without specifying the this estimate to the population in question. (The WHO
number of people involved. definition of the defined daily dose is the assumed average
maintenance dose per day for a drug used, normally in
These databases do not have any information on type of monotherapy, for its main indication in adults.)
diabetes, nor on the number of persons with diabetes who are
not on pharmacological treatment. When interpreting these The ddd classification is calculated by addition:
data sources, a figure of, for example, 20% of the diabetic 1. Total ddd of all OHA medication = the sum of ddd for each
population using insulin indicates that 20% of all people using type of OHA
pharmacological glucose lowering therapies are on insulin. 2. The ddd of all diabetic medication = sum of OHA ddd +
Those on only dietary management are excluded. Furthermore, sum of insulin ddd
it is not possible to determine the proportion of insulin users
who have type 1 or type 2 diabetes. It is tempting to infer that the ddd of all diabetic medication
is an estimate of drug-treated diabetes. However, each
There is no absolute certainty that national databases include person will be counted for each drug, when, in reality, many
all persons using any particular medicine. Each national people are on more than one drug. Thus, for the United
system will have its own peculiarities, so that some Kingdom (UK), the prescription rate for 2003 of 37.5 ddd/1000
prescriptions may not necessarily be included, as they are p/day is nearly twice the estimate of total prevalence of
too expensive to be included on the government scheme, diagnosed diabetes of 2.1% using the United Kingdom
or are so cheap that they can be purchased more cheaply General Practice Research Database (GPRD). Describing
outside the government scheme. Allowances have not been combination therapy was not possible for these studies.
made for such variations.
Prescription data from four countries were available only
There were two general formats in which national from sub-samples of the population, and are not necessarily
prescription data were available. In the most detailed representative of the treatment patterns nationally. Irish data
(Australia, Denmark, Finland, France), records were linked to came from the one-third of the population specifically
persons so that number/proportions of persons on insulin eligible (older age, or lower income) for the subsidized health
only, OHA only, or combination were available. The data insurance3, and Belgian data were derived from a national 2%
indicated the extent of overlap of categories, so that, either sample of private pharmacies4,5. A small sample of records
directly or indirectly, persons using both oral agents and (1,100 persons) from a South African prescription database
insulin concurrently (or sequentially within the one-year was the only report of this nature from Africa6. A report from
time frame) could be determined. Bahrain used prescription data from persons attending a
large sample of the country’s primary healthcare centres to
The French data1, and Australian data (Health Insurance document patterns of treatment7.
Commission) specifically indicated the number (or
proportion) of persons using combination therapy, whereas 2. Population-based data
for Denmark and Finland, the usage of combination therapy Data on treatment derived from population-based reports
was estimated from the difference between those using are included for 14 countries. These studies used self-report
any therapy, and the sum of insulin use and oral medication data to ascertain treatment categories, which may have
Chapter6Fin.indd 274 27/10/06 4:16:09

affected accuracy. The collection of data on treatment was 6. Inpatient Records
frequently a secondary objective of such reports. The Only two studies have been included which describe
population-based reports were of four general groups: treatment for hospital inpatients14,15. Treatment profiles from
national, regional, health insurance, and occupational. these populations are not likely to be representative of the
general diabetic population, and will be biased towards
Unlike the prescription-based data, the population-based those with serious complications.
reports almost always had some form of age restriction on
participants, but the exclusion of younger persons with
diabetes is likely to affect treatment estimates minimally, as
the vast majority of those with diabetes are adults. The preferred format for presenting treatment data was
Differentiation between type 1 and type 2 diabetes was not assignment of persons to one of the mutually exclusive
provided in most of the population-based reports. categories of dietary treatment alone, OHA use alone, insulin
alone, or OHA/insulin combination. This classification was
3. Primary care used by the largest number of reports.
The largest group of studies was for persons with diabetes
selected because of their attendance for care. Most of these For those reports detailing treatment by rates (ddd/1000p/
were attending primary care clinics. There was a large range in day), no measure of overlap of OHA and insulin use was
numbers of such participants, the primary objective of the available, so that total use represents the addition of insulin
reports, and the extent to which the results could reasonably and OHA prescriptions, and, as described above, is likely to
be extrapolated beyond the study population. The studies be an overestimate of the proportion using medication for
were almost invariably retrospective reviews of case records. diabetes. Similarly, for each of insulin and OHA use, the ddd/
Both primary and secondary care patients were recruited from 1000p is likely to be an overestimate of persons using that
six South American countries (Argentina, Brazil, Chile, Colombia, type of medication, as many individuals use more than one
Paraguay, Uruguay)8, to assess management among the type of insulin and many use more than one type of OHA.
QUALIDIAB participants, but data have not yet been published Data from these studies relating to individual classes of OHA
or analysed by country of health facility site, so that only the (e.g. sulfonylureas or metformin) are likely to be accurate
broadest description is available from the data. estimates of the numbers of people using these drugs.
4. Secondary Care Dietary treatment

The majority of the persons recruited from specialized
diabetes clinics, for whom there are reported treatment data, For some studies, the percentage of participants on dietary
were participants of the DiabCare Asia study9. The study’s treatment alone (i.e. not on pharmacological therapy for
objective was assessment of many aspects of diabetes diabetes) was explicitly stated. In others, however, it was not.
control among the 12 participating countries, involving 230 In such cases, when the sum of all those reported to be on
centres (ranging from one centre in Bangladesh to 34 centres pharmacological treatment was less than 99% of the study
in the Philippines). Individual data for India10 and Taiwan11 sample, and where it was not stated that those on diet alone
including treatment have been published. were excluded from the population, it was assumed that the
remainder were on dietary treatment alone.
5. Diabetes Registry
Diabetes registries attempt to register all people known to Oral hypoglycaemic agents
have diabetes, and living within a certain area or obtaining
care from a single provider. Data are usually completed by All studies provided specific data relating to use of OHAs.
healthcare professionals (rather than based on self-report by Where data were available, this was broken down into different
people with diabetes), and information on medication has classes of OHA. Data on use of combinations of OHAs were
been extracted from the registers. Most registries attempt to either available in the source material, or have been calculated
include all people with diabetes, but the Canadian Vascular from the degree of overlap apparent from the data. For
Protection Registry only enrolled people with diabetes if they example, a statement that 50% of those on OHAs were on
also had cardiovascular disease12, and the Ontario (Canada)13 metformin, and that 70% were on sulfonylureas indicates that
register only had data for people aged 65 years and older. 20% were on metformin-sulfonylurea combinations.
Chapter6Fin.indd 275 27/10/06 4:16:09

Insulin and insulin-OHA combinations majority of reports not based only on prescription rates, and
varied markedly, from about 50% to 1% (median 15%). Almost
Most studies reported data on the use of insulin. It should be all of those with rates less than 6% were from the DiabCare Asia
noted that in many studies, there was no information on the countries9,17, or with secondary care recruitment, or from less
proportion of the population that had type 1 diabetes, and developed countries. The highest levels of dietary treatment
so the figures presented should be interpreted cautiously. (>30%) were generally reports from developed countries,
While some studies differentiated between those on insulin although the sample of studies from less developed countries
alone, and those on insulin-OHA combination therapy, others was markedly biased to secondary source recruitment.
did not. In some circumstances combination use could be
calculated. For example, if dietary treatment was 10%, any Oral hypoglycaemic agents
OHA use 70%, and any insulin use 30%, OHA/insulin
combination can be calculated as 10%. Oral medication use had been recorded for nearly all the
reports, and median use (OHA only or insulin-OHA
combination) was about 70%. The highest proportion of
OHA use (>90%) was from the Bahrain national prescription-
Table 6.1 presents the data relating to the broad categories based report7 and a population-based report from India24.
of insulin and oral medications, or dietary treatment without There was, in general, a preponderance of less developed
medication for 100 reports. countries among those studies with OHA use for more than
70% of persons. The only reports for which OHA use was less
Insulin use than 30% of persons were those aged less than 45 years20.
About 35% of the studies indicated the percentage of persons Data on combination insulin-OHA use were available for about
with type 1 diabetes. Of these, the median percentage was 7%, two-thirds of studies in Table 6.1. For the 70 reports with data,
and the highest rate was nearly 20%, for Finland2. the median use of such was about 7%. High combination
usage tended to be associated with more recent reports, high
For those reports that differentiated between type 1 and non-type 1 insulin use, and secondary care recruitment.
type 2 diabetes, the percentage of those with insulin-treated
type 2 diabetes could be derived. The median use was 20% Prescription rates
and ranged from 1% (inpatients, Argentina) to 40%
(outpatient clinic, Mexico16). The greatest use of insulin (>30% Table 6.2 provides data indicating prescription rates of OHA
of persons) for those with type 2 diabetes generally occurred and insulin, as population rates, for 10 European countries.
in studies based on secondary care recruitment. Low usage Comparisons between countries and temporal trends for
of insulin in type 2 diabetes (<10%) was reported for the each country can be assessed. The average annual rate of
DiabCare study countries of Indonesia and Malaysia17, South increase of use of diabetes medication was 6.8% (6.5% for
Asian (but not the white) UK patients 18, Argentinian insulin; 7.0% for OHA). This progressive rise in medication use
inpatients15, and the Italian cohort from 198619. could have been due to an increasing prevalence of diabetes
and/or more aggressive treatment. The relative proportions
For the 65 studies which did not differentiate the type of of insulin and OHA use thus had hardly changed. There were
diabetes, median insulin use was 25%, and was greatest for considerable differences between countries for the most
those aged under 45 years (50-70%)20, and for the prescription- recent year with data available (between 2000 and 2003).
based reports for northern Europe (Belgium4,5, Denmark21, Total prescriptions rates varied between 28 (Denmark) and
Finland2, Germany22 and Sweden23). Lower insulin use (<15%) in 58 (Finland) ddd/1000p/day. The proportion of defined daily
general appeared to be more common for developing countries doses that were prescribed for insulin varied from 16.3%
(West Indies, India) and particularly for population-based (Portugal) to 51.2% (Sweden).
(Mexico, Thailand), or elderly cohorts (>65 years; Canada13).
Comparative use of specific medications
Diet therapy
The comparative use of specific oral medications is indicated
The percentage on ‘dietary therapy only’ was available for the in Tables 6.3 and 6.4. For Table 6.3 the rates represent the
Chapter6Fin.indd 276 27/10/06 4:16:10

proportion of persons using OHA who are taking the specific Although intermediate insulins account for a higher proportion
medication (except for the two South African reports6,25, and of all insulin prescribed in Spain than in Sweden or Germany34,
Irish data3,26 and the USA report of national volume of the absolute rate of insulin prescription is relatively low in Spain,
prescriptions 27, for which data represent prescription so that the absolute rate of intermediate insulin prescription is
numbers, and proportion of prescriptions). In Table 6.4 the still considerably lower in Spain than in Sweden or Germany.
data are for prescription rates (as ddd/1000 persons/day),
with proportion of the total OHA ddd prescribed as each
medication.
Significant limitations remain in interpreting these data on the
Sulfonylureas were more commonly prescribed than pharmacological treatment of diabetes. Many of the studies
metformin, except for several of the most recent reports. were designed to answer other questions, and the information
From Table 6.3, there were only four reports, for which more on medication use was very limited. Even for prescription
persons were taking metformin than sulfonylureas: Australia, database studies, in which the information on drug use is likely
Health Insurance Commission; Finland Insurance Agency; to be highly accurate, the limitations of not knowing either the
Germany22,28,29, and all relate to the last five years. type of diabetes, or the numbers of individuals on non-
pharmacological treatment are significant.
Other reports included in Table 6.3 also demonstrate an
increase in metformin use. The Denmark national data (Danish Nevertheless, it is possible to make some conclusions,
Medicines Agency) show the total use of metformin to have particularly on the use of metformin. It seems very clear that
increased from 30% to 60% of OHA between 1997 and 2003. the use of metformin has increased over recent years. This is
Increases in metformin use over time were also apparent in no doubt a result of its value both in terms of weight control
data from the USA (where metformin only became available and in prevention of cardiovascular disease, as a result of the
in the mid-1990s)27,30 and Trinidad and Tobago31. United Kingdom Prospective Diabetes Study (UKPDS) reports.
However, metformin still does not appear to be the most
The reports listed in Table 6.4 indicate overall and specific commonly used first line agent. In most reports, the
OHA usage, as prescription rates. There are considerable percentage of individuals on metformin alone was much
differences between countries, with a two-fold range in total lower than the percentage on sulfonylureas alone or on
OHA use for the most recent year (2002-03) between lowest combination OHA, suggesting that metformin is mainly used
and highest use (Denmark, 17.2 ddd/1000p/day and Portugal, as an add-on to sulfonylureas. The fact that combination
37.5 ddd/1000p/day). Usage of sulfonylureas was greater therapy (sulfonylurea plus metformin) was widely used (in up
than of metformin for all countries, but the rate of increase of to 67% of those on OHAs) indicates that metformin side-
metformin use over time was far greater than of sulfonylurea effects are not a major barrier to its use, nor an explanation
use. The median annual increase in per capita metformin of the relatively low rates of metformin monotherapy.
consumption was 18%, whereas the average increase in non-
metformin OHA prescription was 4%. In summary, there appears to be a very wide range of
prescribing habits across the world. Whilst some of these
Type of insulin use differences are easily explicable in terms of different
prevalences of type 1 and type 2 diabetes, and others are
There was a paucity of data and reports concerning types of attributable to differences in study methodology, there is a
insulin being used/prescribed, with most of the data coming clear need to investigate further how prescribing habits can
from Europe. Among the six developed countries with data be brought into closer alignment with treatment
(see Table 6.5), there were some clear differences in prescription guidelines.
practice. Fast acting insulins were being used considerably less
in Spain than the other countries. Since the data on insulin
type include both type 1 and type 2 diabetes, the less frequent
use of fast acting insulin in Spain32 (as well as in the small study
from the United Republic of Tanzania33) may be partly explained
by the lower prevalence of type 1 diabetes than in northern
European countries and Australia.
Chapter6Fin.indd 277 27/10/06 4:16:10

TABLE 6.1
Classification of diabetes medication use: insulin, oral, diet, oral/insulin combination
REGION COUNTRY/TERRITORY AUTHOR STUDY TYPE
AFR Kenya Otieno et al35 Secondary care; regional

South Africa Truter6 Prescription database; national. private insurance
Tanzania. United Republic of Gulam-Abbas et al14 Inpatient
Gulam-Abbas36 Secondary care; regional
Neuhann et al33 Secondary care; regional
EMME Bahrain Al Khaja et al7 Prescription database; national
United Arab Emirates Malik et al37 Population-based
EUR Belgium Donker et al20 Primary care; national. aged ≥ 45 years
Donker et al20 Primary care; national. aged <45 years
Sartor and Walckiers5 and Walckiers et al4 Prescription database; national
Croatia Donker et al20 Primary care; national. aged ≥ 45 years
Denmark Danish Medicines Agency21 Prescription database; national
Danish Medicines Agency21 Prescription database; national
England Donker et al20 Primary care; national. aged ≥ 45 years
Estonia Vides et al38 Diabetes register; regional
Finland Reunanen et al2 Prescription database; national
Social Insurance Institute39 Prescription database; national
France Le Floch et al40 Primary care; national
Ricordeau et al1 Prescription database; national
Germany Meisinger et al28 Population-based; regional
Meisinger et al28 Population-based; regional
Ott et al22 Primary/ secondary care; national
Rothenbacher et al41 Primary care; regional
Greece Gikas et al42 Population survey; regional
Katsilambros et al43 Population survey; regional
Ireland Barry et al3 and Tilson26 Prescription database; national
Israel Stern et al44 Population-based; occupation
Italy Ciardullo et al45 Primary care; regional
De Berardis et al46 Secondary care; national
De Berardis et al46 Primary care; national
Di Cianni et al47 Prescriptions & primary/ secondary clinics; regional
Muggeo et al19 Prescriptions & primary/ secondary clinics; regional
Netherlands Donker et al20 Primary care; national. aged ≥ 45 years
Spain Donker et al20 Primary care; national. aged ≥ 45 years
Sender Palacios et al48 Primary care; regional
Sweden Farnkvist and Lundman23 Diabetes register; regional
United Kingdom (White European) Abbott et al18 Population-based
United Kingdom (South Asian) Abbott et al18 Population-based
United Kingdom (African Caribbean) Abbott et al18 Population-based
United Kingdom Hippisley-Cox and Pringle49 Primary care; regional
Hippisley-Cox and Pringle50 Primary care; regional
Mulnier51 Primary care; national
Wales Harvey et al52 Multisource; regional
NA Barbados Gulliford et al53 Primary/ secondary care; national
Hennis et al54 Population-based; national
Canada Hackam et al12 Secondary care; regional
Shah et al13 Diabetes register; regional
Jamaica Swaby et al55 Primary care: national
Wilks et al56 Primary care; regional
Wilks et al56 Secondary care; regional
Mexico Aguilar-Salinas et al57 Population-based; national
Chapter6Fin.indd 278 27/10/06 4:16:11

YEAR PERSONS (n) TYPE 1 (%) DIET ONLY (%) OHA ONLY (%) INSULIN ONLY (%) OHA AND INSULIN (%)
1998 288 13.5 4.9 61.8 23.6 9.7

1996 1,100 NSt EX 64.4 30.5 5.2
1997-1998 92 NSt NSt 80.4a NSt NSt
1997-2005 2,165 NSt 7.8 66.5 18.1 7.7
1996-1998 474 15.8 NSt NSt 41.4b NSt
1998-1999 1,459 EX EX 88.8 7.1 4.0
1999-2000 699 NSt 32.0 59.0 8.0b NSt
1999-2000 4,034 NSt 15.4 63.7 12.8 8.2
1999-2000 252 NSt 14.3 32.5 46.0 7.1
1990 884 NSt EX 62.0 30.0 8.0
1999-2000 2,825 NSt 21.9 54.8 13.4 9.9
1999-2000 131 NSt 19.8 22.9 51.1 6.1
2003 124,811 NSt EX 59.9 30.4 9.7
1997 87,731 NSt EX 58.6 37.5 3.9
1997 1,192 NSt 25.8 56.0 16.9 1.2
1997 180 NSt 11.7 18.9 67.2 2.2
1993-1995 181 10.0 19.9 50.3 23.2 6.6
1995 116,224 19.8 EX 52.1 31.9 16.0
2003 181,894 NSt EX 57.8 24.3 17.9
1996-1997 7,391 8.9 6.9 64.3 10.6 18.4
1999 est. 1.8 million NSt EX 81.2 14.5 4.3
1999-2001 170 NSt 17.8 53.8 16.6 11.8
1989-1990 235 NSt 34.9 47.2 9.8 8.1
2002-2004 2,488 EX 12.5 40.6 26.3 20.6
2000 1,065 EX 32.0 44.0 13.0 11.0
2002 245 1.2 17.0 69.0 14.0b NSt
1990 490 NSt 29.6 55.1 15.3b NSt
2002 est. 50,000 NSt EX 81.9 15.0 3.2
1996 289 NSt 54.0 41.9 3.5 0.7
1998 4,610 EX 31.3 68.5 0.3b NSt
1998-1999 2,658 EX 15.5 61.5 13.5 9.5
1998-1999 779 EX 19.5 65.2 9.6 5.7
1994 4,503 3.2 10.2 63.0 25.4 1.5
1986 5,873 2.8 12.4 78.3 5.5 3.7
1996-1997 2,693 NSt 13.8 57.9 22.4 6.2
1996-1997 295 NSt 8.1 26.8 62.0 3.1
1986 6,881 NSt 25.4 55.2 16.0 3.4
1986 345 NSt 18.3 20.0 58.0 3.8
2002 1,495 3.8 30.8 49.0 16.3 3.8
1996-1997 5,143 13.0 19.0 40.0 29.0 12.0
1994-1996 13,409 10.8 30.9 46.5 22.7b NSt
1994-1996 1,866 7.3 23.3 67.0 9.6b NSt
1994-1996 371 4.9 19.9 62.7 17.6b NSt
2003 8,626 8.8 31.3 NSt NSt NSt
2000 5,849 EX 34.1 44.9 11.3 9.7
2001 24,348 NSt 24.6 49.0 19.9 6.5
1998 8,877 14.8 28.6 44.8 26.5b NSt
1991 690 NSt 10.4 77.8 11.7b NSt
1988-1992 736 2.0 17.0 70.9 11.3 0.8
2001-2003 1,871 NSt 21.7 62.9 7.6 7.8
1999 est. 250,000 NSt 40.0 46.0 11.0 3.0
1999 est. 550 NSt NSt NSt 14.0b NSt
1995 247 NSt 6.1 87.4 6.5b NSt
1995 190 NSt 2.6 45.8 51.6b NSt
2000 2,878 NSt 21.7 69.4a 5.8b NSt
Chapter6Fin.indd 279 27/10/06 4:16:11

TABLE 6.1
Classification of diabetes medication use: insulin, oral, diet, oral/insulin combination
REGION COUNTRY/TERRITORY AUTHOR STUDY TYPE
Mexico Bautista-Martinez et al16 Secondary care; regional

Tortola (British Virgin Islands) Gulliford et al53 Primary/ secondary care; national
Trinidad and Tobago Gulliford et al53 Primary/ secondary care; national
Mahabir and Gulliford31 Primary/ secondary care; insurance public
United States of America CDC58 Population-based; national
CDC58 Population-based; national
Cohen et al30 Population survey; insurance private
Cohen et al30 Population survey; insurance private
Karter et al59 Diabetes register; insurance private
Karter et al60 Population survey; insurance private
Koro et al61 Population-based; national
Koro et al61 Population-based; national
SACA Argentina Gagliardino et al15 Inpatient
Puerto Rico Perez-Cardona et al62 Population-based; national
Perez-Cardona et al63 Population-based; insurance private
Perez-Cardona et al64 Population-based; insurance public
Perez-Cardona et al65 Population-based; insurance private
Perez-Cardona et al65 Population-based; insurance public
South America Gagliardino et al8 Primary/ secondary; international
SEA Bangladesh Chuang17 Secondary care; national
India Mohan et al66 Secondary care; regional
Raheja et al10 Secondary care; national
Rema et al24 Population-based; regional
Chuang17 Secondary care; national
Sri Lanka Chuang17 Secondary care; national
WP 12 countries Chuang et al9 Secondary care; international
Australia Davis67 Population-based; regional
Health Insurance Commission68 Prescription database; national
Kemp et al69 Population-based; national
China Chuang17 Secondary care; national
Indonesia Chuang17 Secondary care; national
Korea Chuang17 Secondary care; national
Malaysia Chuang17 Secondary care; national
New Zealand Coppell et al70 Diabetes register; regional
New Zealand (European) Simmons et al71 Population-based; regional
New Zealand (Maori) Simmons et al71 Population-based. regional
New Zealand (Pacific Islander) Simmons et al71 Population-based. regional
Philippines Chuang17 Secondary care; national
Singapore Chuang17 Primary/ secondary care; national
Taiwan Chang et al72 Population-based; national
Chuang et al11 Secondary care; national
Thailand Aekplakorn et al73 Population-based; national
Viet Nam Chuang17 Secondary care; national
a. Includes unknown percentage also using insulin

b. Includes unknown percentage also using OHA
est. Estimated number of persons with diabetes (from rates indicated in data)
Ex Excluded
NSt Not stated
Chapter6Fin.indd 280 27/10/06 4:16:12

YEAR PERSONS (n) TYPE 1 (%) DIET ONLY (%) OHA ONLY (%) INSULIN ONLY (%) OHA AND INSULIN (%)
1999 570 11.2 EX 52.3 47.7b NSt

1991 180 NSt 9.4 72.2 18.3b NSt
1991 791 NSt 8.5 79.1 12.4b NSt
1993 690 NSt 5.8 82.3 11.9b NSt
1998 1,579 NSt 13.9 74.0 12.1b NSt
2003 1,952 NSt 6.7 78.0 15.3b NSt
1997 est. 10.2 million NSt 17.6 49.0 22.5 10.8
2003 est. 13.7 million NSt 15.3 56.9 15.3 12.4
1997 81,324 EX 32.5 43.4 18.3 5.8
2000 177,718 EX 33.5 47.6 13.0 5.9
1996-1997 24,312 4.8 22.8 52.6 24.6b NSt
2000-2001 11,922 NSt 7.6 62.5 18.1 11.8
1988-1994 1,215 EX 27.4 45.4 24.2 3.1
1999-2000 372 EX 20.2 52.5 16.4 11.0
1996 117 7.0 36.0 56.3 7.7b NSt
1999 244 NSt NSt NSta 34.6b NSt
1997-1998 22,424 NSt NSt 59.4a 29.1b NSt
1997-1998 38,139 NSt NSt 36.4a 27,8b NSt
2000 23,903 NSt NSt 46.1a 16.4b NSt
2000 49,197 NSt NSt 47.1a 29.7b NSt
1999 11,425 9.1 14.0 60.2 25.8b NSt
1998 1,565 0.2 17.8 60.3 14.4 7.5
pre-1997 9,873 EX 1.2 71.6 27.2b NSt
1998 2,269 7.6 4.5 53.9 21.8 19.8
2001 442 EX 5.9 81.0 3.8 9.3
1998 2,228 7.6 4.0 53.9 21.9 19.8
1998 1,183 3.6 13.0 72.1 11.4 3.0
1998 21,817 4.4 5.2 70.8 14.3 9.3
1993-1996 1,426 9.3 29.0 50.9 17.8 2.4
2004 433,072 NSt EX 73.1 18.5 8.4
1999-2000 475 7.2 29.7 52.9 14.1 3.4
1998 2,414 5.6 3.1 67.3 17.0 10.9
1998 2,086 2.0 5.1 88.1 4.6 2.1
1998 946 3.8 3.6 61.2 29.7 5.0
1998 1,013 5.0 2.6 82.6 10.8 3.7
2003-2004 3,599 9.4 29.4 44.5 18.2 7.9
1992-1994 176 NSt NSt 52.0a 28.0b NSt
1992-1994 176 NSt NSt 64.0a 19.0b NSt
1992-1994 495 NSt NSt 71.0a 15.0b NSt
1998 2,713 3.8 4.5 70.2 15.2 10.0
1998 1,667 8.2 8.2 70.7 15.0 6.1
2000 764 NSt NSt 78.9a 14.7b NS
1998 2,439 NSt 1.5 74.7 13.7 10.2
1998 2,435 2.7 1.5 74.7 13.6 10.2
2000 est. 245 NSt NSt 81.9a 2.8b NSt
1998 2,332 3.8 2.2 75.5 11.8 10.5
1998 1,235 7.3 2.3 73.5 8.9 15.1
Chapter6Fin.indd 281 27/10/06 4:16:12

TABLE 6.2
Comparative European national prescription rates: insulin and oral medication
COUNTRY/TERRITORY AUTHOR YEAR PRESCRIPTION RATE OHA RATE

ddd/1000p/day ddd/1000p/day
Belgium Melander74 1997 27.6 19.4

Melander74 2000 34.7 24.7
Denmark Melander74 1994 14.0 7.6
Melander74 2003 28.0 17.2
England Melander74 1994 16.3 9.3
Melander74 2003 37.5 23.2
Finland Melander74 1994 29.4 18.2
Melander74 2003 57.9 37.7
Germany Melander74 1994 32.1 21.1
Melander74 2002 55.8 32.6
Joost and Mengel34 1994 30.5 20.7
Joost and Mengel34 2003 50.4 28.3
Italy Melander74 2000 29.8 20.3
Melander74 2003 39.0 29.6
Portugal Melander74 2000 10.0 32.4
Melander74 2002 44.8 37.5
Slovakia Melander74 1998 34.2 25.8
Melander74 2000 31.6 22.3
Spain Melander74 1994 22.7 15.6
Melander74 2002 46.7 33.5
Del Pozo et al32 1989 16.0 11.2
Del Pozo et al32 1998 32.7 23.2
Sweden Melander74 1994 27.2 13.0
Melander74 2003 41.0 20.0
ddd/1000 p/day defined daily doses/1000 persons of the whole population/day

OHA oral hypoglycaemic agent
Chapter6Fin.indd 282 27/10/06 4:16:12

INSULIN RATE INSULIN PROPORTION ANNUAL CHANGE RATE (AVERAGE) (%)
ddd/1000p/day (%) TOTAL OHA INSULIN
8.2 29.8
10.0 28.9 7.9 8.4 6.9
6.4 45.7
11.0 39.3 8.0 9.5 6.2
7.0 42.9
14.3 38.3 9.7 10.7 8.3
11.2 38.1
20.2 34.8 7.8 8.4 6.8
11.0 34.3
23.2 41.6 7.2 5.6 9.8
9.8 32.0
22.1 43.8 5.7 3.5 9.5
9.5 32.0
9.4 24.1 9.4 13.5 -0.5
6.4 64.0
7.3 16.3 111.7 7.6 6.7
8.6 25.1
9.3 29.4 -3.9 -7.0 4.0
7.0 30.9
13.2 28.3 21.6 22.6 19.1
4.8 30.2
9.5 28.9 9.3 9.6 8.7
14.2 52.2
21.0 51.2 4.7 4.9 4.4
Chapter6Fin.indd 283 27/10/06 4:16:13

TABLE 6.3
Proportion of people (or prescriptions) using different oral hypoglycaemic agents, among all those using oral hypoglycaemic agents
REGION COUNTRY/TERRITORY AUTHOR YEAR PERSONS
AFR South Africa Steyn et al25 1998 249s

Truter6 1996 9,078s
Truter6 1996 708
Tanzania. United Republic of Gulam-Abbas et al36 2005 1,608
EMME Bahrain Al Khaja et al7 1998-1999 1,358
EUR Denmark Danish Medicines Agency21 1997 54,848
Danish Medicines Agency21 2003 86,818
Estonia Vides et al38 1993-1995 104
Finland Social Insurance Institute39 2003 137,663
France Le Floch et al40 1996-1997 6,078
Germany Rothenbacher et al41 2000 586
Meisinger et al28 1984-1985 44
Ott et al22 2002-2004 1,617
Ireland Barry et al3 and Tilson26 2002 est. 380,000s
Italy Ciardullo et al45 1998 3,156
United Kingdom Hippisley-Cox and Pringle50 2000 2,626
Mulnier51 2001 11,924
NA Barbados Hennis et al54 1988-1992 378
Gulliford et al53 1991 537
Jamaica Wilks et al56 1995 314
Tortola (British Virgin Islands) Gulliford et al53 1991 130
Trinidad and Tobago Gulliford et al53 1991 626
Mahabir and Gulliford31 1993 568
Mahabir and Gulliford31 1998 1,169
Mahabir and Gulliford31 2003 1,523
United States of America Wysowski et al27 1990 23.4 millionb
Wysowski et al27 1996 41.0 millionb
Wysowski et al27 2001 91.7 millionb
Cohen et al30 1997 40,011
Cohen et al30 2000 95,079
SEA Bangladesh Chuang17 1998 1,062
India Chuang17 1998 1,642
Sri Lanka Chuang17 1998 888
WP Asia (DiabCare) Chuang et al9 1998 16,217
Australia Davis et al75 2001 727
Health Insurance Commission68 2004 352,928
China Chuang17 1998 1,886
Indonesia Chuang17 1998 1,881
Korea Chuang17 1998 626
Malaysia Chuang17 1998 874
Philippines Chuang17 1998 2,176
Singapore Chuang17 1998 1,279
Taiwan Chuang17 2002 2,066
Thailand Chuang17 1998 2,031
Viet Nam Chuang17 1998 1,094
a. Nearly all combination therapy was of metformin with sulfonylurea

b. Numbers of prescriptions; proportions are of prescriptions. For year 2001 the combination represents specific metformin/sulfonylurea mix
s. Prescriptions; proportions are of prescriptions
NA Not applicable
NSt Not stated
Chapter6Fin.indd 284 27/10/06 4:16:13

nts
COMBINATION MEDICATION
SULFONYLUREAS ONLY (%) METFORMIN ONLY (%) OTHER (%) (IF SPECIFIED)a (%)
63.2 35.1 1.7 NA

63.1 33.3 3.6 NA
61.3 65.0 0.0 0.3
16.2 13.3 3.6 66.9
59.8 5.4 0.0 34.8
66.4 4.0 3.9 25.8
37.0 23.8 5.5 33.7
96.2 3.8 NSt NSt
25.2 28.9 5.9 40.1
41.8 23.1 NSt 35.1
41.8 34.5 NSt 23.6
100.0 NSt 0.0 0.0
96.9 0.8 0.0 2.3
53.5 17.1 0.0 29.5
29.7 31.5 0.0 38.7
14.1 32.7 10.0 43.2
51.0 44.5 4.6 NA
48.0 7.8 9.8 34.4
44.9 22.0 0.4 32.6
30.9 22.6 0.5 46.1
62.1 5.4 0.0 32.6
90.5 5.4 4.1 NSt
46.2 4.1 0.0 49.7
84.6 7.7 7.7 NSt
97.0 2.9 0.2 NSt
70.1 3.7 NSt 26.2
75.7 4.4 NSt 19.9
17.3 13.8 NSt 68.9
100.0 0.0 0.0 NSt
79.8 19.0 1.2 NSt
42.7 32.7 19.6 4.9
57.6 15.0 7.3 20.2
37.0 22.0 10.8 30.1
50.7 16.9 0.0 32.5
41.7 9.7 0.4 48.2
38.2 22.0 0.0 39.9
35.5 1.7 12.2 50.5
44.8 24.6 0.0 30.6
20.9 37.7 1.9 39.4
26.5 13.7 4.9 54.8
40.5 12.0 0.4 47.1
40.7 8.3 5.8 45.2
33.1 9.5 0.1 57.3
36.6 15.5 4.2 43.7
35.4 10.9 0.6 52.9
18.5 14.5 0.0 66.9
34.0 9.0 0.9 57.2
48.4 2.8 3.9 44.9
Chapter6Fin.indd 285 27/10/06 4:16:13

TABLE 6.4
Prescription rates of oral hypoglycaemic agents within the whole population, and proportionate use of individual oral hypoglycaemic agents
COUNTRY/TERRITORY AUTHOR YEAR PRESCRIPTION RATES

(ddd/1000p/day)
Belgium Sartor and Walckiers5 and Walckiers et al4 1990 6.6
Melander74 1997 19.4
Denmark Melander74 1994 7.6
England Melander74 1994 9.3
Finland Melander74 1994 18.2
Germany Melander74 1994 21.1
Joost and Mengel34 1994 18.6
Joost and Mengel34 2003 32.9
Italy Melander74 2000 20.3
Portugal Melander74 2000 32.4
Slovakia Melander74 1998 25.8
Spain Melander74 1994 15.6
Del Pozo et al32 1989 11.2
Del Pozo et al32 1998 23.3
Sweden Apoteket AB76 2000 16.8
Apoteket AB76 2004 21.2
ddd/1000 p/day defined daily doses/1000 persons of the whole population/day Nst Not stated
TABLE 6.5
Comparative use of type of insulin
COUNTRY/TERRITORY REPORT YEAR
Australia Health Insurance Commission68 2003

Australiaa Health Insurance Commission68 2004
Denmarka Danish Medicines Agency21 1997
Denmarka Danish Medicines Agency21 2003
Finlanda Social Insurance Institute39 2002
Germany Joost and Mengel34 2003
Jamaica Swaby et al55 1999
South Africab Truter6 1996
Spain Del Pozo32 1989
Del Pozo32 1998
Sweden Apoteket AB76 2000
Apoteket AB76 2004
Tanzania, United Republic ofb Neuhann et al33 1996-1998
a. The total number of persons is less than the sum of those on each type of insulin, as many people use more than one type of insulin
b. Data are for small samples; all other reports describe total use over 12-month interval
(r) ddd/1000 p/day
Chapter6Fin.indd 286 27/10/06 4:16:14

SULFONYLUREAS (%) METFORMIN (%) OTHER (%) METFORMIN VOLUME CHANGE NON-METFORMIN CHANGE
(ANNUAL) (%) (ANNUAL) (%)
68.5 31.5 NSt
66.2 33.8 NSt
61.1 38.9 NSt 13.4 13.6
85.5 14.5 NSt
67.4 32.6 NSt 19.8 20.4
74.2 25.8 NSt
56.8 43.2 NSt 17.2 17.4
84.6 15.4 NSt
62.6 37.4 NSt 19.7 20.2
90.5 9.5 NSt
67.2 32.8 NSt 23.3 24.6
90.4 9.6 NSt
55.6 37.4 7.0 23.9 25.1
78.7 21.3 NSt
69.6 30.4 NSt 27.7 28.3
75.6 24.4 NSt
70.7 29.3 NSt 18.0 18.4
78.3 21.7 NSt
73.1 26.9 NSt 3.5 4.0
94.2 5.8 NSt
84.2 15.8 NSt 24.8 26.8
93.1 6.3 0.6
78.4 8.4 13.2 12.1 12.7
64.0 31.7 4.3
40.9 49.2 9.9 18.4 18.7
83.1 16.9 NSt
54.0 46.0 NSt 17.2 17.7
SCRIPTS (s),
PERSONS (p), FAST ACTING INTERMEDIATE BIPHASIC ULTRALONG
RATES (r)
550,427 (s) 157,210 151,027 221,212 20,978
149,210 (p) 66,138 67,683 72,195 7,869
36,299 (p) 19,601 31,036 9,583 0
50,056 (p) 25,398 39,253 16,682 0
76,839 (p) 37,682 67,638 14,963 8,969
22 (r) 9 4 8 2
80 (p) 0 0 67 13
4,387 (s) 1,215 1,470 1,619 83
5 (r) 0 3 0 1
10 (r) 1 6 3 0
19 (r) 7 7 5 0
22 (r) 8 6 6 3
196 (p) 10 118 58 •
Chapter6Fin.indd 287 27/10/06 4:16:14

term ‘type 1 diabetes’, both because scarcity of ketone testing
makes for difficulties with the term ‘ketosis-prone’, and
nsulin is vital for the survival of people with type 1 because of differences in the spectrum of insulin-requiring
diabetes and is necessary for some people with type 2 diabetes between Africans and Caucasians82,83.
diabetes77. Also of central importance are the means to
administer the treatment such as syringe and needles, the
means to monitor the response to insulin such as blood and
urine tests, supportive care and education, and an Selection of countries
understanding of how diabetes impacts the life and work
of the individual. Mali, Mozambique and Zambia are three countries located in
sub-Saharan Africa. They are all defined as Highly Indebted
Some 85 years after its discovery, insulin is still not available Poor Countries (HIPC) by the World Bank on the basis that the
on an uninterrupted basis in many parts of sub-Saharan demands for debt repayment heavily exceed their ability to
Africa (SSA)78-80 . Very little primary data exist on type 1 generate income, and as a consequence, programmes of
diabetes in SSA and most information is based on anecdote. social investment including health are suffering. An
The Rapid Assessment Protocol for Insulin Access (RAPIA) was assessment of the barriers to insulin access and diabetes care,
developed81 in order to clearly assess the barriers to insulin using the RAPIA, was carried out in these three countries by
access and proper diabetes care, and to attempt to improve the International Insulin Foundation (IIF).
these.
These countries were chosen due to their geographical,
For the purpose of this section, insulin-requiring diabetes has historical and socio-economic differences, and as it was
been defined as diabetes diagnosed before age 30 and with felt that they were representative countries for sub-
insulin treatment being commenced within one month of Saharan Africa, with one being affected by civil war, two
diagnosis. This term is used instead of the more common by famine and the HIV/AIDS epidemic. Implementing the
Chapter6Fin.indd 288 27/10/06 4:16:14

RAPIA in these three HIPCs was to see how a sustainable
solution could be found to the issues of access to insulin
and proper diabetes care under extreme conditions of Insulin
scarce resources in the health sector. In addition as the
main burden of disease in these countries is still A lack of data at various levels of the health system led to
communicable diseases such as malaria, respiratory many problems, especially with regards to quantification of
infections, diarrhoeal diseases and HIV/AIDS, the aim of needs for insulin. For example in Mozambique, 77% of the
the RAPIA and the IIF’s work was also to raise awareness insulin imported nationally remained in the capital city.
about diabetes in these countries. Insulin is purchased by governments using tenders
(Mozambique and Zambia), from local wholesalers
Mozambique was chosen as a pilot country due to strong (Mozambique and Zambia) or, in Mali, directly with a
local support and availability of funding to develop and wholesaler based in France. Tendering and bulk purchasing
implement the RAPIA. Strong support and interest from the can substantially reduce insulin prices, but problems with
diabetes associations and Ministries of Health in Zambia quantification lead to unnecessarily high prices being paid
and Mali lead to the implementation of the protocol in for insulin.
these countries.
In 2003 the government of Zambia purchased 21% of its
Aim insulin from local suppliers rather than by national tender,
representing 32% of total insulin cost. Had the 10,260
The assessment was carried out in three different locations additional vials been purchased through the tender process,
in each country — the capital city, an urban area and a this would have saved USD38,000*, or around 15% of the
predominantly rural area. The aim was to see if the problems total. The drawback of tenders is that delivery of insulin can
in different areas of the country varied due to their take several months compared to a matter of days when it is
geographical and socio-economic situation. bought locally.
The Project Coordinator together with a team of local Insulin was exempt from any taxes and duties in Mozambique
interviewers from the respective national diabetes associations and Zambia while insulin in Mali is subject to 2.5% duty. Mali,
(Mozambique and Zambia), and a local non-governmental Mozambique and Zambia’s Essential Drug List all listed both
organization (NGO) and the diabetes association (Mali) carried regular and slow acting human100 IU/ml insulin.
out the RAPIA in these three countries in collaboration with
the respective Ministries of Health. Insulin is supposed to be available at hospitals and at the
smaller Referral Health Centres in each of the three countries.
The topics covered by RAPIA included: During the assessments, however, insulin was present at
some Referral Health Centres only in Zambia. In Mozambique
• Health service structure and functioning with regards to insulin was present at most hospitals and in Mali only the
procurement of medicines and diabetes management two national referral level hospitals in the capital city had
• Diabetes policies, written and enacted insulin available at the time of the study.
• Reported and observed practice for diabetes management
• Availability of insulin, syringes and monitoring equipment In both Mozambique and Zambia the Central Medical Stores
• Price of insulin, syringes and monitoring equipment were the main supplier of insulin to the public sector. In Mali
• Existence of distribution networks for insulin private wholesalers sold directly to the public sector, although
• Insulin supply-related knowledge and attitudes amongst in August 2004 a purchase of insulin by the Central Medical
people with diabetes and their carers Stores was destined to the public sector, the first in two or
• Other problems that hamper the access to proper insulin three years. Figure 6.1 shows the different average purchasing
and care prices of insulin at different levels of the healthcare system.
*All currency amounts are stated in USD for ease of comparison and were converted Mozambique and Zambia have instigated measures to allow
from other currencies at the time of reporting (Mozambique September 2003; people with diabetes to receive free or subsidized insulin.
Zambia April 2004; Mali December 2004). However these are not standardized and are unclear to
MANAGING INSULIN-REQUIRING DIABETES IN SUB-SAHARAN AFRICA CHAPTER 6 289
Chapter6Fin.indd 289 27/10/06 4:16:15

FIGURE 6.1
Average purchasing prices per vial of 100 IU insulin (USD) in Mali, Mozambique and Zambia
Average purchasing price (USD)

20.0
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0
Central Medical Store Public Sector Private Sector Patient (public sector) Patient (private sector)
Mali Mozambique Zambia
individuals. In Mali no such assistance exists and people with This financial barrier is coupled with problems of availability of
diabetes need to bear the total cost of their insulin. these tools, reagents and consumables (see Table 6.7). The
reason for this was primarily financial, with health facilities
Syringes lacking the appropriate budget for purchasing these tools.
Syringes are vital for the delivery of insulin. In all countries

syringes had some form of Value Added Tax (VAT) applied to
their cost, and also were rarely available in the public sector
as they were not ordered by Central Medical Stores or Many people were initially diagnosed with diabetes only
facilities. In consequence, people with diabetes in rural areas following the onset of complications, primarily due to the
had the most difficulty accessing them. There was substantial lack of diagnostic tools and healthcare worker training.
variation reported in the costs of syringes by people with
diabetes (see Table 6.6), and in the duration of single use From previous studies, it has been claimed that the life
syringes (range of changing syringe: daily to every three expectancy of a child with newly diagnosed type 1 diabetes
weeks, median four days). in much of sub-Saharan Africa may be as short as one year84,85.
From different interviews and site visits, and using aggregate
Testing materials data of different registers, an estimate of prevalence for all
age groups for the different areas studied in the three
Another financial hurdle for people with diabetes is the cost of countries was calculated (see Table 6.8).
their testing. For example children and the elderly in Zambia
had their diabetes monitored for free. Others paid anywhere It is seen that there are substantial differences in prevalence
from USD1.06 to USD51.06 per month for their monitoring between different countries, and between urban and rural
costs, depending on whether they had one or more urine and/ areas within countries. These differences are most marked in
or blood tests per month or their own blood glucose meter. Mali and least obvious in Zambia. While some of the
Chapter6Fin.indd 290 27/10/06 4:16:15

FIGURE 6.2
Differences in calculated average life expectancies for people with insulin-requiring diabetes
from different areas of Mali, Mozambique and Zambia
Life expectancy (years) 0-14 years Life expectancy (years) 15+ years
30 30
25 25
20 20
15 15
10 10
5 5
0 0
National Capital city Urban area Rural area National Capital city Urban area Rural area
Mali Mozambique Zambia It was not possible to estimate regional differences in life expectancy in Mali
because people with diabetes commonly travelled to the capital city for treatment.
differences in prevalence in Mali are consequent upon Zambia had the highest life expectancy (11 years), but in
people with diabetes travelling to the capital city for their Mozambique and in Mali, the onset of insulin-requiring
care, this is much less so in Mozambique, where a six-fold diabetes in childhood will mean an average life expectancy
urban-rural difference in prevalence was found. of 12 months and of 30 months respectively. Zambia showed
substantially less variation between different areas of the
Using the estimated national prevalence rates in Table 6.8, country compared to Mozambique. Thus, despite similar
and assuming incidence rates from studies in Nigeria86 and national indices of poverty, the newly presenting diabetic
Tanzania87, estimates were made for life expectancy (see child can expect around 5-10 times better prognosis in
Figure 6.2). Zambia than in Mozambique, a difference likely to be
accounted for by differences in the organization of healthcare.
It should be noted that 3.3% of adults in Mali is estimated to These differences are closely linked to the availability of
have diabetes in 2007, as shown in Chapter 1 (see Table 1.7). insulin, syringes and testing materials, but factors such as
The numbers shown in Table 6.8 are for both adults and healthcare worker training and guidelines, costs for the
children, but highlight that very few people with diabetes in person with diabetes, and the advocacy role of the diabetes
these countries are actually diagnosed, that the health systems associations also impact the outcome for a person with
lack many resources and that access to insulin is difficult. insulin-requiring diabetes.
In Figure 6.2, the National series shows the overall life

expectancy in the country taking into account the difference
in urban and rural populations. It was calculated by taking One key aim of the IIF is to promote and support the
the total population, minus the population of the capital city, development of national diabetes programmes, which
and seeing the proportion of urban and rural dwellers in address the identified problems during the RAPIA assessment
each country. The value for life expectancy for the urban and and provide sustainable solutions. This work contributes to
rural areas was then applied to these values. the WHO AFRO and IDF African Region African Declaration
Chapter6Fin.indd 291 27/10/06 4:16:20

RAPID ASSESSMENT PROTOCOL FOR INSULIN ACCESS
The RAPIA is a series of assessment tools aimed at The meso and micro levels are carried out in three distinct
investigating different levels of the health system. It looks at geographical locations – the capital city, a large city or
the availability, price and distribution of insulin and related urban area and a predominantly rural area to represent
supplies. By looking at the entire health system the RAPIA different geographical and economic situations. Each
is able to identify problems that hamper access to proper interview had as its main aim to obtain the person’s
insulin and care. This information is gathered through perspective on the problems people with diabetes face
specific questionnaires (see Table 6.9), site visits, document in gaining access to insulin and diabetes care in the given
reviews and discussions81,88. country. Through overlap in the areas of questioning and by
using other sources of information (site visits, discussions
The RAPIA is divided into three levels (see Table 6.9): and document reviews), the information gathered was
validated by cross-checking and triangulation between
Macro level: aimed at the Ministries of Health, Finance and different sources and types of information.
Trade, national diabetes associations, educators, Central
Medical Stores and private wholesalers of medicines and
medical equipment.
Meso level: designed to focus on Regional and District

Health Offices, health facilities including pharmacies and
laboratories, as well as private clinics.
Micro level: comprises interviews with healthcare workers,

traditional healers and people with diabetes.
on Diabetes which calls on governments, NGOs, donors, but one of the necessities is information on the size and scope
industry, healthcare providers and all partners and of the problem of diabetes. The role of a strong diabetes
stakeholders in diabetes to ensure: association is also essential in pushing this forward.
• Adequate, appropriate and affordable medications and Development of national diabetes programmes
supplies for people with diabetes Once information about health system performance has
been collected, the development of a national diabetes
• Earlier detection and optimal quality of care of diabetes programme/policy is needed in order to ensure
continuity and guiding principles. These should help
• Effective efforts to create healthier environments and establish a comprehensive organization of the health
prevent diabetes system able to provide care for a chronic condition. The
appropriate infrastructure is vital within the system to
Such initiatives need to be supported and promoted by supply medicines, provide diagnostics, and the tools
governments and stakeholders at a national and international within health facilities to provide appropriate care. The
level in order to ensure that people with diabetes benefit national programme should also include such elements
from these. The work carried out by the IIF in these three as prevention of diabetes and complications, and should
countries indicate that a combination of factors have to be address the issues of accessibility and affordability of
in place in order for a comprehensive solution to succeed. medicines and care.
These include:
Diabetes training
Political will In parallel diabetes training for healthcare workers needs to
Based on the IIF’s experience, strong political will is necessary be implemented, both for those in training and those already
in order for a national diabetes programme to be established. practising. This training needs to include both clinical aspects
This political will can be generated through different means, of diabetes and how to manage a long-term condition.
Chapter6Fin.indd 292 27/10/06 4:16:20

Diabetes education and empowerment the diabetes associations, Ministries of Health and local NGOs
Healthcare workers and the diabetes association need to in Mali, Mozambique and Zambia have been able to formulate
work in conjunction with the community at large towards clear action plans based on a sound assessment. The IIF and
education for people with diabetes and empowerment in the IDF African Region have assisted these three countries in
order to ensure proper adherence to treatment. developing and implementing the recommendations put
forward after the RAPIA assessments.
By addressing these different elements, governments can
not only ensure the survival of those with type 1 diabetes, This model of assessing the health system, developing
but also improve the health system for the care of people country specific recommendations and following this with
with type 2 diabetes, which could act as a model for other implementation should be a gold standard applicable to
non-communicable diseases. other non-communicable diseases beyond diabetes. This will
ensure that real needs are being tackled and that appropriate
means are used to address the problems in the health system
identified by the RAPIA.
The RAPIA provides information on the different barriers that
exist in a given country with regards to access to essential Note: the data are correct at the time of the RAPIA assessment
elements needed for the diagnosis, care and management in each of these countries.
of people with diabetes. The work of the IIF is not only in
documenting the problems, but to also work in close
collaboration with local stakeholders and international
agencies to develop feasible solutions.
The RAPIA tool empowers local stakeholders by involving

them in all the steps of the assessment. By using the RAPIA
Chapter6Fin.indd 293 27/10/06 4:16:21

TABLE 6.6
Comparison of the price range per syringe (USD) in Mali, Mozambique and Zambia
COUNTRY PRICE RANGE PER SYRINGE (USD)
Mali 0.20-0.60
Mozambique 0.04-0.20
Zambia 0.15-1.50
TABLE 6.7
Availability of various diagnostic tools in Mali, Mozambique and Zambia at different health facilities visited
COUNTRY URINE GLUCOSE KETONE BLOOD GLUCOSE PRESENCE OF A

STRIPS (%) STRIPS (%) METER (%) SPECTROPHOTOMETER OR
OTHER LABORATORY
EQUIPMENT FOR BLOOD
ANALYSES (%)
Urban Rural Urban Rural Urban Rural Urban Rural

Mali 67 0 40 0 67 30 50 0
Mozambique 21 0 9 0 38 0 15 0
Zambia 64 56 54 38 51 63 10 6
TABLE 6.8
Estimated prevalence of insulin requiring diabetes in areas studied in Mali, Mozambique and Zambia
LOCATION PREVALENCE PER 100,000 POPULATION

OF INSULIN-REQUIRING DIABETES
MALI NATIONAL (extrapolation) 3.9

Bamako (capital city) 27.9
Sikasso (urban area) 1.8
Timbuktu (geographically inaccessible area) 2.9
Kadiolo (rural area) 1.4
Douentza (rural area) 0.2
MOZAMBIQUE NATIONAL (extrapolation) 3.5

Maputo (capital city) 9.1
Beira (urban area) 5.0
Lichinga (rural area) 1.4
ZAMBIA NATIONAL (extrapolation) 12.0

Lusaka Province (capital city and surrounding province) 18.0
Copperbelt Province. (urban area) 12.6
Eastern Province (rural area) 9.5
As interviews, site visits and aggregate data of different registers were used in these calculations, the following assumptions were made:
• Patients attended clinics for their diabetes care once a month
• No overlap in patients from different facilities within the same area
Chapter6Fin.indd 294 27/10/06 4:16:21

TABLE 6.9
The different questionnaires that comprise the RAPIA
LEVEL ISSUES ADDRESSED IN EACH RAPIA QUESTIONNAIRE

MACRO Ministry of Health Organization of delivery of diabetes care
Resources available for diabetes and insulin
National Programmes for diabetes and insulin
Pricing of insulin
Distribution of insulin
Funding for insulin and diabetes
Insulin tendering and purchase
Ministry of Trade Trade issues (laws, barriers to trade)
Trade infrastructure
Ministry of Finance Funding of health system
Taxes on insulin
Funding for insulin and diabetes
Private sector Pricing of insulin
Distribution of insulin
National diabetes association Issues with diabetes and insulin
Central Medical Store Insulin tendering and purchase
Insulin distribution and storage
Insulin pricing
MESO Regional Health Organization Issues with diabetes and insulin
Organization of care for people with diabetes
Hospitals, clinics, health centres, etc Treatment and management of people with diabetes
Access to appropriate tools to diagnose and treat patients
Infrastructure present and/or lacking for insulin provision
Laboratory Infrastructure present and/or lacking for proper diagnosis and follow-up
Pharmacy Insulin distribution and storage
Insulin pricing
MICRO Health workers and traditional healers Problems encountered in diagnosis and treatment of patients
Training
Infrastructure present and/or lacking
Tools present and/or lacking
People with diabetes Diagnosis
Access to treatment
Cost of treatment
Chapter6Fin.indd 295 27/10/06 4:16:21

Chapter7fin.indd Sek1:296 26/10/06 14:06:17
CHAPTER 7
MENTAL HEALTH, ANTIPSYCHOTIC DRUGS AND HYPERGLYCAEMIA

It has been estimated
that people with
diabetes are twice as
likely as the general
population to suffer
from depression.

outcome has not yet been fully elucidated. Nevertheless,
it has been estimated that people with diabetes are twice
he chronically mentally ill are a high-risk population for as likely as the general population to suffer from
diseases such as diabetes and cardiovascular disease depression, with the risk being higher in women than in
due to a number of factors. These include suboptimal access men3,4. Depending on the definition used the prevalence
to medical services, a propensity to smoking, poor diet, of depression among people with diabetes ranges from
sedentary lifestyle and obesity1,2. 8.5 to 32.5%5-7.
There is increasing information regarding the association People with poorly controlled diabetes are more likely to
between diabetes and psychotic disorders. However, the have depression7. This may be because depression leads to
true prevalence of diabetes in this population may be problems with adherence to medication and diet, and affects
underestimated due to inconsistencies in surveillance quality of life8,9. Depression also seems to be a factor in
protocols. increasing the risk of developing diabetes-related
complications10, and also increased mortality11. Having
Evidence is also mounting for the association between diabetes and depression may also be associated with higher
antipsychotic medication and the development of diabetes, risk of suicide, with some reports of a 10-fold increased risk
and a link between depression and diabetes has been of suicide and suicidal ideation12,13. Thus the combination of
recognized. diabetes and depression appears to be associated with a
poorer quality of life, and with increased morbidity and
mortality.
There is an increasing awareness of the link between Type 2 diabetes and schizophrenia
diabetes, both type 1 and type 2, and depression. But
which one leads to the other or affects its course and There has been a purported association between abnormal
MENTAL HEALTH, ANTIPSYCHOTIC DRUGS AND HYPERGLYCAEMIA CHAPTER 7 299

FIGURE 7.1
Pharmacological agents implicated in the development of diabetes
mellitus
Inhibition of
insulin secretion
Thiazide diuretics
Calcium channel
antagonists
Destruction Phenytoin
of beta cells Pentamidine
Streptozotocin Cyclosporin A
DIABETES MELLITUS
Sympathetic Impaired insulin

stimulation/ action
blockade Corticosteroids
α, β agonists/ Oral contraceptive pill
antagonists Anabolic steroids
Xanthines
Unknown mechanisms
Nalidixic acid, Rifampicin, Isoniazid, Phenothiazines
glucose tolerance and psychiatric disorders that goes back As an illustration of the link between schizophrenia and
almost 100 years14, and by the 1960s and 1970s it was diabetes, a study from the USA 18 reported a diabetes
recognized that phenothiazines (drugs used to treat prevalence of 15% among those with schizophrenia,
schizophrenia) were associated with hyperglycaemia15. compared to 3% from the general population. Increasing
More recently there have been numerous reports of age and African American background were highlighted
diabetes occurring among people with psychotic disorders. as being important risk factors. Notably, much of this
However, these studies, many of which have been study predated the widespread use of atypical
retrospective and of variable size, have not always been antipsychotics.
controlled for potential confounders such as age, race,
gender, family history and obesity. In addition, many studies
have not been controlled for use of antipsychotic drugs,
which themselves, especially some of the newer, atypical A wide variety of antipsychotic drugs has been used in the
agents, have been implicated in the development of treatment of schizophrenia and mood disorders.
diabetes. Antipsychotic drugs are split into first and second generation,
or typical and atypical antipsychotics (see Table 7.1). Second
Furthermore, it has been suggested that the apparent generation drugs have only been around for some 20
difference in risk between medications may partly be years.
attributed to a greater degree of vigilance with more glucose
monitoring being done among those taking atypical First generation agents used to be commonly prescribed for
antipsychotics such as clozapine or olanzapine, as opposed the treatment of schizophrenia, but have now been largely
to older drugs such as risperidone16. Other shortfalls include superseded by atypical antipsychotics. Second generation
differences in whether subjects were screened before or or atypical antipsychotic drugs have been favoured due to a
after initiating medication and the type of test(s) used for better side effect profile.
diagnosing diabetes17.

TABLE 7.1
Examples of some first and second generation antipsychotic agents
FIRST GENERATION ANTIPSYCHOTIC DRUGS
Chlorpromazine
Fluphenazine
Thioridazine
Haloperidol
Droperidol
Flupenthixol
Zuclopenthixol
SECOND GENERATION OR ATYPICAL ANTIPSYCHOTIC DRUGS
Olanzapine
Clozapine
Risperidone
Quetiapine
Aripiprazole
Ziprasidone
Amisulpride
Drug induced hyperglycaemia antipsychotics (10/1,000 person years for clozapine; 5.4/1,000
for risperidone; 5.1/1,000 for conventional agents). Compared
A variety of drugs has been implicated in precipitating to those not on any antipsychotic treatment (and adjusted
diabetes mellitus (see Figure 7.1). for age, sex and use of drugs known to affect glucose
metabolism), olanzapine was an independent risk factor for
Case reports linking atypical antipsychotics with diabetes, but risperidone and conventional agents were not
hyperglycaemia have appeared for some years going back (olanzapine odds ratio (OR) 5.8 (2.0-16.7); risperidone OR 2.2
to 1994 for clozapine19, 1998-99 for olanzapine20 and 1999 for (0.9-5.2); and conventional agents OR 1.4 (1.1-1.7)). When
quetiapine21. Reports linking older antipsychotic drugs such compared to those treated with conventional agents,
as chlorpromazine to increased blood glucose levels22 and olanzapine, but not risperidone, was again an independent
aggravation of existing diabetes23 go back to the 1950s and risk factor.
1960s24.
A retrospective study examined claims data from a health
A study set in 1999 reviewed the records of 38,632 outpatients plan of nearly two million members from 1997 to 200027.
with schizophrenia receiving either atypical (58.6%) or typical Over 16,000 people with psychosis were identified, and
antipsychotics (41.4%)25. The overall prevalence of diabetes those treated with antipsychotics (n=6,582) were compared
was high at 19%, and in those under the age of 60, there was to those not treated with antipsychotics (n=10,296). Major
an increased risk of developing diabetes for those who were depression was the most common diagnosis in both groups
on clozapine, olanzapine and quetiapine (but not risperidone), (76% versus 38%). Treatment with olanzapine was a significant
compared to those on other antipsychotic agents. predictor of the development of diabetes, but other
antipsychotics showed no association with diabetes.
A study, using the UK-based General Practice Research
Database (GPRD)26, showed that the incidence of diabetes However, this finding was not supported by another similar
was higher among users of atypical than conventional study28. In another study of a huge claims database, which

FIGURE 7.2 FIGURE 7.3
Factors associated with higher morbidity and mortality among people ADA Consensus monitoring protocol for patients initiating
with psychotic conditions antipsychotic medication38
14:$)04&4
4VCPQUJNBMMJGFTUZMFQPPSEJFU MBDLPGFYFSDJTF TNPLJOH Baseline
6TFPGBOUJQTZDIPUJDNFEJDBUJPO 4 Weeks
8 Weeks
12 Weeks
*/$3&"4&%3*4,
Quarterly
%*"#&5&4 0#&4*5: Annually
*/$3&"4&%3*4, Personal / family history X X
$BSEJPWBTDVMBSEJTFBTF Weight (BMI) X X X X X

*TDIBFNJDIFBSUEJTFBTF %JBCFUJD
$BSEJBDGBJMVSF NJDSPWBTDVMBS Waist circumference X X
):1&35&/4*0/
.ZPDBSEJBMJOGBSDUJPO DPNQMJDBUJPOT
4USPLF Blood pressure X X X
Fasting plasma glucose X X X

).#2%!3%$ Fasting lipid profile X X X
-/2")$)49!.$-/24!,)49
handles 300 million prescription claims per year for over 50 compared to risperidone (OR 1.13 (0.99-1.28)), to clozapine
million members in the USA29, those on antipsychotic (OR 1.41 (1.08-1.83)), and to quetiapine (OR 1.17 (1.00-
medications were 3-4 times more likely to develop diabetes 1.37)).
(after adjusting for age and sex), compared to the general
population. Of note, there was no difference in the risk of Although the vast majority of cases of diabetes associated
developing diabetes between those treated with typical and with antipsychotic drugs are type 2 diabetes, there are a
atypical drugs. number of case reports linking these drugs with diabetic
ketoacidosis (DKA) 31. DKA is a life-threatening, acute
A meta-analysis of 14 studies (10 retrospective cohort and metabolic disturbance, which is usually associated with type
four case control studies) included 256,000 people with 1, not type 2, diabetes.
schizophrenia or related disorders30. Comparisons between
atypical and conventional antipsychotics revealed a strong Although there are many studies examining the link between
association between atypical agents and the development antipsychotic use and development of diabetes they tend to
of diabetes (clozapine OR 1.37 (1.25-1.52), olanzapine OR 1.26 have similar limitations. That is, they are often retrospective,
(1.10-1.46) and risperidone OR 1.07 (1.00-1.13)). Although not randomized control studies and do not always take into
there was a trend towards diabetes development for account risk factors such as race, body mass index (BMI) and
quetiapine, results did not reach statistical significance. family history. Other factors include not allowing for lack of
compliance32, which is a problem in this population, changing
When compared to those not receiving antipsychotics, medications during the study period and detection bias33.
there was a significantly increased risk of developing
diabetes for clozapine (OR 7.44 (1.59-34.75)) and a borderline Potential causes of drug-induced
significant increase in risk for olanzapine (OR 2.31 (0.98- hyperglycaemia
5.46)). Head to head comparisons showed a possible
increase in diabetes risk associated with olanzapine, when The specific biochemical links between psychosis,

antipsychotic drugs and diabetes remain poorly understood. therefore careful consideration is required when choosing
However, it is abundantly clear that people with psychoses the best drug for the patient and the likely non-psychiatric
such as schizophrenia have markedly suboptimal lifestyles consequences of using that drug. It is somewhat concerning
(see Figure 7.2). They also have lower standards of living, that although there has been an increasing number of
being less educated and more likely to suffer from poverty reports published on the link between antipsychotic drugs
and unstable living conditions18. They do not exercise as and diabetes, a survey of psychiatrists in the USA found that
much; their diet is poor and they have high rates of 49% did not recognize diabetes as a potential metabolic
smoking 34,35. Studies examining diet found a lower complication of atypical antipsychotic medication41.
consumption of dietary fibre, fruit and vegetables compared
to a matched control group. They also appear to consume More work is required to explain a possible link between
more sugar and fat, which seem to be independently depression and diabetes. As with diabetes and psychosis, the
associated with the severity of symptoms particularly in combination of diabetes and depression leads to greater
schizophrenia36. Poor dietary choices may however, also be morbidity and mortality than the general population and
related to the use of antipsychotic medication which therefore treatment needs to follow a multi-disciplinary
increases appetite37. approach.
The American Diabetes Association (ADA) has issued a

consensus statement outlining screening, which should be
done on commencement of antipsychotic therapy, and
periodically thereafter38 (see Figure 7.3).
Other recommendations have been for testing to be done

at the initiation of therapy, and then repeated at four months
and annually thereafter39. An Australian Consensus working
group has addressed the practical problems of screening this
population, including taking into account the ethnicity of
the person and recommends finger-prick testing and the use
of a modified OGTT where necessary, where standard
investigations are not possible40. Monitoring should also be
individually tailored together with an emphasis on
modification of lifestyle factors such as diet and exercise.
Healthcare professionals should be aware that people with

a psychotic illness are at higher risk of developing diabetes
and other metabolic disturbances. This risk is derived from a
disordered lifestyle, use of antipsychotic medication, and
possibly because of intrinsic pathophysiological effects of
mental illness. Management of these people has to not only
encompass mental illness but general health issues and
therefore treatment should be multi-disciplinary.
Medical practitioners need to be aware that drugs used for

psychosis have differing risk profiles for weight gain,
hyperglycaemia and other metabolic disturbances and

CHAPTER 8
THE METABOLIC SYNDROME

The metabolic syndrome is
now thought to be a key
driver of the modern day
epidemics of diabetes and
cardiovascular disease.

have surfaced and this has caused considerable confusion,
just as has the variety of names used to describe the
The metabolic syndrome, the clustering of visceral syndrome4.
(abdominal) obesity, dyslipidaemia, hyperglycaemia and
hypertension, is a major public health challenge worldwide
as more and more people fall victim to the syndrome1,2.
The syndrome is not benign as it is associated with a The cause of the metabolic syndrome remains poorly
substantially elevated risk not only of type 2 diabetes understood, and likely to be complex and multifactorial1.
(five-fold) but also of cardiovascular disease (CVD) (two- Insulin resistance and abdominal obesity have received the
to three-fold)1. The metabolic syndrome is now thought most attention as the putative underlying features most
to be a key driver of the modern day epidemics of diabetes likely to explain the frequently observed clustering of the
and CVD1. Its increasing occurrence could possibly reverse other components. However, further research is required to
the gains that have been made in many communities and determine which factors are central to the development of
nations through recent declining CVD morbidity and this syndrome. Several different factors are probably involved,
mortality. many related to sedentary lifestyle but clearly, genetic factors
also play a role.
The metabolic syndrome is not a new condition. Its
description goes back at least 80 years being first Confusion arising from various definitions
described in the 1920s by Kylin3, a Swedish physician. This
cluster of CVD risk factors has had a number of names Since its initial description, several definitions of the
including Deadly Quartet, Syndrome X, Syndrome X plus, syndrome have emerged. Each of these definitions used
and Insulin Resistance Syndrome1 but metabolic syndrome differing sets of criteria, the combination of which either
is likely to remain the popular choice for the foreseeable reflected contrasting views on pathogenic mechanisms or
future. Numerous definitions for the metabolic syndrome clinical usefulness. The use of these definitions to conduct
THE METABOLIC SYNDROME CHAPTER 8 307

research into the metabolic syndrome in diverse populations perspective, the ATP III definition was probably the most
resulted in wide ranging prevalence rates, inconsistencies practical for alerting healthcare professionals to those at
and confusion, and spurred on the vigorous debate highest risk1,8.
regarding how the metabolic syndrome should be
defined.
Of the various attempts, the WHO definition5 and two It was because of this confusion and the need to take into
others, the European Group for the Study of Insulin account ethnic differences that the International Diabetes
Resistance (EGIR)6 and National Cholesterol Education Federation (IDF) embarked on the process of arriving at an
Program – Third Adult Treatment Panel (NCEP ATP III)7 were urgently needed consensus on a new global definition of the
the main ones in use. Each of these agreed on the essential metabolic syndrome (see Table 8.1). This has now been
components of obesity, hyperglycaemia, dyslipidaemia and published on the web9 and in both The Lancet8 and recently
hypertension. However, the definitions differed in the cut- in more detail, in Diabetic Medicine10.
off points used for each component, and the way in which
the components were combined. This has led to The new IDF definition recognizes the mounting evidence
considerable confusion and it has been particularly that visceral adiposity is common to each of the components
apparent in attempts to compare the burden in different of the metabolic syndrome although it does not necessarily
populations1,2. imply an aetiological link. Thus, an excessive waist
circumference (demonstrated to be a good proxy
One of the major issues that these three definitions failed to measurement for visceral adiposity) is now a necessary
address was the inherent ethnic differences in measurements requirement for the metabolic syndrome. This is based on
of obesity (body mass index and waist circumference). It was the strong evidence linking waist circumference with
also uncertain which of the definitions best predicted those cardiovascular disease and the other metabolic syndrome
at risk of CVD and diabetes, although from a clinical components, and the likelihood that central obesity is an

FIGURE 8.1
Guide to measuring waist circumference
Inferior margin of the ribs
Waist
Anterior superior iliac crest
Waist circumference should be measured in a horizontal plane, midway between

the inferior margin of the ribs and the anterior superior iliac crest. Data show that
if BMI is greater than 30 kg/m2, waist circumference is highly likely to be above
the diagnostic cut-points for the metabolic syndrome, and measurement is not
necessary.
early step in the aetiological cascade leading to the full numbers of people with impaired glucose tolerance
metabolic syndrome 1. The optimal technique for its (because an oral glucose tolerance test is not required), it
measurement is shown in Figure 8.1. retains the simplicity of the instrument, particularly in a
primary healthcare setting. In the short time since the new
The waist circumference cut-off selected was the same as definition has been made available, a number of
that used by EGIR and lower than the main ATP III publications have reported the prevalence, and these are
recommendations, because most available data suggest an shown in Table 8.2.
increase in other cardiovascular disease risk factors in
Europids when the waist circumference rises above 94 cm in The IDF consensus report10 also includes recommendations
men and 80 cm in women1. Since it is clear that the levels of for future research into components not currently included
obesity at which the risk of other morbidities begins to rise in the core definition of the metabolic syndrome. These
varies between population groups1,11, ethnic-specific waist factors should be combined with assessment of
circumference cut-offs have been incorporated into the cardiovascular disease outcome and development of
definition (see Table 8.1). The cut-offs have been based on diabetes so better predictors can be developed.
available data linking waist circumference to other
components of the metabolic syndrome in different The IDF consensus report also highlights strategies for the
populations12,13. treatment of the metabolic syndrome and its components.
It addresses both clinical and research needs and:
The levels of the other variables were as described by ATP III,
except that the most recent diagnostic level from the • provides a simple entry point for primary care physicians
American Diabetes Association (ADA) for impaired fasting to diagnose the metabolic syndrome;
glucose (5.6 mmol/L [100 mg/dL]) was used14.
• provides an accessible, diagnostic tool suitable for
Although the new definition will still miss substantial worldwide use, taking into account ethnic differences in

TABLE 8.1
The International Diabetes Federation (IDF) definition of the metabolic syndrome9,10
ACCORDING TO THE IDF DEFINITION, FOR A PERSON TO BE DEFINED AS HAVING THE METABOLIC SYNDROME, HE/SHE MUST HAVE:
Central obesity (defined as waist circumference):
≥ 94cm for Europid men and ≥ 80cm for Europid women
≥ 90cm for men and ≥ 80cm for women for those of South and South-East Asian, Japanese, and ethnic South and Central American origins
plus any two of the following four factors:

• raised triglycerides: ≥ 1.7mmol/L
• reduced HDL-cholesterol: <1.03mmol/L in males and <1.29mmol/L in females, or specific treatment for these lipid abnormalities
• raised blood pressure: systolic BP ≥130 or diastolic BP ≥85mm Hg, or treatment of previously diagnosed hypertension
• impaired fasting glycaemia (IFG): fasting plasma glucose ≥5.6 mmol/L, or previously diagnosed type 2 diabetes
waist circumference and associated type 2 diabetes and

CVD risk; and
• establishes a comprehensive ‘platinum standard’ list of The IDF definition should provide researchers with a common
additional criteria that should be included in platform for investigating the syndrome and its consequences.
epidemiological studies and other research into It provides for the first time a useful practical global tool that
the metabolic syndrome. will draw attention to healthcare professionals of the
metabolic consequences of obesity. The new definition
serves a useful purpose to focus on people, in both the
community and clinical settings, who are at high risk of
developing CVD and type 2 diabetes, and are likely to benefit
from (lifestyle) interventions.

TABLE 8.2
Prevalence of the metabolic syndrome, according to the IDF definition
COUNTRY/TERRITORY DATA USED AGE SAMPLE SIZE PREVALENCE (%)

MEN WOMEN TOTAL
Australia Adams et al, 200515 18+ 4,060 26.4 15.7 •
Zimmet et al, 20054 25+ 11,247 • • 29.1
Germany Rathmann et al, 200616 55-74 1,373 57.0 46.0 •
Greece Athyros et al, 200517 18+ 9,669 • • 43.4
Korea, Republic of Park et al, 200618 20-80 6,824 13.5 15.0 •
Mexico Guerrero-Romero et al, 200519 30-64 700 • • 22.3
Lorenzo et al, 200620 35-64 1,990* 54.4 61.0 •
Peru Lorenzo et al, 200620 35-64 346* 26.0 28.1 •
Spain Lorenzo et al, 200620 35-64 2,540* 27.7 33.6 •
United Kingdom Lawlor et al, 200621 60-79 3,589 47.5 •
United States of America Ford, 200522 20+ 3,601 40.7 37.1 39.1
USA (Mexican-American) Lorenzo et al, 200620 35-64 1,150* 46.3 41.0 •
USA (non-Hispanic white) Lorenzo et al, 200620 35-64 1,323* 38.3 28.8 •
* People with diabetes not included in this study

Chapter9Fin.indd 312 26/10/06 0:52:45
he mission statement of the International Diabetes the strong evidence base for the primary prevention of type
Federation (IDF) has been revised and expanded to 2 diabetes will slow down and, eventually, reverse the
include the prevention of diabetes as well as the promotion hitherto inexorable rise in the burden of type 2 diabetes. It
of diabetes care and its cure. Some of the rationale for this is enthusiastically advocates this for developed countries but
provided in Chapter 10 but, in part, this revision is a reflection does so even more strongly for developing countries.
of the accumulating evidence for the efficacy of specific
interventions directed at the primary prevention of type 2
diabetes as well as the likelihood that, unless we act decisively,
and act now, the health systems of developed and developing
countries will be overwhelmed by the fast growing numbers
of people affected by diabetes and its complications.
The growth in numbers of people with type 1 diabetes is well

documented. At the present time, there is no evidence base
for the primary prevention of this important but numerically
smaller sub-type of diabetes. To date, no large scale trials
have been successful in preventing type 1 diabetes, although
there is suggestive evidence from small studies that some
drugs may prove to be useful in preventing or delaying its
onset.
Chapter 9 focuses on the primary prevention of type 2

diabetes, and looks to the future – a future in which the
practical application, in clinical and public health practice, of
PREVENTION AND ACTION PART 3 313
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Chapter9Fin.indd 314 26/10/06 0:52:47
CHAPTER 9
PREVENTION AND DIABETES: POSSIBILITIES FOR SUCCESS AND CONSEQUENCES OF INACTION
Chapter9Fin.indd 315 26/10/06 0:52:47

Lifestyle modification
with moderate but
consistent physical
activity and a healthy
diet helps to prevent
type 2 diabetes in
high-risk groups.
Chapter9Fin.indd 316 26/10/06 0:52:48

leisure facilities, work, nutrition, food labelling and pricing,
institutional catering and many more behavioural influences
The scope of this chapter is the primary prevention of type all have a part to play. This chapter explores the potential for
2 diabetes. Although the prevention of diabetic complications success in the prevention of type 2 diabetes and some of the
is of critical importance when diabetes is already established, consequences of failure.
this is part of therapy and management. This is firmly in the
domain of the diabetes multidisciplinary team – with, at its
centre, the person with diabetes and the family. It is the
concern, by and large, of health services and the effectiveness The evidence base for the primary prevention of type 2
with which complications can be averted is largely diabetes, at least in people who are classified as having
determined by access to these services, the quality of these impaired glucose tolerance (IGT) is clear and overwhelming1.
services, the rapport that develops between the person with The notion that weight loss, where appropriate, and increased
diabetes and the health professionals concerned, the quality physical activity is beneficial in such persons has long been
of education, motivation for personal behavioural change a belief and is now supported by randomized controlled trial
and the availability of appropriate diabetes medication and (RCT) studies in many countries. In addition, certain specific
supplies. pharmacological interventions have also been proven to be
effective.
The prevention of diabetes itself, on the other hand, has
wider connotations throughout society. Health services have The recent RCTs carried out in China2, Finland3, the USA4,
a part to play in identifying ‘at risk’ individuals, and advocating Japan5 and India6 have conclusively shown that lifestyle
and supporting one or more of the effective person-based interventions in people with IGT can prevent, or at least delay,
interventions. However, in terms of preventing type 2 the transition to type 2 diabetes. These interventions
diabetes (by preventing obesity, for example), policies in investigated weight loss and increased physical activity in
education, transport, the form of our physical environment, the overweight and obese3,4 but also lifestyle management
PREVENTION AND DIABETES: POSSIBILITIES FOR SUCCESS AND CONSEQUENCES OF INACTION CHAPTER 9 317
Chapter9Fin.indd 317 26/10/06 0:52:58

FIGURE 9.1
In touch with: an advocate for prevention
Cumulative incidence of diabetes (%) in the Indian Diabetes
Prevention Programme*
Diabetes is preventable. Lifestyle modification with moderate
Cumulative incidence of diabetes (%) but consistent physical activity and diet modification helps
60
to prevent type 2 diabetes in high-risk groups. Type 2 diabetes
50 once considered a disorder of the affluent is now seen among
people of all walks of life. It affects the rich and the poor, the fat
40 and the lean, the young and the old alike. Dr A Ramachandran
and his colleagues at the Diabetes Research Centre (DRC) in
30
Chennai, India, undertook a major research study on primary
20 prevention of diabetes in the Indian population, who are
genetically susceptible, highly insulin resistant and have a lean
10 body mass index. People who had impaired glucose tolerance
(IGT) were targeted.
0
0 6 12 18 24 30 36 42
Dr VJ Krishnamurti, 54, a senior professor at an institute
Control group Time taken to
develop diabetes of technology, walked in reluctantly to the prevention
Metformin (MET)
( months) camp organized by DRC in May 2001. He walked in with
Lifestyle modification + metformin
Lifestyle modification (LSM) lots of questions and the research team could sense his
apprehension. His attitude was one of “I know everything
*Cumulative incidence of diabetes, calculated using the Cox proportional hazards and what more do you have to tell me?”. On screening he
model. The number of subjects who underwent an annual OGTT was 484, 403 and 345
at 12, 24 and 30/36 months, respectively. The p values for relative risk reduction were was found to have IGT.
as follows: LSM = 0.018, LSM + MET= 0.022, MET = 0.029. LSM and LSM + MET showed
identical results, therefore, the graphs overlap. Source: Ramachandran et al, 20066
in those who were not obese2. The pharmacological In a recent systematic review and meta analysis of these RCTs
interventions investigated were medication with the of lifestyle interventions in type 2 diabetes11, lifestyle
biguanide drug metformin4 or with the alpha-glucosidase education reduced two-hour plasma glucose by a mean 0.84
inhibitor acarbose7 or with sibutramine8 or, in those with a mmol/l (95% CI 0.39-1.29) over one year and the incidence
history of gestational diabetes, troglitazone9. of type 2 diabetes by approximately 50% (RR 0.5, 95% CI 0.44-
0.69) compared with the control group over the same period
The main features and conclusions of these trials are of time. No publication bias was evident in this body of
summarized in Table 9.1. In the Diabetes Prevention Program evidence.
(DPP) in the US the risk reduction effect following lifestyle
changes were much more apparent than intervention with The cost-effectiveness of preventing type 2 diabetes or, more
metformin, which was also significant. generally, of preventing cardiovascular disease (CVD) in
people who are at high risk (such as those with diabetes) has
In the Indian DPP, the effect of following lifestyle changes been investigated. The results are highly encouraging. A
and intervention with metformin produced similar results as recent study12 concluded that lifestyle intervention was cost
combining both, and did not show an additional benefit (see effective in all age groups and cost-saving in those aged 25-
Figure 9. 1). 44 years. Metformin intervention, while cost effective in
younger age groups, was not cost effective in those aged
Not shown in Table 9.1 is the fact that, for the interventions over 65 years.
shown, the number needed to treat (NNT) over three years
ranged from 2.25 (Da Qing) to 36 (in the IGT group of the In low-income countries preventing diabetes by means of
XENDOS study). That is, the number of people needed to be lifestyle intervention is likely to be highly cost effective. Other
treated with these interventions over three years to avoid methods to reduce the risk of cardiovascular disease in
one person with IGT progressing to type 2 diabetes ranged people at high risk are also attractive from the humanitarian
from 2.25 to 3610. and economic points of view. Another study13 found that a
Chapter9Fin.indd 318 26/10/06 0:53:00

The research team had a testing time explaining that and upon repeated counselling by telephone. He
although he was not diabetic, he may eventually develop reduced his intake of fatty and fried foods, and started
the condition if not prevented. The stages leading to eating more vegetables. At the end of one year in the
diabetes were explained, and the physician of the team prevention programme, Dr Krishnamurti was able to see
emphasized the need for intervention as a preventive visible changes such as weight reduction, and his blood
measure. The social worker and the dietitian spent time sugars returned to normal. This was a motivation for him
with him to elucidate details on his diet and other habits. to continue the preventive measures suggested by the
He was a regular walker, but did not practise any dietary research team.
restrictions.
“My apprehensions and reluctance were laid to rest at the
“It came as a rude shock to me when I was first told that end of the year when I could see changes in my weight
I had impaired glucose tolerance and that I may become and blood sugar level,” said Dr Krishnamurti. “From then
diabetic if I didn’t prevent it then,” recalled Dr Krishnamurti. on there was no looking back for me and I have become
“I am a health buff and thought that I was taking proper an advocate of prevention of diabetes to my colleagues
care of my health. I was quite sceptical and found it hard and friends. I strictly follow the dietician’s advice, and I am
to believe when the research team told me that diabetes is thankful and full of appreciation for the Diabetes Research
preventable with proper lifestyle modification.” Centre for having helped me to prevent diabetes.”
Dr Krishnamurti’s response to the changes in his diet Dr VJ Krishnamurti is a pseudonym.

pattern suggested by the dietician was guarded. However,
the dietician was effective in reducing his calorie intake
from 2120 to 1565 calories in a year, achieved in phases
number of population-based and person-based interventions of type 2 diabetes enables surveillance of the development
to lower blood pressure would be cost effective in all regions of microvascular complications to be initiated and their
of the world. Some of the results are shown in Table 9.2. Costs treatment to be started if this is available and appropriate. If
in international dollars (ID) per Disability Adjusted Life Years these preventive goals are realized, the potential health
(DALY) saved range from below ID200 in countries such as benefits, both to the individual and to society, are enormous.
Egypt, Iraq, Pakistan and Yemen to around ID1,500 in the As a result, the global profile of diabetes would be
wealthier countries of Europe, North America and transformed.
Australasia.
As has recently been pointed out14, there is little direct (i.e.

RCT) evidence that people at high risk selected specifically If we do nothing to prevent type 2 diabetes then the
on the basis of other risk factors (those with a family history numbers of people predicted to be affected by diabetes
of diabetes, for example) can benefit from these (or other) will reach the figures listed in Chapter 1, or perhaps more.
interventions. Also, with the exception of the STOP-NIDDM Even though methods for estimating the future prevalence
trial15, none of the trials listed in Table 9.1 have directly of diabetes are becoming more sophisticated, no amount
demonstrated a reduction in risk of cardiovascular disease of methodological sophistication can overcome all of the
consequent upon the reduction in risk of transition to type problems inherent in making future predictions of disease
2 diabetes. (Although the Diabetes Prevention Program has occurrence. Experience from the past suggests that such
demonstrated a reduction in surrogate risk factors16). predictions are often underestimates. A major problem in
However, it could logically be argued that those with other making these future predictions now is the uncertainty
risk factors should benefit and that cardiovascular risk should relating to future levels of obesity. We know that the
be reduced if the progression to diabetes can be delayed. prevalence of obesity is increasing but we do not know
(and have no reliable means of estimating) how large the
Additional to this possible benefit is that the early diagnosis increases will be.
Chapter9Fin.indd 319 26/10/06 0:53:10

MAIN FEATURES OF THE PROGRAMME FOR THE
PREVENTION OF TYPE 2 DIABETES IN FINLAND (2003-2010)
• A population strategy: aimed at promoting the health of

the entire population by means of nutritional
interventions and increased physical activity. Comprising
society-orientated measures and action targeting
individuals with the aim of preventing obesity.
• A high-risk strategy: individual-orientated measures

targeted at individuals at particularly high risk of
developing type 2 diabetes. A systematic approach for
identifying, educating and monitoring people at risk.
• A strategy for the early diagnosis and management of

existing type 2 diabetes: this aims to bring these people
into the sphere of systematic treatment thus preventing
the development of diabetic complications. It offers
practical guidance for intensive lifestyle management.
Adapted from ‘Programme for the Prevention of Type 2 Diabetes in Finland 2003
2010’, Finnish Diabetes Association, Finland, 2003. The programme is available in
English at www.diabetes.fi.
Despite this uncertainty, doing nothing is clearly not a viable In Chapter 5, the economic impacts of diabetes and its
option. The declaration of the Diabetes in Asia meeting in complications are set out in stark detail. The total sum that
Colombo, Sri Lanka in 2002 (featured in the second edition of will be spent on treating diabetes and its complications and
the Diabetes Atlas) called for “programmes [for primary on preventing diabetes in 2007 is estimated to be at least
prevention] which must be tailored to local circumstances in USD232 billion, increasing to over USD302 billion in 2025. In
order to be effective”. These programmes have already middle-income countries around half of the medical
commenced in a few countries. The main features of a expenditure devoted to diabetes is spent on the treatment
particularly prominent example, The Programme for the of the acute life-threatening effects of the condition such as
Prevention of Type 2 Diabetes, in Finland are summarized in this hyperglycaemia. The remainder is divided between general
chapter. medical care and the specific measures necessary to identify
and treat complications.
In economic terms, the consequences of inaction are likely to
be disastrous - disastrous for national economic wellbeing, for While much can be done to improve outcome for individuals
public health and social services, and for individuals and and to reduce these costs by the more effective management
families. As with most phenomena such as these, the blow will of the acute phases of the condition and the longer term
fall particularly heavily on developing countries, on the poor effects, the most substantial economic benefit is likely to be
in these countries in particular, and on the poorer sections of realized only when the onset of diabetes itself can be
the developed countries. In developing countries like India, prevented or at least substantially delayed. With many of the
which has the largest number of people with diabetes, the proven effective treatments for diabetic complications either
burden is mainly on families and individuals, who bear the unavailable or unaffordable in developing countries and in
expenses for diabetes treatment. There are indications that the the poorer sections of many developed countries, the
cost of diabetes care is increasing with time. It is indeed, a benefits of better management of established diabetes may
major healthcare burden for the nation too. be unrealizable, at least with current resources.
Chapter9Fin.indd 320 26/10/06 0:53:10

IN TOUCH WITH
A 45-year old man with diabetes in India had developed a

wound on his foot which would not heal. His condition grew
worse with pain; there was discharge from the wound and
an offensive smell. For a living he ran a vegetable stall in the
local market. People stopped buying from his stall because
of the smell from his foot. There was no unemployment
benefit and he had no health insurance. A visit to the doctor
cost him 45 rupees each time and he believed that the
amputation which he needed would cost him 15,000 rupees.
In desperation, he went down to the local railway track and
allowed the wheels of the next train to cut off his foot. The
article did not say what happened to him after that.
Source: New Indian Express, 19 February 2000
Out-of-pocket expenses for diabetes care are known often to • The extent to which transition to type 2 diabetes is
be severe when a member or members of the family is found prevented as opposed to being delayed.
to have diabetes. A recent re-examination, using the same
methodology as the original study17, of the amount poorer • The extent to which the micro- and, particularly, the
Indian families who opt for private care have to pay for diabetes macrovascular complications of diabetes can be
care showed that the original proportion of 25% of family modified by this prevention or delay.
income has increased to 34% from 1998 to 200518. The heavy
financial burden of diabetes, when added to other aspects • The extent to which other factors, as yet unknown,
such as anxiety, physical pain and loss of livelihood, can be contribute to a change in the epidemiology of the
devastating to individuals and families, particularly when state condition.
support or personal health insurance is not available.
In the context of the explanatory RCT, transition to type 2
diabetes can be reduced by as much as 50% over three years.
The annual rate of progression from IGT to type 2 diabetes in
Predicting the impact of primary prevention programmes on observational studies varies from 3%-13%10,11 and, in the
the incidence and prevalence of type 2 diabetes in future years control arms of the DPP and Finnish Diabetes Prevention Study
has even more difficulties than predicting the future of diabetes (DPS) were, respectively, 12% and 6% at the end of the first
in the ‘do nothing’ scenario. The extent to which the potential years, increasing to 28% and 20% at three years. Public health
for success will be realised depends upon a number of factors: interventions (as distinct from RCT interventions) could not be
expected to decrease these rates by as much as 50% but, even
• The extent to which the spectacular results of the if they decreased this conversion rate by 10% or 25% the future
explanatory RCTs summarized in Table 9.1 can be replicated maps of type 2 diabetes would be very different.
in pragmatic RCTs and in the ‘real world’ of clinical public
health practice. A more likely scenario is that public health interventions
Chapter9Fin.indd 321 26/10/06 0:53:13

FIGURE 9.2
Kaplan-Meier survival plots for total cardiovascular mortality*
Survival probability
1.00
0.95
0.90
0.85
0.80
0.75
0.70
0.65
0.60
0.55
0.50
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Simulated years
10 year delay
5 year delay
3 year delay
1 year delay
No delay
*Assumes no delay in the onset of diabetes and a one, three, five and 10-year delay
in onset. Source: McEwan et al19
will delay the transition from IGT to type 2 diabetes rather The cost savings and QALY improvements relating to
than prevent it entirely. A ‘first pass’ in predicting the extent macrovascular complications when running the model over
to which such preventive programmes will change future this time horizon resulted in a mean, total discounted cost
experience of diabetes and its complications in one country decrease of GBP1,200 per subject from a mean of GBP11,500
(the United Kingdom) can be provided by modelling a per subject assuming no intervention. Discounted QALYS
number of ‘what if’ scenarios. The DiabetesForecaster model19 per subject were 12 assuming no intervention, increasing by
investigates the impact of delaying the onset of type 2 approximately one for lifestyle intervention (that is, an
diabetes on the rate of progression to micro- and important increase in expected length and/or quality of
macrovascular complications and death, and estimates the life).
impact on direct financial healthcare costs and quality-
adjusted life years (QALYs) of delayed onset. Clearly these are modelled estimates and take no account of
the cost of introducing these interventions on a community
Running the model over a 40-year time horizon for 1,000 scale. However, they do suggest that the gains in adverse
people in the absence of any preventive intervention predicts outcomes averted, healthcare resources available for other
just under 500 coronary heart disease (CHD) events, uses and improvements in the quality of life will be real and
approximately 450 stroke events and 350 cardiovascular- worthwhile striving for.
related deaths. Running the model once more, this time with
a delay of 11 years in the transition to type 2 diabetes (as
predicted in DPP simulation studies), decreased the number
of predicted CHD, stroke and fatal cardiovascular events by Although the above emphasizes that we now have
22%, 25% and 20% respectively. Figure 9.2 shows the effects sufficient firm evidence on the prevention of type 2
on total cardiovascular disease mortality of delaying the diabetes to be active, both in clinical and public health
onset of type 2 diabetes by one, three, five or 10 years practice to act, this does not mean that we should cease to
compared with no delay. understand better the phenomena leading to type 2
Chapter9Fin.indd 322 26/10/06 0:53:13

diabetes in susceptible people. Two particularly fruitful activity and maintaining a health body weight or, where
areas for further research are the effects of early nutrition necessary, reducing body weight will be effective and cost-
and the effects of external stresses on the nervous system effective. Individual interventions to reduce risk of type 2
of adults and, perhaps particularly, on the young developing diabetes and cardiovascular disease in those at high risk will
individual. These areas may be interconnected as has been also work. Prevention strategies, therefore, must be at least
recently suggested20. two-fold:
As people move from place to place, as with migration • Population-based measures to encourage active lives and
from rural to urban settings, they experience stress and healthy weight maintenance; and
the physiological effects of this, through a combined
effect of the nervous system and endocrine system, can • Individually focussed measures to identify those at high
influence adversely the standard risk factors for risk and reduce that risk.
cardiovascular disease. For some time it has been
proposed that maternal nutrition can influence early fetal As specified in the 2002 Colombo declaration, these
development sufficiently to confer additional risk for the population-based programmes must be tailored to local
development of type 2 diabetes in adult life. It seems that circumstances in order to be effective. The individually
early environment may be influential in increasing the focussed measures, similarly, must adopt the most
susceptibility of the individual to the adverse effects of acceptable and affordable means of identification
external stresses20. (possibly through risk assessment questionnaires such as
that used in the Finnish national programme) followed by
We need not wait until this new knowledge is available. appropriate biochemical investigation and therapeutic
This and other more thorough reviews of the evidence on measures to manage established diabetes if present, or
prevention suggest strongly that population-based ‘pre-diabetes’ (impaired glucose tolerance or fasting
measures aimed at maintaining or increasing physical hyperglycaemia).
Chapter9Fin.indd 323 26/10/06 0:53:14

EXAMPLES OF PREVENTION PROGRAMMES
Cite des Palmiers Health District, Douala, Cameroon Fleurbaix-Laventie Ville Santé Study, France
• Health education campaign with posters, stickers, • 12-year programme to reduce childhood obesity
handouts, flipcharts • Comparison with control towns
• Target groups identified, including health facilities, • Prevalence of obesity stabilized (at 11%) compared with
schools, churches, social and cultural groups increase in control towns (11% in 1992 and 18% in 2004)
• Health education sessions held • Larger programme (EPODE) set up as a result
• Traditional healers involved • Local stakeholders will deliver consistent messages to
• Raised awareness and increased knowledge of diabetes families
and obesity, including among traditional healers • Keys to success are “concrete, visible, sustainable and local
• Increased number of people presenting for voluntary actions, the involvement of all local players”
screening
• Demand from other districts for similar health promotion The website for the programme is www.villesante.com.
initiatives
Source: Borys and Raffin, 200622
Source: Tuo-uo Kpu, 200621
Practical examples of programmes already established to

increase awareness, encourage healthier lifestyles and, in
most instances, identify and manage individuals at high risk
are shown in this chapter.
We cannot afford the ‘do-nothing’ option. Our own and our

children’s futures depend on it. As is often said at IDF:
“The time has come to act…NOW!”
Chapter9Fin.indd 324 26/10/06 0:53:14

TABLE 9.1
Recent trials relevant to the primary prevention of type 2 diabetes
TRIAL INCIDENCE (%) OF PROGRESSION FROM IGT INTERVENTION

TO TYPE 2 DIABETES (INTERVENTION VS CONTROL)
Da Qing2 44 vs 66 Lifestyle
TRIPOD9 14 vs 30 Troglitazone
DPP4 14 vs 29 Lifestyle
DPS, Finland3 32 vs 42 Lifestyle
STOP-NIDDM7 32 vs 42 Acarbose
XENDOS8 6 vs 9 Xenical
Kosaka et al5 3 vs 9 Lifestyle
Indian DPP6 39 vs 55 Lifestyle
Adapted from Davies et al, 200410
TABLE 9.2
Cost-effectiveness of a combined preventive strategy by region*
REGION COST (X106) DALY-SAVED COST/DALY-SAVED EXAMPLE NATIONS

ID (X105) ID
Africa
High adult and child mortality 733 18 400 Algeria, Nigeria, Ghana
Very high adult and high child mortality 543 17 320 Botswana, Eritrea, Uganda, United
Republic of Tanzania
The Americas
Very low adult and child mortality 12,783 91 1,410 Canada, Cuba, United States of America
Low adult and child mortality 2,056 58 350 Argentina, Colombia, Mexico
High adult and child mortality 298 5 650 Bolivia, Ecuador, Guatemala, Haiti
Eastern Mediterranean and Middle East

Low adult and child mortality 789 21 380 Iran, Libyan Arab Jamahiriya, Saudi
Arabia, Tunisia
High adult and child mortality 952 52 180 Egypt, Iraq, Pakistan, Yemen
Europe
Very low adult and child mortality 15,474 99 1,570 Belgium, Denmark, Italy, Spain,
United Kingdom Low adult and child mortality N/A 88 310 Bulgaria, Poland, Turkey
High adult and low child mortality 4,198 176 240 Estonia, Hungary, Russia, Ukraine
South-East Asia
Low adult and child mortality 733 20 360 Sri Lanka
High adult and child mortality 2,994 95 310 Bangladesh, India,
Western Pacific
Very low adult and child mortality N/A 42 1,320 Australia, Japan, Singapore
Low adult and child mortality 6,072 158 388 China, Philippines, Republic of Korea,
Samoa
*Mean Expected Annual Costs (2000 ID), Disability Adjusted Life Years saved, and Costs/DALY-saved for a combined programme of salt-reduction, mass media health
education, and four-drug therapy for all citizens with CVD risk > 25%.
N/A not available

Adapted from Murray et al, 200313
Chapter9Fin.indd 325 26/10/06 0:53:15

CHAPTER 10
FROM VISION TO ACTION

Diabetes is a global problem
and needs a global solution

deaths as HIV/AIDS annually (3.8 million) and clearly deserves
greater recognition as a major disease in itself. The data
The new mission statement of the International Diabetes indicate that diabetes is responsible for a million lower limb
Federation (IDF) to ‘promote diabetes care, prevention and a amputations each year and is a major cause of kidney failure
cure worldwide’ signalled its readiness to become more and blindness. Its direct healthcare costs are huge and its
active on the world scene in a broader range of issues without indirect costs much greater.
foregoing any of its commitment to be a strong advocate for
people with diabetes. The Diabetes Atlas reveals that the major burden of diabetes
falls on the developing world where it threatens not only to
The third edition of the Diabetes Atlas provides stark new subvert the gains of economic development but also the gains
figures on the extent of the global burden of diabetes, and brought about by international humanitarian programmes
its release at the 19th World Diabetes Congress in December addressing the UN Millennium Development Goals.
2006 in Cape Town has provided an invaluable opportunity
to highlight the need to continue the fight against diabetes. Furthermore, the data show that type 2 diabetes is not only
The data confirm beyond all doubt that the diabetes a disease of the elderly but that it is now affecting younger
epidemic is real and that its magnitude is larger than previous age groups. Even children and adolescents are being
projections had anticipated. There are now over 240 million diagnosed with this form of diabetes and far from being a
adults with diabetes worldwide, representing 6% of the adult simple ‘touch of sugar’, type 2 diabetes in the young is
population and the numbers are increasing by seven million proving to be as serious as type 1 diabetes. In Japan type 2
per year. It is projected that by 2025 there will be nearly 380 diabetes in young adolescents is now four to eight times
million adults worldwide living with diabetes. more common than type 1 diabetes. Microvascular
complications such as retinopathy are as frequent and as
Far from being regarded simply as a risk factor for severe as in type 1 diabetes, and the risks for nephropathy
cardiovascular disease, diabetes is responsible for as many and cardiovascular disease are both significantly greater.
FROM VISION TO ACTION CHAPTER 10 329

our living environment. It is clear that people do need to
accept greater responsibility for their wellbeing but at the
What has changed and what is driving the diabetes same time whole-of-government action is needed to
epidemic? The answers are complex. Some reflect factors create the conditions for a healthy living environment.
we cannot change (genetic, ethnic differences, ageing)
while others are clearly environmental and involve Governments have been slow to recognize that chronic
changes in diet, decreased physical activity, increases in diseases are better prevented rather than treated. The
overweight and obesity as well as profound changes in failure of the World Health Assembly Resolution on
our living environment which include changes in work ‘Diabetes’ and on ‘Diet, Physical Activity and Health’, and
practices, globalization, urbanization, town planning, of the World Health Report on ‘Preventing Chronic
transport, schooling, sport, and the development of Diseases: a vital investment’ to stem the diabetes epidemic
mega-cities. These genetic and environmental risk factors has led to the realization that the diabetes world must
collide especially in indigenous peoples (e.g. native US, participate in the debate, take a leadership role, and be
Canadian and Mexican Indians, Australian Aboriginal part of the solution and not simply accept the present
people, Torres Strait Islanders), where diabetes occurs in unsatisfactory situation which exists. For the first time,
50% or more of adults aged over 35 years. The very there are now evidence-based cost-effective strategies to
existence of some indigenous populations is threatened reduce or prevent diabetes complications and evidence
and it is a race against time to turn this epidemic around that much of type 2 diabetes can be prevented. Public
in these populations. health strategies to improve nutrition, prevent overweight
and obesity, increase physical activity and reduce smoking
The debate over the causes is complex and encompasses can prevent not only diabetes but many of the chronic
areas of personal responsibility over health (e.g. “no one diseases.
forces people to over-eat”) as well as societal or
governmental responsibilities for deleterious changes to

WORLD DIABETES DAY
World Diabetes Day is an annual global awareness campaign which focuses on issues that would help prevent diabetes and its complications.
of access to insulin. In such developing countries, access to

insulin is determined not only by the ability of the family to
World Diabetes Day pay for lifesaving insulin which often retails for over USD20 a
vial, but also by availability of insulin and distribution networks
Not only must IDF lead in turning the epidemic of type 2 throughout the country. The lifespan of children in rural areas
diabetes around but it must also become a stronger advocate is less than in urban areas not only because of greater poverty,
for all people with all types of diabetes. With the burgeoning but also because of less access to expert help and because
numbers of adults with diabetes, children and adolescents rural distribution networks of insulin are less reliable. The
have to compete for limited resources. Strong advocacy for the world must no longer quietly accept that children with
rights of children with diabetes has never been more needed. diabetes die needlessly because their diabetes had not been
To this end World Diabetes Day 2007 will focus on the needs diagnosed or because insulin is not available or is not
of children with diabetes. The Diabetes Atlas estimates that the affordable.
incidence of type 1 diabetes in children is increasing at the rate
of approximately 3% per year, with many countries reporting Unite for Diabetes
a higher rate of increase in the very young (under five years).
Worldwide there are approximately 440,000 children with type IDF’s role as a global advocate for people with diabetes will
1 diabetes under the age of 15 years; about half live in the be enhanced by recently being accredited as a non-
developing world and about a quarter in the poorest 50 governmental organization to the United Nations. At the
countries where people have to live on less than USD1 a day. time of writing this, the outcome of the campaign for a
United Nations Resolution on Diabetes has not yet been
The actual prevalence of childhood diabetes may well be decided but, whatever the outcome of the campaign, what
significantly greater than these current estimates indicate as is clear is that the diabetes world has realized the need to join
many children with diabetes in developing countries die forces, to ‘unite for diabetes’ and to call for increased
without the correct diagnosis being made or because of lack recognition of diabetes as a major global disease.
FROM VISION TO ACTION CHAPTER 10 331

UNITE FOR DIABETES
The blue circle, developed as part of the IDF-led campaign for a United Nations Resolution, will provide diabetes with a visual symbol which
hopefully in time will become as readily recognized as the red ribbon of AIDS.
By putting diabetes on the global agenda with this campaign,

IDF is working towards a successful outcome which would
result in: The epidemic of diabetes is one of the most serious
challenges facing the modern world. It is largely a hidden,
• Raised global awareness of diabetes silent epidemic causing much hardship, but it has not as yet
received serious consideration from the world community.
• Increased recognition of the humanitarian, social and Prevention of diabetes is essential, as millions, especially in
economic burden of diabetes low- and middle-income countries, develop the disease each
year. To do nothing is not an option and is morally
• Individual nations making diabetes a health priority indefensible.
• Widespread implementation of cost-effective strategies Cost-effective strategies for the prevention of diabetes are
for the prevention of diabetic complications available. However, because they require changes in diet,
physical activity and lifestyle, they will require whole-of-
• Development of affordable public-health strategies for government implementation, rather than unilateral action
the prevention of diabetes by the governmental agency responsible for health, in order
to change nutrition, public behaviour and the environment
• Recognition of ‘special needs’ groups (children, the we live in. Diabetes is a global problem and needs a global
elderly, indigenous peoples, migrant people from solution.
developing nations, and women during pregnancy)
Much needs to be done. But progress can only be made if
• More research towards a cure for diabetes strategies are based on accurate data and are evidence-
based. The Diabetes Atlas provides health planners with the
evidence needed to translate IDF’s vision into action.

APPENDICES
METHODOLOGY
333
Appendices.indd 333 26/10/06 1:11:17

334
Appendices.indd 334 26/10/06 1:11:22

geographical region were contacted and requested to provide
information on the prevalence of diabetes for countries within
he search for data was limited to studies published after their region. In addition, IDF member associations in each
1979. This cut-off was chosen as data collected prior to member country were asked about relevant data. In the
1980 may no longer reflect the current prevalence of diabetes. absence of data for a country, the member association was
Selection of articles was limited to those published pre- further asked to comment on the use of data from another
March 2006. country (see section on Extrapolation below).
The Medline database and internet were used for the

literature search. Systematic searches were conducted for
each country using the following search formulae: The search obtained data in a variety of forms such as
prevalence studies, registry reports, hospital statistics,
1. Country name (all the countries of the world were entered government estimates, etc. Studies for a particular country
for separate searches) together with ‘diabetes’ or ‘impaired were included based on their level of reliability. The following
glucose tolerance’ and ‘prevalence’ or ‘incidence’; and factors were taken into account when assessing a study’s
level of reliability:
2. ‘NIDDM’ or ‘IDDM’ or ‘non-insulin-dependent diabetes
mellitus’ or ‘insulin-dependent diabetes mellitus’ or ‘Type 1 • The year of the study — more recent studies were preferred.
diabetes’ or ‘Type 2 diabetes’, combined with ‘prevalence’ • The screening method used — the oral glucose tolerance
or ‘incidence’. test (OGTT) was the preferred method of screening, followed
by two-hour blood glucose (2hBG) alone, then the fasting
Relevant citations from each article were also obtained. A blood glucose (FBG) alone, and then self-report (SR).
number of other avenues were explored in the search for • Sample size — studies with larger sample sizes and higher
relevant data. Diabetes researchers in each major IDF response rates were preferred.
METHODOLOGY FOR CHAPTER 1.1 APPENDIX 1.1 335
Appendices.indd 335 26/10/06 1:11:22

EXAMPLES OF MODELLED AND PUBLISHED DIABETES PREVALENCES
FIGURE A1.1 FIGURE A1.2
Jordanian males and females combined (urban) Chinese males
Prevalence (%) Prevalence (%)

30 8
7
25
6
20 5
4
15
3
10
2
5 1
0 0
Age group 25-29 30-39 40-49 50-59 60-69 70-79 Age group 25-34 35-44 45-54 55-64 65-74
Smoothed curve Published data Smoothed curve Published data
When more than one study was available for a country, and exercise, diet, and socio-economic factors often result in
there was no clear superiority of one over the other, the significant differences in diabetes prevalence rates. Therefore,
results from the available studies were averaged, and then for low- and middle-income economies (except those of the
applied to the national population. former socialist economies in Europe), the urban and rural
rates were calculated and numbers reported separately.
Extrapolation
The economies were defined according to the 1997 GNP per
If there were no data available for a particular country, capita, calculated using the World Bank Atlas method2. Low-
prevalence rates from a published study from the socio- and middle-income economies had a GNP per capita of less
economically, ethnically, and geographically most similar than USD9,655, and high-income economies had a GNP per
country were applied to that country’s age and sex-specific capita of USD9,655 or more. If the above conditions for
(and in the case of low/middle-income countries, urban/ different urban and rural diabetes prevalences applied, then
rural-specific) population distribution. Socio-economic for countries where available studies showed prevalences
comparisons were based on gross national product (GNP) separately for urban and rural populations, these rates were
per capita. Ethnic comparisons were based on ethnicity data applied to the national urban and rural populations.
from the CIA World Factbook 20051.
For studies reporting on a mixed urban and rural population,
If a dataset did not provide sex-specific data, the data were but where no data were provided as to the urban/rural
disaggregated and assigned 50% to females and 50% to males. distribution of the survey population, the available age and
gender specific data were assigned to the population so as to
Urban: rural prevalence produce a 2:1 urban:rural ratio in diabetes prevalence.
In countries with low or middle-income economies, differences For countries where only urban or only rural data were available,
between urban and rural populations in levels of physical the 2:1 ratio was used to calculate the prevalence of diabetes in
336 APPENDIX 1.1 DIABETES ATLAS THIRD EDITION
Appendices.indd 336 26/10/06 1:11:22

FIGURE A1.3 FIGURE A1.4
Bolivian females Indian females
Prevalence (%) Prevalence (%)

25 35
30
20
25
15 20
15
10
10
5
5
0 0
Age group 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 Age group 20-29 30-39 40-49 50-59 60-69 70-79
Smoothed curve Published data Smoothed curve Published data
the other segment of the population. No urban:rural difference distributions, and not for the likely changes in lifestyle and
was used for IGT prevalence, unless the data for that country obesity, which may tend to increase diabetes prevalence.
indicated a prevalence difference to be present. Thus, the figures may be an underestimate.
Known diabetes The prevalence rate (PR) of diabetes and IGT for each country
was then calculated using the formula:
Studies from several countries — Canada, France, Germany,
Israel, Italy, Netherlands, New Zealand, Norway — only PR (for those people 20-79 years) =
provided data on self-reported diabetes. To account for Total number of expected cases (20-79)
undiagnosed diabetes, the prevalence of diabetes for Canada
Total country population (20-79)
was multiplied by a factor of 1.5, in accordance with findings
from the USA3, and for the other countries doubled, based on
data from a number of countries4-8. Where:
Total number of expected cases of diabetes, or IGT, in the
20-79 year range = the sum of each age and gender (and
urban/rural) specific number, as derived according to the
A list of the world’s countries and 2007 and 2025 population earlier description.
distribution estimates was obtained from the United Nations
Population Division9. The age- and sex-specific prevalence Following calculation of the PR, the expected number of
rates (obtained from the logistic regression — see below) people with diabetes and IGT within the country was reported
were applied to the corresponding age and sex population separately for males and females, according to age groups (20-
distribution for the years 2007 and 2025 for each country. This 39, 40-59, 60-79), and in those low- and middle-income
method for estimating figures for 2025 only takes into economies (only for diabetes), according to residence in urban
account changes in age, sex and urban/rural population and rural areas.
Appendices.indd 337 26/10/06 1:11:23

For countries without available age and gender distribution weight (number of people without or with diabetes, or IGT, for
descriptions i.e. those with populations of less than 100,000 for the each age group), and diabetes or IGT (0 = no, 1 = yes). The age
year 2000, (and Taiwan), for which data are not provided9, the total specific prevalence (or case numbers, when provided) was
world population distribution was applied to the 2005 population used to obtain the weighting in the following manner:
as indicated in the CIA World Factbook 20051. For Andorra,
Liechtenstein, Monaco and San Marino, the total developed world If 3.6% of 1,000 participants of a particular age group had the
population was applied. Populations for all these countries for condition (diabetes or IGT), the weighting for having the
2007 were obtained by applying the annual increase for one condition would be 36, and for not having the condition,
year, and for 2025, by assuming an unchanged proportion of 964.
the world (or developed world) from 2005 to 2025.
Following this, the variable age2 (age x age) was calculated, to
The countries/territories without UN population data that are enable the model to contain a quadratic term, so that the end
included are: Andorra, Anguilla, Antigua and Barbuda, Aruba, model could include the possibility of flattening or reducing
Bermuda, British Virgin Islands, Cayman Islands, Dominica, prevalence for the oldest age groups. A binary logistic
Grenada, Cook Islands, Kiribati, Liechtenstein, Marshall Islands, regression was then performed using diabetes or IGT as the
Monaco, Nauru, Niue, Palau, Saint Kitts and Nevis, San Marino, dependent variable and age and age2 as the covariates, to
Seychelles, Taiwan, Tokelau, Tuvalu. produce parameter estimates for the intercept, B and C. This
provided the values for each of the 12 five-year groups (20-24,
25-29, …75-79) for the following equation:
In addition to calculating the national rates, a prevalence for y = Intercept + (B x age) + (C x age2)
each country and region, adjusted to the world population,
was calculated by applying for each country that country’s The age specific prevalence (for the five-year age group) was
age- and sex-specific rates to a notional population of that then calculated as (ey/(ey+1)).
country’s population size, but with the world population age
and gender distribution for 20–79 years (for 2007 and 2025). The total numbers of persons with diabetes and IGT for each
This was done to facilitate comparison of rates between country were then calculated by applying the calculated age
countries and regions, and this adjustment to the world specific prevalence rates to the demographic data from the
population noted whenever it was used. United Nations Population Prospects9.
For each region the prevalence adjusted to the world An upper limit of age was necessary for the logistic regression
population was calculated by the summation of the number process, and 79 years was the limit chosen. When original
of persons for each member country with the condition, if datasets contained the age group 65+, the assumption was
each country’s world population adjusted prevalence were made that this age group was 65-74. If a dataset contained the
applied to that country, and the sum divided by the total age group 60+, the assumption was that this age group was
regional population (20-79 years). 60-79, unless all previous age group data were in 10-year
groups, in which case a 60-69 year limit was applied. No age
groups with the youngest members being over 79 years were
included, but persons over 80 years were included if part of an
For each country, data for both diabetes and IGT are presented age group 75-84 years.
for people in the 20-79 age group. Most of the datasets used
did not contain data for all age groups in the 20-79 year age Where the data were available, five-year age bands were
bracket. In order to fill in missing data and to ensure a smooth chosen instead of 10-year age bands as they provided 12
relationship between prevalence and age, logistic regression datapoints in the 60 years age range which gave a smoother
was performed on those datasets that contained four or more relationship between age and diabetes prevalence.
datapoints.
Figures A1.1 to A1.4 illustrate how the published age specific
Observed data were entered into an SPSS spreadsheet under data could be converted by using the described methodology
the following columns: age (mid-age of each age group), into a smoothed curve with respect to age.
Appendices.indd 338 26/10/06 1:11:24

Medline search was undertaken for each complication: Studies with ≥100 participants were included. Where studies
retinopathy, neuropathy, nephropathy, coronary heart presented results for subgroups (e.g. type 1 or type 2
disease, stroke and amputations. Six keywords were used: diabetes) separately, only results for subgroups with ≥100
Diabetic Retinopathy/ep, Diabetes Mellitus/Co participants were included. Where more than one study was
[Complications], Diabetic Nephropathies/ep [Epidemiology], available for a country, preference was given to larger and
Amputations/sn [statistical & Numerical Data], Diabetic population-based studies, those published after 1989, and
Neuropathies/ep [Epidemiology], Diabetic Foot those with the fewest restrictions (e.g. on age). Where
Complications/co [Complications]. For CHD and stroke a complete articles were not available or were not translated
combination of key words were used: cardiovascular into English, details from abstracts were used.
disease, coronary disease, diabetic angiopathies, myocardial
infarction, myocardial ischemia, cerebrovascular disorders, Where possible the authors of the abstracts were contacted to
cerebrovascular accident, prevalence and diabetes verify and complete missing details. Studies were excluded in
mellitus. instances where details from the abstracts were insufficient and
the authors could not be located. Unpublished studies which
A final search, for countries without data, was performed were the only available data for a country have been included.
using the keyword ‘Diabetes Mellitus’, along with each
country name. The references of each paper selected for Prevalences are reported for cardiovascular disease,
inclusion were reviewed and relevant articles from the nephropathy, neuropathy and retinopathy, while incidence
reference lists were also reviewed. In addition, each IDF and prevalence are reported for lower extremity amputations
member country was contacted and asked to provide (with preference given to incidence studies). Where
recent papers or unpublished reports on each amputation studies presented data as a time trend, the most
complication. recent data have been included.
Appendices.indd 339 26/10/06 1:11:24

Where possible, the age ranges of the populations are included, as they do not reflect the general diabetic
reported. Where the age range of the population was not population of the country.
available, the mean or median age is reported. Where a
publication only recorded the age range as groups in a Table, There are some important differences between the section
the lower and upper age groups are presented as the age on diabetic complications (Chapter 1.3) and the section on
range. diabetes prevalence (Chapter 1.1). The total numbers of
individuals within a country who may have complications are
Diagnostic criteria for each complication are recorded, as not estimated, nor is a national prevalence. Furthermore,
variation in definitions can affect the prevalences reported. data have not been projected from one country onto other
Diagnostic criteria for neuropathy were divided into five countries. There are two reasons for these differences: first,
categories: clinical, quantitative sensory testing, such calculations require knowledge of the age and sex
electrophysiology, autonomic function tests and structure of both the original study population, and of the
questionnaire to general practitioners. Where validated target (national diabetic) population. In most cases, neither
clinical scores were used, the name of the scale is recorded. of these is known. Secondly, many studies are clinic based,
Retinopathy was defined as the presence of at least and so their generalizability is limited.
microaneurysms or haemorrhages or exudates. The types of
retinal examination are listed. Criteria for nephropathy are
listed (type of measurement and diagnostic values used).
Five types of studies were included: population based,

register, clinic (primary care), clinic (secondary care), and
clinic (primary and secondary care). For amputation studies
reporting incidence, the sources of the amputation data are
presented. The sources used for these studies were registers,
hospital records, operating theatre records, limb fitting
centres, hospital discharge records and hospital discharge
codes.
Amputations were recorded as first or all amputations. The

lowest (most distal) level of amputation included in each
study, and the total numbers of amputees (rather than
amputations) are reported. In most of the incidence studies,
the authors calculated amputation incidence using the
recorded number of amputations and an estimated figure
for the total diabetic population. In two studies, a cohort
design was used in which a defined population was followed
over time allowing a more accurate calculation of amputation
incidence.
For some countries, results from more than one study are
presented. This is usually because they cover different aspects
of the diabetic population such as type 1, type 2, undiagnosed
diabetes and previously diagnosed diabetes. Furthermore,
since studies vary considerably in design, the presentation of
two or more studies can help to build a broad picture of the
prevalence of a complication. Studies of small minority
groups from populations, e.g. Pima Indians, have not been
Appendices.indd 340 26/10/06 1:11:24

he following systematic searches were performed to
identify sources of published data for the rates of type 1
diabetes in childhood: The following criteria were used, although not necessarily in
the order shown, to select the most suitable studies in
1. Medline was accessed using OVID restricted to human countries with a number of available studies:
studies published since 1980 and using (exp registries OR exp
incidence OR exp prevalence) AND exp diabetes mellitus, • More recent studies, preferably covering periods into the
insulin-dependent AND exp <country name> with the /ep 1990s.
[Epidemiology] sub-heading. If a country was not indexed in • Studies with widest coverage within the country.
Medline then it was included in the search as a text word. • Studies providing rates for the target age range of 0-14
years.
2. PubMed using the Boolean search terms (incidence OR • Studies providing sex-specific rates for the 0-4, 5-9 and 10-
prevalence) AND diabetes AND <country name>. 14 year age groups.
3. Published abstracts from recent international meetings If necessary the numerators and denominators of rates from
including those in the Institute for Scientific Information (ISI) a number of registers within a country were combined to
Proceedings were also searched. obtain pooled rates.
The titles and abstracts of all articles were reviewed and those
likely to provide incidence or prevalence rates were obtained.
The reference lists of articles were also scanned to check for The majority of studies found by the literature search provided
further relevant publications. No restrictions were placed on incidence rates rather than prevalence rates. An estimate of
the language of published articles. the number of cases in each country was obtained by
multiplying the population projections in each of six age/sex
METHODOLOGY FOR CHAPTER 2.1 APPENDIX 2 341
Appendices.indd 341 26/10/06 1:11:25

subgroups (males or females aged 0-4, 5-9 or 10-14 years) by low and any adjustment for mortality is unlikely to have
the corresponding estimated prevalence rate. much impact. In less developed countries, which often have
poorly estimated incidence rates based on small numbers,
Prevalence rates in each age group were obtained by the application of an adjustment for mortality was not felt to
averaging cumulative incidence rates for the five individual be justified. In many African countries estimates of numbers
years in the age group. For example, the prevalence in the of cases were derived directly from reported prevalence rates
5-9 age group was obtained as an average of: (usually extrapolated from other countries), rather than
indirectly through incidence rates and in this situation no
Prevalence (age 5) = 5* (0-4 year incidence rate) + 0.5*(5-9 adjustment for mortality was required.
year incidence rate)
Prevalence (age 6) = 5* (0-4 year incidence rate) + 1.5*(5-9




In a few countries that reported age-specific rates pooled for

boys and girls, the rates were taken to apply to both boys and
girls.
The incidence rate is not uniform in the 0-14 year age group
but rather it tends to be lower in young ages and increases
to a peak usually in the 10-14 year age group. For countries
in which age-specific rates were not available, a single
multiplier to convert incidence rates to prevalence rates was
derived as the median multiplier for the 65 countries for
which age- and sex-specific incidence rates were available.
Equal-sized populations in each age-sex subgroup were
assumed in this calculation. The resulting prevalence to
incidence ratio of 6.2 was therefore employed to convert
incidence rates to prevalence rates in all countries in which
age-specific incidence rates were unavailable. Using an
assumption that the mean age at onset of diabetes occurring
before the 15th birthday was 8.5 years, a similar conversion
factor of 6.5 was derived in the second edition of the Diabetes
Atlas, as the mean duration of diabetes in the 0-14 year age
range.
This method of estimating prevalence from incidence

assumes that the effects of mortality are minimal. In
developed countries, which tend to have high quality
incidence data, mortality rates amongst diabetic children are
Appendices.indd 342 26/10/06 1:11:25

he estimates in Tables 5.1-5.9 were created by formula, paid for them. The WHO definition also includes expenditures
using country-by-country estimates of diabetes for public health programmes, water supply and hygiene
prevalence by age and sex, population size by age and sex, activities, nutritional support activities, education, training,
total healthcare expenditures by age and sex, and the ratio and research — but only when these activities intentionally
of expenditures per person with diabetes to expenditures per and primarily address a health problem. The WHO definition
person without diabetes, matched for age and sex. None of excludes the unpaid care-giving of relatives and others, and
these inputs are known with certainty in industrialized the opportunity costs of this care-giving, including loss of
countries and, in the rest of the world, no direct measurements paid employment. It also excludes other opportunity costs,
have ever been published. One parameter, the diabetes cost such as loss of educational opportunities for children who
ratio, is known by 10-year categories of age and sex only for must stay home to care for disabled parents.
a US population; assumptions about the relative magnitudes
of expenditures for persons without diabetes were also based A significant portion of healthcare spending in the poorest
on US data. Although IDF and WHO are sponsoring studies countries comes from governmental programmes and from
that will obtain estimates from more settings, the estimates external donors, who focus on communicable and parasitic
presented here rely on limited information. diseases rather than on diabetes and cardiovascular disease
(despite diabetes causing as many deaths as HIV/AIDS). The
IDF estimates of expenditures for diabetes in poor countries
may therefore be exaggerated.
The expenditures displayed in Tables 5.1 through 5.9 are the
estimated total health expenditures caused by diabetes.
Initial data on per capita total health expenditures by country
were obtained from Annex Table 6 to the WHO World Health
Report for 200410. WHO defines ‘total health expenditure’ to
include all expenditures for medical care regardless of who In each country, expenditures for persons without diabetes
METHODOLOGY FOR CHAPTER 5 APPENDIX 3 343
Appendices.indd 343 26/10/06 1:11:25

were estimated for 42 subpopulations based on sex and five- To ensure that average total per capita expenditures in each
year strata of age, ranging from age zero to ages greater than country still matched the estimates published by WHO,
100. Because data on total health expenditures by age and aggregate expenditures were compared to the WHO
sex are very rare, even for developed countries, estimates of estimates for 2002, country by country. Expenditures were
population-wide total health expenditures per capita adjusted up or down so that the estimated countrywide
published by WHO for the year 200210 were used. expenditure equalled the country’s WHO-published
expenditure for 2002. This result was then increased to
Per capita WHO expenditure estimates were divided into two account for population growth since 2002, the year of the
components: a portion that was assumed to vary with age- WHO estimates, by dividing the UN medium-variant
and sex-specific mortality (about 80% of total expenditures) projected population for each country in either 2007 or 2025,
and a portion (about 20%) that was assumed to be constant as appropriate, by the population assumed in WHO estimates
within each age- and sex-subgroup. Total expenditures per for 2002, and multiplying by the resulting ratio.
subgroup were calculated as the sum of (a) constant
expenditures multiplied by subgroup size and (b) the product The diabetes expenditure ratio, R
of mortality-related expenditures and the predicted number
of annual deaths in the subgroup. The Tables give alternative estimates for values of a parameter
called R, which is the ratio of all medical care expenditures
Reliable mortality statistics by country are not universally for persons with diabetes to all medical care expenditures for
available so each country’s mortality rates were assumed to age- and sex-matched persons who do not have diabetes.
match the rates published for its WHO Demographic Group By comparing the total expenditures of matched persons
(N=14)11. Because mortality rates vary more widely with age with and without diabetes, the expenditures that diabetes
than medical care expenditures do, rates by sex and five-year causes can be isolated. Because R varies from country to
age group were transformed using a log function, ln(3.00 + country and over time, the Tables show results for likely lower
mortality rate). Subgroup mortality rates were further and upper bounds of R, R=2 and R=3.
modified to account for the fact that only about half the
children who die in countries with high and very high The present analysis attempts to improve on the ground-
childhood mortality receive medical care, and for the breaking estimates calculated for the second edition of the
generally lower average expenditures for conditions that Diabetes Atlas, by explicitly accounting for demographic
cause death in childhood. The 20% of annual expenditures variation in R. R is quite sensitive to age and sex, and countries
that were assumed not to vary with mortality were adjusted differ markedly in the age structures of their populations. In
by age and sex to account for natural differences in medical industrialized countries, R is higher in younger age groups
care utilization, such as the higher use of medical care because younger persons without diabetes do not usually
services by women of child-bearing age. incur large medical expenditures. Conversely, R is lower at
older ages because old persons without diabetes use
The resulting estimates were then fine-tuned by substantial medical care. Younger men without diabetes also
approximately equalizing, for each age and sex subgroup, use less medical care than younger women in industrialized
the ratio of total per capita medical care expenditures countries.
predicted via these methods for the US population to the per
capita medical care expenditures observed in a US sample of When the single global R’s used in the second edition of the
persons who did not have diabetes. (The sample without Atlas were replaced with age- and sex-specific R’s, most
diabetes were members of the Kaiser Permanente medical country estimates of expenditures for diabetes increased,
care programme in the United States, selected and analyzed often quite substantially. Global expenditures nearly doubled.
by one of the authors [GN].) Per capita expenditures for men This is an encouraging result because IDF’s earlier results
were further adjusted to maintain the male/female ratios to appeared to underestimate true diabetes care expenditures,
expenditures found in the Kaiser Permanente data. The when compared with published national studies.
resulting relative distributions of per capita health
expenditures by age and sex, when multiplied by the To obtain an empirical basis for age- and sex-specific values
population in each subgroup, yielded for each country an of R, authors [GN and JBB] affiliated with Kaiser Permanente
aggregate total health expenditure. Northwest Region (KPNW), a large not-for-profit pre-paid
344 APPENDIX 3 DIABETES ATLAS THIRD EDITION
Appendices.indd 344 26/10/06 1:11:26

medical care system in the United States, calculated ratios Computational details
from this organization’s large diabetes registry. The mean R
for all KPNW registrants aged 20-79 for 2004 was 2.066 for For this third edition of the Diabetes Atlas, data and calculations
women and 2.088 for men. To create age by sex distributions for each country were broken down into 10-year age-sex
of R’s for standard R’s with a population-weighted mean of subgroups, starting with age 20-29 and ending with age 70-
2.0 and 3.0, the KPNW distributions of ratios were adjusted 79. (Persons aged less than 20 or more than 79 years were
up and down. Table A3.1 displays these observed and omitted because data on the prevalence of diabetes in these
adjusted ratios and the numbers of subjects that contributed age groups are lacking for most countries.) Expenditures
data. Because of low sample sizes in the age groups were calculated for each subgroup, one at a time, for men
between 20 and 50, R’s for these ages were estimated en and for women, using a different value of R for each subgroup.
bloc. The subgroup expenditures were then combined, first within
sex, and then combining the sexes, weighting each
R undoubtedly varies among and within countries. In subgroup’s contribution to the total by the proportion of the
addition, values of R may be decreasing, at least in country’s diabetic population that fell into each age-sex
industrialized countries. Earlier studies from the USA reported subgroup.
mean R’s of 2.6 in 199212 and 2.4 in 199413, much higher than
the R’s of 2.07 and 2.09 described above for KPNW in 2004. A Specifically, countrywide and per capita expenditures of
recently published German study reported an R for sick-fund medical care in 2007 were estimated by combining data
reimbursed medical care expenditures of 2.014. There are describing:
several reasons why a lowering could be underway. One is 1. the estimated current prevalences of diabetes in 2007 (Pas,
that persons with type 2 diabetes are being diagnosed as estimated in Chapter 1 from epidemiologic studies);
sooner, which means that the average person with diabetes 2. estimated 2007 populations (Nas, based on United Nations
will have fewer and fewer costly complications. projections, median fertility variant18 or, for non-UN
members, the CIA World Factbook1);
One US study showed that R is lower (~2) during the first six 3. total current healthcare budgets in 2002 (Cas, obtained
years after diagnosis15. Additionally, the control of risk factors from WHO estimates and projections19); and
for diabetic complications (hyperglycaemia, hypertension, 4. ratios (Ras) of medical care expenditures for persons with
dyslipidaemia) has been improving in developed countries, diabetes compared to persons without diabetes.
as has the use of classes of drugs (aspirin, statins, ACE-
inhibitors, other antihypertensives) that are known to be All these data were divided into age deciles (a=1–6), by sex
highly effective in preventing cardiovascular complications. (s=1,2). The formula used to calculate the expenditures of
This means that the incidence of diabetic complications is medical care for diabetes in each country was:
probably decreasing, which also reduces average medical
2 6
care expenditures. Finally, effective drugs in each of the
D = C {∑ ∑ ( N as / N ) P ( R as as
− 1) /[ P (R
as as
− 1) + 1] }
classes used in diabetes are now less expensive because they s =1 a =1
are off-patent, which further lowers treatment expenditures

(when generic drugs are used). where
D = the total expenditure of care for diabetes in a country
Do the age and sex patterns of diabetes treatment C = the estimated annual budget for all healthcare in the
expenditures in industrialized countries like the US and country in 2002
Germany accurately describe the rest of the world? Nas = the total population of persons, in each age and sex
Expenditure patterns in low- and middle-income countries subgroup, projected for a country in 2007
are not yet known. One study in China of relatively wealthy N = the total population of the country of all ages
patients of endocrinologists reported an overall R of 2.516. A Pas = the prevalence of diabetes in the country, by age and sex
study in Taiwan reported a ratio of 4.3 but this estimate is Ras = the ratios of expenditures for persons with diabetes to
high because it is not age- or sex-adjusted17. Studies persons without diabetes, by age and sex, and where
supported by IDF, WHO and the World Diabetes Foundation a is an indicator for age decile (20-29, 30-39, …70-79),
will yield more data soon. The first of these studies, in and
Shanghai and Iran, should have results by 2007. b is an indicator for sex (men, women).
Appendices.indd 345 26/10/06 1:11:26

This formula corrects for the fact that per capita health is spent for diabetes care. These expenditures can be used to
expenditures per person with diabetes include expenditures compare how much individuals and institutions paid or will
caused by many conditions, not just diabetes. The formula pay for diabetes care.
yields the costs caused by diabetes.
A unit of internationally traded currency can buy many more
Projection to 2025 goods and services in some countries than in others.
Converting USD to ID corrects for such differences, which
Estimates of expenditures in 2025 differ from estimates for economists call differences in purchasing power. Expenditure
2007 only as a result of projected changes in population estimates in ID can be used to compare the amounts of
structure (total size, sex, age, and percent urban). Expected diabetes care that countries actually produce.
growth in diabetes incidence is not included. Also ignored
are increases in medical care expenditures due to economic The market-basket studies from which ID multipliers are
growth and/or relative inflation in prices for medical care. For calculated involve a wide range of products and services.
these reasons, these projections underestimate future These multipliers might not be accurate for the medical care
diabetes expenditures. sectors of some countries. For example, healthcare workers
in many poor countries are said to be underpaid relative to
US and international dollars workers in other occupations in the same country. If so, the
true difference between USD and ID estimates might be
Expenditures are shown both in US dollars (USD) and greater than is reported here. On the other hand, medicines
international dollars (ID), valued as of the year 2002, the most and medical supplies are often imported and, in many low-
recent year for which national healthcare expenditure data income countries, medicines are taxed upon entry. Some
for all countries are currently available. (Projected expenditures manufacturers of diabetes medicines lower their wholesale
in 2025 are also shown in 2002 dollars.) Expenditures in USD prices to poor countries, but shortages and black-market
estimate the amount of internationally traded currency that distribution can erode these efforts. Consequently, estimates
346 APPENDIX 3 DIABETES ATLAS THIRD EDITION
Appendices.indd 346 26/10/06 1:11:28

TABLE A3.1
Diabetes expenditure ratios (R) by age and sex*
WOMEN MEN
AGE (YEARS) KPNW ADJ. ADJ. KPNW KPNW R** ADJ. ADJ. KPNW
R** R=2*** R=3*** SAMPLE SIZE R=2*** R=3*** SAMPLE SIZE
20-49 2.23 2.15 3.15 1,145 2.74 2.66 3.66 1,108

50-59 2.30 2.22 3.22 1,996 2.23 2.15 3.15 2,239
60-69 2.11 2.03 3.03 2,031 2.03 1.95 2.95 2,356
70-79 1.70 1.62 2.62 1,774 1.57 1.50 2.50 1,901
*Ratio of total medical care expenditures for persons with diagnosed diabetes divided by total medical care expenditures of persons not diagnosed with diabetes.
**Source: Kaiser Permanente Northwest Region, 2004
***Calculated so that the mean R in all age groups equalled 2 or 3 when weighted by the KPNW population sizes in each age group.
in ID could overestimate the amount of medicine that can be which receive large portions of their health budgets from
purchased in poorer countries. external donors, who generally want to focus their giving on
public health initiatives and infectious disease. Finally,
Summary of limitations purchasing power parities estimated for general baskets of
goods and services may not describe purchasing power
Expenditure estimates derived by the methods described medicines and medical care, increasing the uncertainty of
above have many limitations. First, they depend on estimates the estimates in international dollars.
of population size, diabetes prevalence, aggregate health
expenditures and rates of mortality that are imperfect. These limitations mean that the estimates here for most
Second, they depend on assumptions whose accuracy has countries will be very imprecise. Nevertheless, some
not been confirmed in most of the world. For example, the conclusions shine through clearly. Diabetes causes huge
data used to calculate R and to adjust mean per capita amounts of spending and loss. Wealthy countries do almost
expenditures for age and sex came from a single country, the all the spending. Low- and middle-income countries bear
USA, and from a single medical care system within that most of the loss. Better diabetes treatment would be cost-
country. Almost nothing is known about R or about general effective everywhere.
medical expenditure patterns by age and sex in poor and
middle-income countries. It was also assumed that estimates
of R derived from persons with diagnosed diabetes apply to
persons with undiagnosed diabetes, which could be wrong.
And it was assumed that estimates of R derived from data on
medical care can be generalized to apply to all money
expended for health purposes, the only definition of
expenditure for which there are estimates for every country.
This may be especially inaccurate in low-income countries,
Appendices.indd 347 26/10/06 1:11:29

GLOSSARY, ACRONYMS & REFERENCES
GLOSSARY
A
flow problem within, or leading to, the brain time lost due to premature mortality. One
and is considered a form of CVD. DALY can be thought of as one lost year of
acanthosis nigricans (AN) ‘healthy’ life and the burden of disease as a
A skin disease characterized by grey-black measurement of the gap between current
warty patches usually situated in the armpit or coronary heart disease (CHD)
health status and an ideal situation where
groin or on elbows or knees and sometimes Any disease of the heart caused by coronary
everyone lives into old age free of disease and
associated with cancer in the abdomen. artery disease, although it usually refers to
disability.
heart attack and angina.
albumin dyslipidaemia
Albumin is the protein of the highest D
It indicates abnormalities of the lipid
concentration in plasma, and transports many metabolism and is often associated with insulin
small molecules in the blood. Because albumin diabetes mellitus (DM) resistance in type 2 diabetes.
is synthesized by the liver, decreased serum Diabetes mellitus is a chronic condition that
albumin may result from liver disease. It can arises when the pancreas does not produce
also result from kidney disease, which allows enough insulin or when the body cannot E
albumin to escape into the urine. effectively use the insulin produced. This
causes hyperglycaemia (an abnormally high epidemiology
albuminuria concentration of glucose in the blood), which The branch of medicine which deals with the
The presence of albumin in the urine that is seriously damages many of the body’s systems, incidence, distribution and possible control of
usually a symptom of kidney disease but especially the blood vessels and nerves. There disease and other health-related factors.
sometimes a response to other diseases or are two basic forms of diabetes: type 1
(requiring insulin for survival) and type 2
physiological disturbances of benign nature. F
See microalbuminuria. (requiring insulin for metabolic control). People
with type 1 diabetes do not produce enough
insulin. People with type 2 diabetes produce Foot ulceration
atherosclerosis insulin but cannot use it effectively.
Hardening and thickening of the walls of the A foot ulcer is a break in the skin or a deep sore
arteries as a result of deposits of atheroma that can occur in people with diabetes because
(fatty material) on their inner lining. This build- diabetic complications of nerve and/or vessel damage to the foot.
up of atheroma may slow down or stop blood Diabetic complications are chronic conditions Foot ulceration and amputation are among
flow. caused by diabetes. They include retinopathy the most costly diabetic complications.
(eye disease), nephropathy (kidney disease), Diabetes is the most common cause of
B neuropathy (nerve disease), cardiovascular amputation that is not the result of accident.
disease (disease of the circulatory system),
foot ulceration and amputation. These G
beta cells
complications can be prevented by timely
Beta cells are found in the islets of Langerhans
treatment. Public and professional awareness
in the pancreas. They produce and release gestational diabetes mellitus (GDM)
of the risk factors for, and symptoms of,
insulin. A carbohydrate intolerance of varying degrees
diabetes are an important step towards the
of severity with onset or first recognition
control and prevention of complications.
body mass index (BMI) during pregnancy. Gestational diabetes
A key index for assessing body weight in diabetic ketoacidosis (DKA) develops during some cases of pregnancy, but
relation to height. Body mass index (BMI) is Also called diabetic coma. It indicates very usually disappears when pregnancy is over.
calculated by dividing weight in kilograms (kg) high blood sugar level which requires However, women who have had gestational
by the square of height in metres (m). A person emergency treatment. Ketoacidocis occurs diabetes are at greater risk of developing type
is considered obese when BMI is 30 and because of lack of insulin. Without insulin, the 2 diabetes at a later stage in their lives.
above. body uses stored fat instead of glucose for
energy, and acidic waste products called glucose
C ketones are produced, which build up in the Also called dextrose. The main sugar the body
blood, causing ketoacidosis. Its symptoms produces from proteins, fats and carbohydrates.
include nausea and vomiting, which can lead Glucose is the major source of energy for living
C-peptide to loss of water, stomach pain, and deep and cells and is carried to each cell through the
C-peptide is a sub-unit of the hormone insulin. rapid breathing. Other signs are a flushed face, bloodstream. However, the cells cannot use
The C-peptide level may be measured in a dry skin and mouth, fruity breath odour, rapid glucose without the help of insulin.
person with type 2 diabetes to see if any and weak pulse, and low blood pressure. If the
insulin is still being produced by the body. It person is not given fluids and insulin right glycosylated haemoglobin (HbA1c)
may also be measured in the evaluation of away, ketoacidosis can lead to coma and even Haemoglobin to which glucose is bound.
hypoglycemia (low blood sugar) to see if too death. Glycosylated haemoglobin is tested to monitor
much insulin is being produced by the
the long-term control of diabetes mellitus.
person.
Disability Adjusted Life Year (DALY) The level of glycosylated haemoglobin is
The Disability Adjusted Life Year or DALY is a increased in the red blood cells of persons with
cardiovascular disease (CVD) health gap measure that extends the concept poorly controlled diabetes mellitus. Since the
Cardiovascular diseases are defined as diseases of potential years of life lost due to premature glucose stays attached to haemoglobin for the
and injuries of the circulatory system: the heart, death to include equivalent years of ‘healthy’ life of the red blood cell (normally about 120
the blood vessels of the heart and the system life lost by virtue of being in states of poor days), the level of glycosylated haemoglobin
of blood vessels throughout the body and to health or disability. The DALY combines in one reflects the average blood glucose level over
(and in) the brain. Stroke is the result of a blood measure the time lived with disability and the the past three months.
354 DIABETES ATLAS THIRD EDITION

Glycosylated haemoglobin is also known as and use it for energy. Insulin is produced by the The three kinds of macrovascular disease are:
glycohaemoglobin or as haemoglobin A1C beta cells of the islets of Langerhans in the coronary heart disease, cerebrovascular
(the main frac tion of glycosylated pancreas. disease and peripheral vascular disease.
haemoglobin).
insulin resistance (IR) metformin
H A state in which a given level of insulin Metformin is used alone or with other
produces a less than expected biological medications, including insulin, to treat type 2
effect. diabetes. Metformin helps to control the
HbA1c amount of glucose in the blood. It decreases
See glycosylated haemoglobin ischaemic heart disease the amount of glucose absorbed from food
The term ‘ischaemic’ means that an organ, in and the amount of glucose made by the liver.
hyperglycaemia this case the heart muscle, has not received Metformin also increases the body’s response
A raised level of glucose in the blood; a sign enough blood and oxygen. People with this to insulin. Metformin is not used to treat type
that diabetes is out of control. Many things can condition have weakened heart pumps, either 1 diabetes.
cause hyperglycaemia. It occurs when the due to previous heart attacks or due to current
body does not have enough insulin or cannot blockages of the coronary arteries. microalbuminuria
use the insulin it does have to turn glucose into Albuminuria characterized by a relatively low
energy. Signs of hyperglycaemia are great islets of Langerhans rate of urinary excretion of albumin typically
thirst, dry mouth and need to urinate often. Named after Paul Langerhans, the German between 30 and 300 milligrams per 24-hour
For people with t ype 1 diabetes, scientist who discovered them in 1869, these period. Albuminuria is a typical finding of
hyperglycaemia may lead to diabetic clusters of cells are located in the pancreas. disorders such as diabetic nephropathy.
ketoacidosis. They produce and secrete hormones that help
the body break down and use food. There are
microvascular disease
hypertension five types of cells in an islet: alpha cells, which
Disease of the smallest blood vessels that may
Very high blood pressure; this can cause health produce glucagon; beta cells, which produce
occur in people who have had diabetes for a
problems such as heart attacks and strokes. insulin; delta cells, which produce
long time. The walls of the vessels become
somatostaton; and PP cells and D1 cells, about
abnormally thick but weak. Therefore, they
hypoglycaemia which little is known.
bleed, leak protein and slow the flow of blood
Too low a level of glucose in the blood. This through the body.
occurs when a person with diabetes has K
injected too much insulin, eaten too little food, N
or has exercised without extra food. A person ketones
with hypoglycaemia may feel nervous, shaky, Chemicals that the body produces when there
weak, or sweaty, and have a headache, blurred is not enough insulin in the blood and it must nephropathy
vision and hunger. Taking small amounts of break down fat for its energy. Without insulin, Diabetic nephropathy (kidney damage) results
sugar, sweet juice, or food with sugar will ketones build up in the blood and then pass in large amounts of urine protein and
usually help the person feel better within 10-15 into urine so that the body can dispose of hypertension, and progressively leads to
minutes. them. See diabetic ketoacidosis. kidney failure. Diabetes is also the leading
cause of nephropathy. Nephropathy can be
I ketonuria detected by testing for traces of protein in the
The presence of excess ketone bodies in the urine.
urine in conditions, such as diabetes mellitus,
impaired fasting glucose (IFG) involving reduced or disturbed carbohydrate neuropathy
Raised fasting levels of glucose. metabolism. Diabetic neuropathy refers to damage to the
nerve fibres caused by diabetes. It is the most
impaired glucose tolerance (IGT) ketosis common diabetic complication of a
Blood glucose levels that are higher than A condition of having ketones build up in microvascular nature. Hyperglycaemia is a
normal, but below the level of a person with body tissues and fluids. The signs of ketosis are significant risk factor which can cause diabetic
diabetes. Individuals with IGT are at high risk nausea, vomiting and stomach pain. Ketosis neuropathy. Diabetic neuropathy is a major
of progressing to type 2 diabetes, although can lead to ketoacidosis. cause of impotence in men with diabetes.
such progression is not inevitable, and
approximately 30% of individuals with IGT will M NHANES
return to normal glucose tolerance. In The National Health and Nutrition Examination
addition to carrying a risk of future diabetes, Survey (NHANES) is a survey conducted by the
IGT is also a risk factor for future cardiovascular macula National Center for Health Statistics (NCHS),
disease. The part of the retina in the eye used for Centers for Disease Control and Prevention.
reading and seeing fine detail. This survey has been designed to collect
incidence information about the health and diet of
It indicates how often a disease occurs. More macular oedema people in the USA.
precisely, it corresponds to the number of new Swelling of the macula
cases of a disease among a certain group of O
people for a certain period of time. macrovascular disease
Disease of the large blood vessels that may
insulin occur in people who have had diabetes for a oral hypoglycaemic agent (OHA)
A hormone whose main action is to enable long time. Fat and blood clots build up in the Drugs that lower the level of glucose in the
body cells to absorb glucose from the blood large blood vessels and stick to the vessel walls. blood. They work for some people with type
GLOSSARY 355
GLOSSARY ACRONYMS
2 diabetes if their pancreas still produces R A

some insulin. They can help the body in
several ways such as causing the cells in the
pancreas to release more insulin. All oral retinopathy A/CR albumin/creatinine ratio
hypoglycaemic agents belong to a class of Retinopathy is a disease of the retina of the eye ADA American Diabetes Association
drugs known as sulfonylureas. which may cause visual impairment and ADM atypical diabetes mellitus
blindness.
AER albumin excretion rate
P AFI amniotic fluid insulin
S
AFR African Region
pancreas AIDS acquired immunodeficiency syndrome
The pancreas is an organ situated behind the spectrophotometer
AN acanthosis nigricans
lower part of the stomach which produces A device which measures the amount of
insulin. ultraviolet light absorbed by a substance.
B
peripheral neuropathy stroke
A disease or degenerative state of the A sudden loss of function in part of the brain BMI body mass index (kg/m2)
peripheral nerves in which motor, sensory, or as a result of the interruption of its blood BW birth weight
vasomotor nerve fibers may be affected, and supply by a blocked or burst artery.
which is marked by muscle weakness and C
atrophy, pain and numbness. sulfonylureas
Any of several hypoglycaemic compounds (as
glipizide and tolbutamide) related to the CABG coronary artery bypass graft
polycystic ovary syndrome (PCOS)
Polycystic ovary syndrome is an accumulation sulfonamides and used in the oral treatment of CBVD cerebrovascular disease
of many incompletely developed follicles in type 2 diabetes. CCF congestive cardiac failure
the ovaries. This condition is characterized CDC Centers for Disease Control
by irregular menstrual cycles, scanty or T CHD coronary heart disease
absent menses, multiple small cysts on the
CHF congestive heart failure
ovaries (polycystic ovaries), excessive
amounts of facial or body hair (hirsutism) transient ischaemic attacks CI confidence interval
and infertility. Many women who have this ‘Mini strokes’ that produce stroke-like CIA Central Intelligence Agency
condition also have diabetes with insulin symptoms and signs which clear completely CVD cardiovascular disease
resistance. within 24 hours. These attacks are strong
predictors of stroke.
D
pre-eclampsia
A toxic condition developing in late pregnancy tropical and malnutrition diabetes
that is characterized by a sudden rise in blood Diabetes mellitus associated with chronic DALY Disability Adjusted Life Years
pressure, excessive gain in weight, generalized malnutrition and, sometimes, chronic DCCT Diabetes Control and Complications Trial
oedema, albuminuria, severe headache and pancreatitis. Whether tropical diabetes exists ddd/1000 person/day defined daily
visual disturbances. as a distinct entity is under debate. Also called doses/1000 persons of the whole population/day
malnutrition-related diabetes. DECODA Diabetes Epidemiology: Collaborative
prevalence Analysis Of Diagnostic Criteria in Asia
The number of people in a given group or type 1 diabetes DECODE Diabetes Epidemiology: Collaborative
population who are reported to have a disease Type 1 diabetes mellitus develops most Analysis Of Diagnostic Criteria in Europe
at any point in time. frequently in children and adolescents. About
10% of people with diabetes have type 1. The DiabCare Diabetes Care study
symptoms of type 1 vary in intensity. Symptoms DiaMond Diabetes Mondiale study
Q
include excessive thirst, excessive passing of DKA diabetic ketoacidosis
urine, weight loss and lack of energy. Insulin is DM diabetes mellitus
quality-adjusted life years (QALY) a life-sustaining medication for people with DNI diabetic neuropathy index
A quality-adjusted life year (QALY) takes into type 1 diabetes. They require daily insulin
injections for survival. DPP Diabetes Prevention Program
account both quantity and the quality of life
generated by healthcare interventions. It is DPS Diabetes Prevention Study
the arithmetic product of life expectancy and type 2 diabetes
a measure of the quality of the remaining life Type 2 diabetes mellitus is much more E
years. A QALY places a weight on time in common than type 1, and occurs mainly in
different health states. A year of perfect health adults although it is now also increasingly
is worth 1; however, a year of less than perfect found in children and adolescents. The ECG electrocardiogram
health life expectancy is worth less than 1. symptoms of type 1, in a less marked form, may EGIR European Group for the Study of Insulin
QALYs provide a common currency to assess also affect people with type 2. Some people Resistance
the extent of the benefits gained from a with type 2, however, have no early symptoms EMME Eastern Mediterranean and Middle East
variety of interventions in terms of health- and are only diagnosed several years after the Region
related quality of life and survival for the onset of the condition, when various diabetic EPDS Edinburgh Postnatal Depression Scale
patient. complications are already present. People
with type 2 may require oral hypoglycaemic EPODE Ensemble, prévenons l’obésité des
drugs and may also need insulin injections. enfants

ACRONYMS
est estimated number of persons with diabetes N T

EUR European Region
EURODIAB Europe and Diabetes study N/A not available TIA transient ischaemic attack
EX Excluded NA not applicable 2hBG two-hour blood glucose
NA North American Region TRIPOD Troglitazone in the Prevention of
F Diabetes
NCEP ATP III National Cholesterol Education
Program – Third Adult Treatment Panel
FBG fasting blood glucose NDS neuropathy disability score U
FCG fasting capillary glucose NGO non-governmental organization
FPG fasting plasma glucose NHANES National Health and Nutrition UK United Kingdom
Examination Survey UKPDS United Kingdom Prospective Diabetes
G NIDDM non-insulin dependent diabetes Study
mellitus UN United Nations
NNT number needed to treat UnDM undiagnosed diabetes
GDM gestational diabetes mellitus
ns not significant USA United States of America
GDP gross domestic product
NSP neuropathy symptom profile USD United States Dollar
GNP gross national product
NSS neuropathy symptom score
GPRD United Kingdom General Practice
Research Database NSt Not stated V
H O VAT Value Added Tax

VPT vibration perception threshold
OGTT oral glucose tolerance test
HAPO Hyperglycemia and Adverse Pregnancy
Outcome study OHA oral hypoglycaemic agents W
HbA1c Glycosylated haemoglobin A1c OR odds ratio
HIPC Highly Indebted Poor Countries WDF World Diabetes Foundation
P WHO World Health Organization
HIV human immunodeficiency virus
WP Western Pacific Region
I PCOS polycystic ovary syndrome
PGDM pre-gestational diabetes mellitus
PR prevalence rate X
ID International dollar
IDDM insulin-dependent diabetes mellitus PTCA percutaneous transluminal coronary
angioplasty XENDOS Xenical in the prevention of diabetes
IDF International Diabetes Federation
in obese subjects study
IFG impaired fasting glucose
Q
IIF International Insulin Foundation
IR insulin resistance QALYs quality-adjusted life years
QUALIDIAB Quality of diabetes care network
K
R
KDM known diabetes
RAPIA Rapid Assessment Protocol for Insulin
L Access
RBG random blood glucose
RCT randomized clinical trial
LADA latent autoimmune diabetes mellitus in
adults
S
LGA large for gestational age
LSM lifestyle modification
SACA South and Central American Region
M SEA South-East Asian Region
SGA small for gestational age
MMWR Morbidity and Mortality Weekly SMR standardized mortality ratio
Report SPSS Statistical Package for the Social Sciences
MeSH Medical Subject Headings SR self-report
MET Metformin SSA sub-Saharan Africa
MI myocardial infarction STOP-NIDDM Study to Prevent Non-Insulin-
Dependent Diabetes Mellitus
ACRONYMS 357
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2003: consensus summary. Br J Psychiatry 2004; 2005; 366 (9491): 1059-1062. (3): 685-691.
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40. Lambert TJ, Chapman LH. Diabetes, psychotic metabolic syndrome. International Diabetes International Diabetes Federation definition of
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statement. Med J Aust 2004; 181 (10): 544-548. IDF_Metasyndrome_definition.pdf Accessed strongly than older definitions? Findings from
41. Newcomer JW, Nasrallah HA, Loebel AD. The May 2006. the British Women’s Heart and Health Study.
Atypical Antipsychotic Therapy and Metabolic 10. Alberti KG, Zimmet P, Shaw J. Metabolic Diabetologia 2006; 49 (1): 41-48.
Issues National Survey: practice patterns and syndrome—a new world-wide definition. A 22. Ford ES. Prevalence of the metabolic syndrome
k n ow l e d g e o f ps ychiat r is t s . J Clin Consensus Statement from the International defined by the International Diabetes Federation
Psychopharmacol 2004; 24 Suppl 1 (5): 1-6. Diabetes Federation. Diabet Med 2006; 23 (5): among adults in the U.S. Diabetes Care 2005; 28
469-480. (11): 2745-2749.
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mass index for Asian populations and its
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setting. Diabet Med 2004; 21 (5): 403-414. Goldstein DE, Little RR et al. Prevalence of
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of obesity: need to focus on high risk abdominally glucose tolerance in U.S. adults. The Third
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THE WORLD DIABETES FOUNDATION
Diabetes is already a major public health problem stakeholders to ensure that individual project
in the developing world and regarded as a major initiatives live on even after the specific project
cause of premature mortality and morbidity. It is funding has ceased.
amongst the leading causes of blindness, renal
failure, heart attacks, strokes and limb amputations. The World Diabetes Foundation focuses on the
Due to a compromised immune system, bacterial following areas:
and fungal infections are also common and pose a
health hazard for people with diabetes. Poor and • Awareness about diabetes
Her Royal Highness disadvantaged people tend to be diagnosed later, • Prevention of diabetes and its complications
Princess Benedikte have less access to treatment and consequently • Education and training for people with
of Denmark suffer more acute and late complications, limiting diabetes and healthcare professionals
Patron of the World Diabetes productivity and increasing economic burden. • Access to essential medicines in diabetes
Foundation Effective intervention reduces the health and • Detection, treatment and monitoring of
economic burden of diabetes. This requires focus diabetes
MEMBERS OF THE BOARD on prevention – primary prevention – promoting
Chairman healthy living, and secondary prevention -
A CATALYTIC PARTNER
Pierre Lefèbvre reducing the burden of complications by early
diagnosis and proper care. It is very important to the World Diabetes
Vice Chairman Foundation that its funds are directed to people
Leif Fenger Jensen There is an urgent need for a multi-sectoral with the greatest burden and most need: namely
from 1/4 -2006 approach in which governments, non-governmental for diabetes projects in the developing countries.
organizations (NGOs), the health industry, national The strategy is to act as a catalyst - help others do
Members associations, healthcare providers and people more - making a much greater impact than the
Ida Nicolaisen with diabetes can play a role in providing at Foundation’s size would suggest. The WDF seeks
Ib Bygbjerg least minimum standards of care that would help partnerships with established organizations in the
Lars Rebien Sørensen those affected maintain the best possible quality areas of health, diabetes and development aid to
Kaushik Ramaiya of life. This is precisely what the World Diabetes build on existing structure and resources that help
Foundation (WDF) is aiming for. bring diabetes higher on the global healthcare
Managing Director agenda. Through these partnerships we aim to
Anil Kapur raise global awareness of diabetes and help find
DEVELOPING SUSTAINABLE SOLUTIONS
from 1/4- 2006 the resources to address and potentially limit the
FOR DIABETES CARE IN THE DEVELOPING
epidemic.
COUNTRIES
The World Diabetes Foundation aims to address WDF has established project-related
and potentially limit the diabetes epidemic partnerships with organizations such as the
by bringing diabetes higher on the global World Health Organization (WHO), International
healthcare agenda as well as fund sustainable Diabetes Federation (IDF), Danish International
projects in awareness, primary prevention, Development Assistance (DANIDA), The Insulin
building healthcare capacity, and improving Foundation, the German NGO Humanitäre
access to diabetes care in the poorest countries. CubaHilfe, the Spanish foundation Fundación
The World Diabetes Foundation acts as a catalyst para la Diabetes, local diabetes associations,
to build sustainable relations between different the Ministries of Health in various countries,

leading diabetes research institutions and WHO WDF currently supports 86 projects in the
collaborating centres. developing countries. The projects funded by the
Foundation will in the coming 3-4 years directly
WDF, established in 2002 through a commitment of influence the diabetes treatment, awareness and
500 million Danish Kroner over ten years by Novo advocacy of potentially 35,840,000 people in the
Nordisk A/S, is registered as an independent trust developing countries
and governed by a board of six experts in the field
of diabetes, access to health and development WDF promotes the cause
FOLLOW UP TO ENSURE SUCCESS
assistance. The Foundation is currently chaired by of primary prevention and
Professor Pierre Lefèbvre, who is also President The World Diabetes Foundation has developed a proactively seeks projects
of IDF. WDF raises funds from other sources to number of general procedures for monitoring and that target health promotion
support specific projects ensuring a multiplier evaluating the projects. The monitoring process is for the general population,
effect; for every dollar spent the Foundation is now organized into a system, which determines and particularly for school
able to raise approximately three US dollars in the need for precise monitoring activities for each children.
cash or kind from other sources. individual project done on the basis of assessment
of the project’s size, complexity and duration. The new focus area has been
The World Diabetes Foundation supports Diabetes introduced as – The Coming
Action Now, a global collaboration project between It is important for us to have realistic expectations Generation.
WHO and IDF. The initiative represents the major regarding the results and outcome of the projects.
part of the future WHO diabetes programme. Experience shows that not all projects will fare
Working with WHO at a national level, we have as planned and hoped for - not out of ill will, but
launched a diabetes project in Vietnam. Based often due to factors beyond the control of project
on a community approach to prevention, control management and WDF. These factors include -
and management of diabetes, the project aims to but are not limited to - the political and personal
improve the quality of diabetes care in Vietnam. commitment to the activities, transfer of trained
staff, changes in policy or unrest in the country in
There are also a number of projects with IDF to question. These and other such factors will affect
build capacity and raise awareness of diabetes. and hamper implementation and sustainability of
One example is the Clinical Practice Guidelines our projects despite our comprehensive efforts
in sub-Saharan Africa. to pre-qualify projects before granting support. In
order to minimize chances of failure and maximize
The project aims to provide and promote the likelihood of success and sustainability, we
standardized clinical guidelines for diabetes care ensure strong local commitment to the activities;
to improve the quality of care given to people we work with highly competent organizations
living with diabetes in Sub-Sahara Africa. The and project leaders; we focus on close dialogue
guidelines have been finalized and will soon be in our partnerships and we support our partners
distributed and implemented throughout the to address problems and to drive positive project
region. processes further.
The Memorandum of Understanding that was For information on the World Diabetes Foundation
signed with DANIDA in 2002 materialized into and WDF-funded projects please visit:
collaboration on three projects. www.worlddiabetesfoundation.org
WORLD DIABETES FOUNDATION 381

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DIABETES ATLAS

The mission of the International Diabetes Federation is to

Jean-Claude Mbanya (co-chair)

Editor and project manager: Delice Gan

Online version of Diabetes Atlas: www.eatlas.idf.org

First published, 2000

Graphic design AGERGAaRD Graphic Communication

Special thanks to Shirley Murray for coordinating the work at the

IDF member associations

Zulfiqarali G Abbas, Carlos A Aguilar-Salinas, Nizar Albache,

PART 1 THE GLOBAL BURDEN OF DIABETES

Diabetes in the Young: a Global Perspective

CHAPTER 4 Diabetes Mortality 219

CHAPTER 5 The Economic Impacts of Diabetes 237

PART 2 THE CHALLENGES

CHAPTER 7 Mental Health, Antipsychotic Drugs and Hyperglycaemia 299

CHAPTER 8 The Metabolic Syndrome 307

PART 3 PREVENTION AND ACTION

From Vision to Action

D iabetes is no longer an epidemic that can be ignored.

If left unchecked, the number of people with diabetes will

This edition of the Diabetes Atlas brings us face to face with

C hronic diseases account for a large proportion of the

Although we have been extremely vigilant towards the

T he third edition of the Diabetes Atlas confirms beyond all

Part two focuses on some of the major challenges facing

Access to insulin, medication and diabetes supplies remains

Part three is a call for action. It provides the evidence that

 EXECUTIVE SUMMARY DIABETES ATLAS THIRD EDITION

D iabetes is recognized as a group of heterogeneous

• type 1 diabetes • abnormal thirst and a dry mouth

Weight and growth Gestational diabetes

 DIABETES ATLAS THIRD EDITION

Tissue Cells Promotes

Insulin is the internal secretion of the pancreas formed by

Insulin is injected into the body by people with type 1

It is now recognized that it is the developing countries that

D iabetes is now one of the most common non-

10 PART 1 DIABETES ATLAS THIRD EDITION

Chapter 3 highlights the rising trend of gestational diabetes

Chapter 4 provides estimates of mortality attributable to

Chapter 5 examines the economic impact of diabetes and

DIABETES AND IMPAIRED GLUCOSE TOLERANCE

14 CHAPTER 1 DIABETES ATLAS THIRD EDITION

With the forces of globalization and industrialization

D iabetes is recognised as a group of heterogeneous

The data presented in this chapter should be cautiously

DIABETES AND IMPAIRED GLUCOSE TOLERANCE CHAPTER 1 15

This report should act as a stimulus for intervention.

Introduction and other unhealthy lifestyle and behavioural patterns 1.

D iabetes mellitus and lesser forms of glucose intolerance,

16 CHAPTER 1 DIABETES ATLAS THIRD EDITION

2007 Prevalence rates are age standardized to

18 CHAPTER 1 DIABETES ATLAS THIRD EDITION

Prevalence estimates of diabetes, 2007

20 CHAPTER 1 DIABETES ATLAS THIRD EDITION

Prevalence estimates of impaired glucose tolerance, 2007

PREVALENCE AND PROJECTIONS CHAPTER 1 21

Millions Prevalence (%)

22 CHAPTER 1 DIABETES ATLAS THIRD EDITION

By 2025, because of the ageing of the world’s population, Prevalence

Millions Prevalence (%)

Figure 1.8 Figure 1.9

Millions Prevalence (%)

EXECUTIVE SUMMARY DIABETES ATLAS THIRD EDITION

DIABETES ATLAS THIRD EDITION